Nutrition Connection: Dealing With Dementia

(reprinted from Dietary Manager, November/December 2009)

Have you noticed subtle changes in the behavior of some residents?

Maybe it is repeating the same question over and over or forgetting to come to meals or getting irritated easily if the meal is different than expected. These can be early signs of dementia.

Dementia is not a specific disease, but a term that describes symptoms that can be caused by disorders that affect the brain. Alzheimer’s is the most common form of dementia. The prevalence of Alzheimer’s disease in the United States has risen 10 percent since 2000 due to the advances made in treating other major diseases.

Dementia is not new to modern times. Ancient Egyptian physicians described dementia as chronic forgetfulness. While more than a millennium later, Roman physicians believed dementia was simply due to aging. Modern medicine has determined that dementia is not a normal part of aging and it is not limited to older adults.

The Healthy Brain

A healthy adult brain has about 100 billion neurons or nerve cells. Attached to the neurons are about 100 trillion synapse or sensory cell receptors. Nerve cells in the brain communicate with each other when chemicals are released by the sensory cell receptors and received by another neuron. These signals moving through the brain’s circuits create memories, thoughts, and skills. Alternations in the brain’s circuits may result in loss of memories, distorted thoughts, and lost skills. Dementia affects specific parts of the brain resulting in different types of losses.

Dementia

Dementia is a clinical syndrome of loss or decline in memory and other cognitive abilities. All forms of dementia result from the death of nerve cells and/or the loss of communication among these cells. Patients/residents with dementia have considerable impairment of thinking and reasoning that interferes with ADLs and interpersonal relationships. They also lose the ability to solve problems and maintain emotional control. Personality changes and behavioral problems—such as agitation, delusions, and hallucinations—are common. To be classified as dementia, the syndrome must meet the following criteria:

• Decline in memory and at least one of the following cognitive abilities:

• Ability to generate reasoned speech and understand spoken or written language
• Ability to recognize or identify objects (assuming the person can see and hear)
• Ability to understand how to move from one location to another either by walking or using a walker or wheelchair
• Ability to think abstractly, make sound judgments, plan and carry out complex tasks

Decline in cognitive abilities must be severe enough to interfere with daily life. The presence of other medical conditions complicates the care required for an individual with dementia. Many of these conditions can be managed through dietary modifications. See Table.

Prevalence of Dementia in USA

The US Congress, Office of Technology Assessment, estimates that about 6.8 million Americans have dementia. About 2.6 million are diagnosed with dementia and about 1.7 million receive treatment with psychotropic medications, cholinesterase inhibitors, or other medications approved by FDA. Approximately 1.8 million of those are severely affected. Although it is common in very old adults, dementia is not a normal part of the aging process.

Alzheimer’s disease is the most common form of dementia, affecting about 4 million Americans. The prevalence is estimated to be 10 percent of persons older than 65 years and 50 percent of persons older than 85 years. The number of cases is expected to increase to 14 million Americans by 2030. At least 360,000 Americans are diagnosed with Alzheimer’s disease each year and about 50,000 are reported to die from it.

Approximately 60 percent of assisted living residents and 69 percent of all extended care residents in the United States have a diagnosis of dementia. The span of illness is from 2 to 20 years. It is the seventh leading cause of all deaths in the United States, and fifth in those aged 65 and older.

Dining and Dementia

Individuals with dementia have many food and nutritionrelated problems during different stages of the disease. In the early stages of dementia, the individual has less tolerance for changes in routines because of increased confusion. Communication skills deteriorate and frustration rises as the person is unable to ask for help appropriately. Changes in the food delivery system, such as a holiday buffet, may not be well received. The adult may not remember how to self-serve on a buffet line, but is unwilling or unsure how to ask for help. Food safety is another concern if these individuals eat out of serving dishes or use bare hands to serve themselves. The end result is an unpleasant dining experience and perhaps a decline in total dietary intake for the meal.

As the disease progresses to moderate loss, life-long skills— including hand washing and self feeding—deteriorate. These individuals tend to leave out steps such as washing hands, but forgetting to use soap. The adult thinks he or she has washed their hands correctly. If asked to rewash, the adult may become angry, upset, and refuse to eat the meal.

