Common Issues With Dementia — Eating and drinking

Dementia Care and Training Specialist Teepa Snow joins Senior Helpers to discuss common issues that might come up during the course of the dementia disease.

Dementia is more than just “forgetfulness,” as people commonly think. Memory problems are certainly a component of dementia, but eating and drinking problems, communication, emotional, and behavior problems are often also present. Caregivers are often taken by surprise when their loved one suddenly has problems in one of these areas, especially if the only early symptoms were memory problems.

People with dementia often experience problems with eating and drinking. Eating a healthy, balanced diet is important. It can help them maintain their physical and mental wellbeing. This page looks at the importance of a healthy diet and the difficulties a person with dementia may have with eating and drinking. It will also look at some practical ways to support a person with dementia to eat and drink well.

The importance of eating and drinking

Eating and drinking well is important for staying healthy. A healthy diet is likely to improve a person’s quality of life. Not eating enough can lead to weight loss and other problems including fatigue, higher risk of infection and less muscle strength.

People with dementia may become dehydrated if they are unable to communicate or recognise that they are thirsty, or if they forget to drink. This can lead to headaches, increased confusion, urinary tract infection and constipation. These can make the symptoms of dementia worse.

While a healthy, balanced diet is important, in the later stages of dementia the most important thing is making sure the person with dementia takes on nutrition, and a higher-calorie diet may be appropriate. A dietitian can give you advice on what is best in a particular situation.

Weight loss

Weight loss is common in people with dementia, although the causes vary. They may include:

• lack of appetite
• difficulties cooking
• problems with communicating or recognising hunger
• poor co-ordination
• getting tired more easily
• difficulties with chewing and swallowing.
• If the person is losing weight, speak to the GP. They can refer the person to a dietitian.

Common problems

Poor appetite, cognitive impairment (problems with mental abilities), physical disabilities and sensory impairments (hearing and sight loss) can all cause the person with dementia to have problems eating and drinking.

Although eating and drinking difficulties are fairly common in people with dementia, each person’s difficulties will be unique to them and their situation. Because of this you should take into account the person’s preferences, beliefs, culture and life history. For example, their religious beliefs may mean they do not eat certain foods such as pork or shellfish, or they may be affected by the environment around them. You should tailor solutions to the person’s individual needs and preferences.

As dementia progresses, the person is likely to need more support to meet their needs.

Poor appetite

There are many reasons why a person may lose interest in, or turn down, food and drink.

• Depression — Loss of appetite can be a sign of depression. Depression is common in people with dementia. There are effective treatments for depression, including medication and other therapies. If you suspect that the person you care for has depression, consult your GP.
• Communication — The person with dementia may have problems communicating that they are hungry or that they don’t like the food they have been given. They may communicate their needs through their behaviour. For example, they may refuse to eat or hold food in their mouth. Giving them a choice of food, or using prompts and pictures, may help.
• Pain — The person with dementia may be in pain, which can make eating uncomfortable. They may have problems with their dentures, sore gums or painful teeth. Oral hygiene and regular mouth checks are important.
• Tiredness — This can also be a cause of people with dementia not eating or giving up part way through a meal. It can also lead to other difficulties such as problems with concentration or difficulties with co-ordination. It’s important to be aware of this and support the person to eat when they are most alert.
• Medication — Changes to medication or dosage can result in appetite changes. If you think this may be the case, speak to the GP.
• Physical activity — If the person is not very active during the day, they may not feel hungry. Encouraging them to be active will be good for their wellbeing and may increase their appetite. Equally, if the person is very active or restless (walking about or fidgeting) they may use extra calories and need to eat more to replace them.
• Constipation — This is a common problem and can result in the person feeling bloated or nauseous, making them less likely to want to eat. Try to prevent constipation by encouraging activity, offering the person fibre-rich foods and providing plenty of fluids. If constipation becomes a problem for the person, speak to the GP.

Encouraging appetite: tips for carers

There are lots of ways to increase a person’s appetite and interest in food and drink. Knowing the person will help, as everyone has their own routines, preferences and needs. You will also have a better idea about their likes and dislikes. It’s also important to think about what they can physically manage. Here are some ideas that may help:

• Make food look and smell appealing. Use different tastes, colours and smells. The aroma of cooking — eg freshly baked bread — can stimulate someone’s appetite.
• Look for opportunities to encourage the person to eat. For example, if the person with dementia is awake for much of the night then night-time snacks may be a good idea.
• Give the person food they like. Try not to overload the plate with too much food — small and regular portions often work best.
• Try different types of food or drinks, eg milkshakes or smoothies.
• Food tastes may change, so try stronger flavours or sweet foods.
• Don’t stop someone eating dessert if they haven’t eaten their savoury meal. They may prefer the taste of the dessert.
• If food goes cold it will lose its appeal. Consider serving half portions to keep food warm. Use a plate warmer or a microwave to reheat food.
• If the person is having difficulties chewing or swallowing, try naturally soft food such as scrambled egg or stewed apple in the first instance, before considering pureed food.
• If you do consider pureed food, seek advice from a dietitian or speech and language therapist to make sure it’s nutritious and has enough flavour.
• Encourage the person to get involved at mealtimes. They could help prepare the food or lay the table.
• Try to give the person encouragement and gentle reminders to eat, and of what the food is.
• A relaxed, friendly atmosphere with soft music may help.
• Use eating and drinking as an opportunity for activity and social stimulation. It may be an opportunity to talk about food from their childhood, and this can be used to encourage appetite.
• If the person refuses food, try again a bit later. If they continue to refuse food, speak to the GP.
• It is always best to aim for the least stressful solutions. Common sense and a creative approach often help.

