Nutrition for the Dementia Resident

Residents with dementia may suffer from anorexia, undernutrition, and involuntary weight loss. In fact, approximately 90% of all patients with Alzheimer’s disease lose weight.¹ Studies indicate that unintentional weight loss may increase mortality, reduce resistance to infections, and increase risk of pressure ulcers.² Residents with advanced stages of dementia also are at risk for malnutrition, dehydration, and dysphagia. Good nutritional care can help to prevent these serious complications and others, such as poor wound healing.

Good eating habits may help prevent complications, prolong independence, and improve quality of life. But facilities must first have good preventive systems in place: Effective interdisciplinary communication systems to share important information, effective weight-tracking systems to identify significant changes, and efficient methods of tracking food and fluid intake are essential. Moreover, nutrition screening tools for early identification and intervention help to prevent problems and tailor interventions for each individual.

Mealtime Solutions
Mealtime is one of the most important areas of focus for a positive nutritional impact, and the dining atmosphere can have a major influence on how well a resident with dementia eats. Therefore, limit distractions by removing items from the table and dining area that might distract the resident from eating. Minimal noise, calming classical music, colorful dishware, and few interruptions have been shown to improve food intake at mealtimes.

Strategic seating. Concentrate on appropriate and strategic seating to meet each resident’s needs. Family-style seating may be good for one resident, but another may benefit from being in a smaller dining area with fewer people or even one-on-one dining with staff. Provide a regular routine: Present meals at the same time and in the same place each day, with a variety of favorite foods presented appetizingly.

Encouraging independence. Encourage independent eating through the use of adaptive feeding devices, finger foods, verbal or physical cueing, hand-over-hand assistance, and proper positioning for eating. Supervise, monitor, and redirect as needed, providing gentle reminders to eat.

Adequate staffing. Eating assistance is needed for residents who lose the ability to use eating utensils, have difficulty focusing on eating, or are unable to feed themselves. Ensure adequate staffing at mealtimes to assist those who need help. Take an “all hands on deck” approach to dining services-involve all department heads and office staff in helping pass trays, opening packages, cutting foods, and pouring beverages. This will free up nursing assistants to help residents with their needs. Staff must be alert to warning signs of resident malnutrition and dehydration, such as leaving >25% of food uneaten, having difficulty chewing/swallowing, refusing substitutions, hiding food instead of eating it, and/or wandering away before finishing the meal.³ Use the information CMS offers on its Web site for nutrition and hydration, www.cms.gov/partnerships/tools/materials/nutrition, as a good basis for training. Make sure staff understands that they should pass on any concerns to a supervisor for referral to the dietetics professional and care team. Finally, offer food replacements for uneaten foods (offer food first, supplements last). And most importantly, allow adequate time to eat.

Creative Solutions for Specific Problems
Sundowner syndrome. This occurs when a resident is more disoriented and distracted after the sun goes down. This may interfere with food intake during dinnertime and the bedtime snack. With respect to nutrition, the Alzheimer’s Association makes these suggestions for residents with sundowner syndrome:

• Decrease caffeine (coffee, tea, chocolate, colas, etc.) or restrict to early morning hours to decrease agitation and sleeplessness.
• Offer an early dinner or a late-afternoon snack to encourage better food intake.⁴

Weight loss and malnutrition. Studies indicate that residents with Alzheimer’s disease are more likely to lose weight compared with control groups.⁵ This may be caused in part by increased energy requirements as a result of increased activity (walking, pacing, or agitation). Couple this with forgetting to eat, forgetting how to eat, or being distracted from eating, and the result is a dangerous combination for health. Prevent unintentional weight loss by identifying residents at risk and intervening appropriately. Some suggestions:

