Tips for getting Alzheimer's patients to eat and drink

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Many caregivers become frustrated, trying to ensure that their loved ones drink enough fluids, and maintain their weight. I've found many suggestions on how to deal with these problems on the discussion forums.


GETTING ENOUGH FLUIDS

Alzheimer's patients tend to have problems with dehydration at almost any stage, which can have serious consequences. It can increase confusion and muscle weakness and cause nausea. Nausea, in turn, will prevent the person from wanting to eat, thereby causing more dehydration.

Often, our loved ones get dehydrated simply because they won't drink enough, and there are a lot of tricks for getting fluids into them -- for example, offering high-liquid treats such as watermelon, popsicles, ice cream, jello (sometimes with fruit in it), fruit juice or Koolaid, yogurt, or a Boost protein shake with evening medicines. If weight gain is a problem, choose sugar-free treats.

Instead of trying to get your loved one to drink larger quantities, offer smaller quantities frequently. Have a "happy hour" before mealtime, serving non-alcoholic fun drinks. Always offer a beverage when you enter his room, and offer him a glass of water after toileting. Suggest a glass of lemonade after going for a walk or working in the yard.

Try serving beverages at room temperature. Avoid caffeine, which may cause frequent urination and dehydration.

Choose foods that have a high water content. For a list of the water content of many fresh foods, see:

http://waltonfeed.com/old/self/h2ocont.html

[Note: blueberries (84% water), and zucchini(95% water) are not on the list.] Offer snacks of fresh fruits and vegetables several times a day. Some dry foods, such as pasta and beans, are like sponges, and absorb water when cooked. Cook vegetables in the microwave, or steam them, to retain water content.

Alzheimer's patients may have difficulty swallowing (this is called "dysphagia"), especially in the later stages. Use a child's sippy cup or "nosey cups" to make it easier to drink. ("Nosey cups" are plastic cups with a cutout for the nose, which makes it easier to drink if your loved one keeps his head tilted down somewhat.) Using a straw may make drinking easier by encouraging a sucking response.

If that doesn't work, thicken your loved one's drinks, soups, and other liquids, to make them easier to swallow. There are products especially developed for this; for example, see the Nestle Nutrition Store products at:

http://www.nestlenutritionstore.com/dysphagia.asp

60% Pear nectar/honey and cranberry thickened with honey are favorites, since our loved ones often prefer sweet tastes. Drug stores also sell products such as "Thick-It". Although these are over-the-counter, they may be shelved behind the pharmacy desk, so ask.

But you don't have to stick with special products. Use baby cereals such as rice or oatmeal to thicken drinks. Pureed fruits can be added to fruit juices. Yogurt, ice cream, or powdered milk can be added to milk. Thicken soups and shakes with small pastas, rice, instant potato flakes, or oatmeal.

Conversely, solid foods may have to be cut into tiny pieces, or even pureed, to make them easier to swallow.



GETTING ENOUGH NUTRITION

When a loved one refuses to eat, or is eating but still losing weight, there are many ways to encourage them to eat, and to pack each mouthful with calories.


>> Make sure there's nothing preventing your loved one from eating

First, be sure to have a doctor check to make sure your loved one isn't suffering from an infection (urinary tract infections are all too common!) or another problem, such as a bowel obstruction, that is making your loved one too uncomfortable to eat. Perhaps your loved one has arthritis, that is making it too painful to bring his hand to his mouth. Or maybe your loved one has a toothache or sore gums, or his dentures are uncomfortable. A white coating on the tongue or gums might indicate thrush, which can be very painful. Ask the doctor and dentist to check for such problems.

Your loved one may need adaptive feeding equipment, such as a "swivel spoon". Put soup into a mug that's easy to hold. A physical therapist may be able to help you choose suitable eating utensils. When eating utensils are too difficult to use, give your loved one finger foods.

Check the possible side effects of any medications your loved one is taking, especially those recently prescribed. Cholinesterase inhibitors such as Aricept, Razadyne (galantamine), and Exelon, for example, may cause nausea, stomach cramps, bloating, diarrhea, or anorexia. Be sure to have your loved one take such medicines on a full stomach. Many medicines can cause dry mouth, which makes eating difficult and unpleasant, and can cause a host of other problems, as well. It may be necessary to decrease the dosage of drugs that interfere with eating, or even switch to a different medicine, if the symptoms don't go away in a few days.

Perhaps your loved one is suffering from depression, and an antidepressant would help.

Talk with the doctor about prescribing a medication which stimulates the appetite, such as Megace or Megesterol. The tricyclic antidepressant doxepin (Sinequan) can serve double duty as an appetite stimulant.


>> Set the stage for a pleasant dining experience

Engage your loved one in physical activity right before the meal, to stimulate his appetite.

Some Alzeimer's patients enjoy being involved in preparing the meal, and doing so may also stimulate their appetites. They may also enjoy helping to set the table, even if they require assistance, including verbal cues.

Some Alzheimer's patients like a formal dining table set with a centerpiece or vase of flowers, table cloth, place mats, and serving dishes -- others find clutter too confusing. (Even if your loved one prefers a formal table, be sure to keep non-edible items, such as flowers, decorations, sugar packets, etc, out of reach.) Some like to use good china, others may be uncomfortable with it.

Let your loved one eat wherever he is comfortable. Some become agitated at the dinner table, but are happy eating on a TV tray, or even standing by a counter in the kitchen. Your loved one might prefer to dine alone, or may crave the company of family members or a close friend. He may be uncomfortable in a room that is too large, or one that is too small. Be sure that the room is neither too cold nor too hot for your loved one's comfort.