Problems with mental abilities

People with dementia may struggle to recognise food and drink, which can result in it going uneaten. This can be due to damage that dementia causes to the brain, unfamiliar food, or how food is presented. If the person with dementia has problems with their sight, they may not be able to see the food. It may help to explain what the food is and to use pictures. Make sure the person is wearing the correct glasses. It’s important not to assume that the person doesn’t want to eat.

Concentration

People with dementia may not be able to concentrate well, which means they may have difficulties focusing on a meal all the way through. This may be because they are tired. Don’t assume someone has finished because they have stopped eating. Finger foods and smaller portions can help to make the task easier. If you are helping someone to eat and it goes on for too long, it can turn into a negative experience — eg the food can become cold.

Behavioural difficulties

Eating behaviours

A person with dementia may refuse to eat food or may spit it out. This may be because they dislike the food, are trying to communicate something such as the food being too hot, or they are not sure what to do with the food. The person with dementia may become angry or agitated, or behave during mealtimes in a way that challenges. This can be for a variety of reasons, for example:

• frustration at any difficulties they are having
• feeling rushed
• the environment they are in
• the people that they are with
• not liking the food
• changed perceptions about mealtimes or the environment — eg not eating lunch because they assume they have to pay for it.

They may not want to accept assistance with eating. It can be a challenge to identify what the problem is, particularly if the person is struggling to find the words to explain it. It is important to remember that these reactions are not a deliberate attempt to be ‘difficult’, or a personal attack.

Try not to rush the person with dementia, and help them maintain as much independence as possible. Look for non-verbal clues such as body language and eye contact as a means of communication. If a person is agitated or distressed, do not put pressure on them to eat or drink. Wait until the person is calm and less anxious before offering food and drink. Knowing about someone’s life history, including past routines, may help with understanding any behaviour around eating or drinking that seems unusual.

Changes in eating habits and food preference

It is important to respect the person’s preferences and beliefs when it comes to eating and drinking. For example, they may be a vegetarian or vegan, or have religious or cultural considerations regarding the food and drink they eat.

Sometimes people with dementia make food choices that do not match their usual beliefs or preferences. For example, a person who has been a lifelong vegetarian may want to eat meat. This could be for different reasons — for example:

• the person’s preference has changed
• the person is remembering that they used to eat meat (before they became vegetarian)
• the person has forgotten they don’t eat meat
• the person may see you eating meat and want the same, without knowing what it is.

For similar reasons, people who have other preferences may start to want something different — eg a person who does not eat pork for religious reasons may start to want pork.

It may be difficult to know what to do in these situations. Try to use what you know about the person and, if they are showing a different preference, consider what might be the reason for this. Be aware of any impact on the person’s digestion — eg if they are finding something they don’t usually eat difficult to digest — and always try to do what is in the person’s best interests.

Catering for changing eating habits: tips for carers

• If someone has a preference for sweet foods, fruit or naturally sweet vegetables (such as carrots or sweet potato) may be a healthier option.
• Add small amounts of honey or sugar to savoury food.
• Sweet sauces or chutneys (eg apple sauce or sweet chilli sauce) can be served with savoury dinners.
• Herbs and spices could be used to enhance flavours.
• Adding a small amount of syrup, jam or honey to puddings will increase sweetness.
• Try food the person has never eaten before but remember the person’s personal preferences and practices.
• If the person asks for meat but isn’t a meat eater, you could try meat substitutes.
• If the person is eating unusual food combinations it is best to accept it. It is unlikely to cause them harm.

As dementia progresses, a person may put things that aren’t food into their mouths, eg napkins or soap. There could be a number of reasons for this, including:

• The person no longer recognises the item for what it is or understands what it is for. Remove from view the items that the person may confuse for food.
• The person may be hungry. Offer food as an alternative to the item. Make sure food is available, easy for the person to see (both within eyesight and in clear contrast with the plate or immediate environment) and easy to access throughout the day so they can eat when they want to.

Overeating

Some people with dementia may eat too much or too often. They may have forgotten that they have recently eaten, or be concerned about where the next meal is coming from. If a person is overeating, they may also eat foods that aren’t appropriate, or things that aren’t food. They might be frequently asking or searching for food. This can be a stressful situation for everyone involved.

People with behavioural variant frontotemporal dementia are likely to experience excessive eating and other changes to eating behaviour, such as changes in dietary preference and obsession with particular foods.

Tackling overeating: tips for carers

• Ensure that the person has something to do so they do not feel bored or lonely.
• Divide the original portion into two, and offer the second one if the person asks for more.
• Fill most of the plate with salad or vegetables.
• Leave bite-sized fruit or healthy snacks, eg chopped bananas, orange segments or grapes, within reach for the person to snack on when they want to.
• Offer the person a drink such as a milkshake or hot chocolate instead of more food.
• Some carers remove certain foods from the house and try to manage how much a person eats.
• If the person eats things that aren’t food, then it may help to remove these and offer snacks as a distraction.
• If the person has developed a strong preference for particular foods, and is not eating enough of other foods, or they are struggling with excess weight gain, ask the GP for a referral to a dietitian.

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