• Adequately assess needs for proper diet and cater to individual preferences. Keep diets as liberal as possible while still maintaining good health. Overly restrictive diets reduce the palatability of foods and contribute to poor food intake.²
• Have healthy snacks available whenever a resident is willing to eat.
• Address cognitive and behavioral issues at mealtimes, including possible depression. Take notice if the resident exhibits disinterest in the meal, engages in inappropriate behaviors or comments, has a sudden change in usual food intake, or refuses to leave his or her room to eat a meal. Make sure frontline staff is trained on addressing these situations and making appropriate referrals.
• Offer real food first. Remember that for some residents, every bite counts, so offer favorite foods at times the resident prefers. Enhanced foods (nutrient-dense) such as fortified cereal, potatoes, soups, and sauces can boost calories and protein in the foods already being served. Supplements are the next line of defense after other interventions have failed. Ensure that residents actually receive the recommended interventions.
• Have a registered dietitian (RD) conduct a complete nutritional assessment, which should include a calculation of nutritional needs (caloric, protein, and fluid) and evaluation of the potential use of dietary stimulants as appropriate. An RD can assist in choosing the healthiest interventions for your residents. Find a dietetics professional in your area on the American Dietetic Association’s Web site at www.eatright.org/Public/index_7684.cfm.

Dehydration. Dehydration may be caused by an altered thirst sensation, fear of incontinence, an inability to request adequate fluids, and medication side effects. Encourage at least six to eight 8-oz glasses of fluid each day. Also:

• Offer fluids multiple times throughout the day (upon every contact).
• Offer a variety of fluids, being sure to offer favorite beverages. Or try popsicles, sherbet, gelatin, fruit slushes, or other forms of fluid.
• Train staff to use TAPS (Turn, Align, Position, Sips) for residents who need to be positioned and for those residents who need to be turned. Every time staff members perform this function, they should offer the resident sips of fluid.

Advance directives. When a resident is malnourished, has lost weight, and is unable to maintain or improve at the current rate of food intake, and when all normal interventions have been exhausted, some difficult decisions must be made. Residents have the right to make their own informed medical decisions-after first being given adequate information regarding the disease and the treatment options. For residents with dementia, it is often the person having durable power of attorney who will make these decisions. A special meeting with this person (and/or the family) should be offered to discuss the resident’s status and treatment options in order to assist in the decision making process. It is important to know what the resident’s wishes are regarding feeding tubes, IVs, and total parenteral nutrition. Many facilities struggle with decisions regarding the “to feed or not to feed” dilemma. The interdisciplinary team should develop protocols to address these difficult challenges.^6,7

Conclusion
Work together as a team: Be aware of each resident’s conditions, problems, and concerns in relation to nutrition and hydration; participate in team care meetings; and provide the most appropriate interventions for each individual. Prevention is the key for residents with dementia. Adequate assistance; creative dining strategies; and preventive screening, assessment, and intervention for nutritional problems will help to ensure nutritional health and prevent further health complications. So the next time a resident asks you, “Do you know where I can get something to eat?” you’ll know how to intervene with compassion, care and, best of all, food.

References
1. Cederholm T. Sixth International Stockholm/Springfi eld Symposium on Advances in Alzheimer Therapy. Stockholm; April 5-8, 2000.
2. Dorner B, Niedert KC, Welch PK. Position of the American Dietetic Association: Liberalized diets for older adults in long-term care. Journal of the American Dietetic Association 2002;102:1316-23.
3. Health Care Financing Administration. Nutrition and Hydration: A fact PAC for Nursing Home Administrators and Managers. www.cms.gov/partnerships/tools/materials/nutrition.
4. Graham H. Alzheimer’s patients require more calories. Gerontological Nutritionists; Winter 1997:7.
5. Hemmelgarn M. Topics on nutrition and dementia: Research and resources. Food & Nutrition Resource Newsletter; September/October 1996. Available at: www.outreach.missouri.edu/hesnutrnews/fnr88-97/fnr96-5.htm.
6. Dorner B, Gallagher-Allred C, Deering CP, Posthauer ME. The “to feed or not to feed” dilemma. Journal of the American Dietetic Association 1997;97(10 suppl 2):S172-6.
7. Dorner B. When a resident won’t eat. Providers consider advance directives when establishing a nutrition risk protocol. Provider 1997;23:61-4.