In addition, hoarding behavior is common. These individuals take food, condiments, salt and pepper shakers—anything that is not ‘nailed down’ back to their rooms. Food is often forgotten or stored without proper refrigeration. Pest management and food safety are critical issues requiring diplomatic finesse.

In the middle loss stage, there is an increased interest in visual, tactile, and taste sensations. Food preferences shift dramatically during this stage of dementia. The adult handles everything visible, and often cannot differentiate between edible food and inedible food. For example, the person may eat the banana and the peel—unaware that humans usually discard the peel. In addition, the adult does not recognize ownership of others and may feel comfortable eating not only their meal, but also food served to others.

Dietary intake may decline because of a loss of ability to use eating utensils. For example, eating utensils may be used inappropriately, such as tapping the glass of water instead of eating. The adult may use the fork or spoon to rearrange or play with the food, but has no idea how to use the utensil to eat. Finger foods are an alternative to menu items requiring eating utensils.

Walking, pacing, and wandering are common unless ambulation is limited by other health problems. Eating can become difficult because the individual cannot focus long enough to eat a meal or is confused over what to do when a meal is served. Several smaller meals served ‘on the go’ may help meet nutrition needs.

In the final stages of dementia, the adult may have difficulty chewing and swallowing. Some changes may be due to lost skills due to alterations in the brain or loss of muscle strength in the mouth and throat to chew and swallow foods. In either case, foods and liquids may be aspirated into the lungs and lead to pneumonia. Collaborate with the swallowing therapist to determine the safest food consistency to serve.

Medical Nutrition Therapy and Dementia

While there is not a therapeutic diet for dementia, a new medical food, caprylidene, has been approved by FDA for the clinical management of mild to moderate Alzheimer’s disease. FDA defines a medical food as ‘a food which is formulated to be consumed or administered enterally or orally under the supervision of a physician, and which is intended for the special dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles are established by medical evaluation.’

The theory supporting the use of caprylidene is that providing an alternative energy source for the brain will improve cognition and memory. Caprylidene is a formulation of medium chain triglycerides. Double-blind randomly controlled studies comparing caprylidene to placebo in patients with mild to moderate Alzheimer’s disease show significant improvement on the Alzheimer’s Disease Assessment Scale. No clinically significant changes in total serum cholesterol, LDL cholesterol, or HDL cholesterol have been observed. The long term clinical significance of using a medical food, such as caprylidene, to manage Alzheimer’s disease remains to be seen.

Role of the CDM

The most common nutrition problems in adults with dementia are unplanned weight loss, chewing and swallowing problems, loss of skills to self feed using eating utensils, and loss of communication skills to state food preferences. In the early stages of dementia, it is important for the medical team to anticipate the needs of the adult. Remember that he or she may not be able to make reasoned choices or communicate in a coherent manner. Honor food preferences. During preparation of quarterly assessments, do meal rounds, monitor food intake data, look for trends in monthly weights and lab test results for subtle changes in nutrition status. Consult with the RD and other members of the medical team if data suggests a change in nutrition status. Talk with family members about their observations of their loved one’s mealtime behaviors.

As dementia progresses and nutritional status begins to decline, look for ways to increase energy intake. Start with increasing food portions or number of menu items served. Offer between-meal snacks. If nutrient needs are still not met, fortify foods or add oral nutritional supplements. Be sure that you taste test all fortified foods and oral nutritional supplements for palatability. If you feel the products are acceptable, offer a taste test of a variety of products to determine the residents’ preferences. If the adult is unable to express a preference, ask the family for historic flavor preferences.

Keep families updated on changes in eating behaviors and changes in nutritional status. Families and friends can be helpful to give the medical team ideas on increasing the amount of food and fluid consumed as well as encourage intake. However, weight loss and a loss of the ability to chew and swallow are part of the progression of dementia despite multiple interventions and aggressive nutrition support.

Remember that family members experience frustration, anger, and sadness as they watch their loved one decline. The CDM can ease the pain of dementia through a caring attitude and a commitment to providing quality food in a form the adult can enjoy.

By Mary Litchford, PhD, RD, LDN

Mary Litchford, PhD, RD, LDN is a nationally recognized speaker and the author of Various articles and books, including Protein Powders, Potions & Elixers.