Minimize distractions, such as a noisy TV or radio, or perhaps an open window if there is too much going on outdoors. Soft music may encourage your loved one to remain seated until the end of the meal ... or it may be a distraction. Be sure the room is well lighted, but avoid glare that may hurt your loved one's eyes. Reflections in a mirror or on glass (the window, or in a picture frame) may be confusing or scaring your loved one.

Invite your loved one to join you in whatever room he likes best, just as you would a guest in your home. If your loved one won't stay at the table, try having everything ready and already on the table when you bring him into the room. Otherwise, he may become agitated waiting for you to bring in the meal.

Make sure the dining atmosphere is peaceful ... and that you remain calm and pleasant. Alzheimer's patients can pick up very quickly on tension or anger, and will react negatively. Your attitude, expression, tone of voice, and body language are very important. Be careful not to make your loved one feel like he is being pressured or forced to do something he doesn’t want to do.

If it won't distract him, engage your loved one in pleasant conversation. Sometimes talking about favorite foods or restaurants, discussing recipes, or reminiscing about adventures such as picnics, will help your loved one focus on food.

Use something your loved one likes as an incentive to get him/her to eat -- tell him that he can take a nap, go for a walk, or play a game when he is finished eating.

Perhaps your loved one is in a nursing home, and state law requires the home to place the dietary slip next to his meal. He may worry that the slip is a bill, and he has no way to pay it. Depending on your loved one's personality and background, you might tell him that you've arranged to pay for it, or that he can simply charge the meal to his room.


>> Use visual cues

Alzheimer's patients often have "visual agnosia." This is a symptom in which the eyes function properly, but the brain does not always process the signals correctly. Your loved one may not be able to see the plate unless there are sharp contrasts in color between the plate and the table or placemat, for example. If your loved one becomes upset over sitting down to eat, perhaps he is having difficulty seeing a chair that is too similar in color to the floor.

Put food on a brightly-colored plate -- bright red or yellow seem to be the ones that work best. In addition to providing the color contrast that may be needed, a bright color often fascinates Alzheimer's patients, and they will get closer and closer, and eventually start eating. When your loved one begins to get used to one color, switch to another. Use plates that are a solid color -- patterned plates may be confusing, and make it difficult for your loved one to see the food.

Or, your loved one may be having trouble seeing something that's on one side of the plate. Experiment with placing foods at different locations on the plate, to see if he favors one in particular.

Another thing that can help is to cook with color. Use red, yellow, orange or green peppers, sweet potatoes instead of white potatoes (which add sweetness, too), grapes, carrots, tomatoes, spinach ... lots of contrasting pretty colors! Keep some dried or frozen blueberries or a frozen berry medley on hand, and add to pears or peaches, pudding or yogurt, or ice cream, to add color and flavor and fiber.

Too much food on a plate can be overwhelming, and so can too many food choices. Sometimes, it's best to put only one small helping of a single food on the plate at a time. You can put more on the plate after your loved one finishes his first helping.

Point to and naming objects may help: Here's your spoon. Here's your plate. This is macaroni, your favorite.


>> Use verbal and tactile cues

Verbal and tactile cues can also be useful. Start with verbal cues. Sometimes, simply talking about the food will help direct your loved one's attention to the food and encourage him to eat. If necessary, give your loved one simple prompts: it's time to eat ... pick up your sandwich ... now take a bite of it. In the later stages, you may even have to remind your loved one to chew, and then to swallow. Give your loved one plenty of time to respond -- don't rush things!

If verbal cues aren't enough, try tactile cues. Touch the spoon while you tell your loved one what it is, and then gently guide his hand to it. If he doesn't pick it up, place the spoon in his hand. And if that isn't enough, try "hand-in-hand": place his hand on yours while you pick up the spoon, fill it with food, and guide it to his mouth. After a while, he may be able to finish up by himself. Sometimes, if your loved one has trouble swallowing, gently stroking the throat may help get him started.

If your loved one still has some ability to help feed himself, don't take over completely. Gently encourage him to do as much as he can.

If you feed your loved one and he keeps pushing the spoon away: slow down! Your loved one may be having trouble chewing and/or swallowing, and simply not be ready yet for the next bite. You may need to feed him small bites very slowly, and reassure him that he has plenty of time. Watch for his throat (larynx) to move up and down so that you know he has swallowed before giving another bite.

Your loved one might say that he doesn’t want another bite or wants to be left alone, but it is worth trying another spoonful -- with an Alzheimer's patient, “no” doesn’t always mean “no.” If he accepts another spoonful willingly, continue assisting him, but pay close attention for when he really is ready to quit.


>> Use sweet and spicy flavorings

Most taste sensations start to fade over time in Alzheimer's patients. Usually, the taste of sweet and the taste of strong spice (such as curries or Carribbean flavors) are the last to go. So try to punch up the meal with very flavorful spices and herbs, (but not much salt!) To add a sweet taste, top foods with jelly, honey, or a berry medley, or serve small cakes with the meal. Don't worry if you don't find a concoction appealing ... if your loved one likes it, that's all that matters!

Try apple salads with chopped apples, maybe some celery, dried fruit (blueberries, cranberries, raisins), and chopped nuts. Sprinkle with sugar and just a little lemon juice ... and if you want a little creamier dressing, add a tablespoon of whipped cream. Or try cubed tomatoes, avocado and mozzarella cheese dressed with a bit of honey mustard dressing. Cooking with fruit is a great way to get in both fiber and sweet. Any time you cook a fruit, it intensifies the sugars in the fruit. So cook chicken with apples, a fruit salsa over chicken or fish, or grilled fruit as a side dish.


>> Pack in the calories

Offer high-calorie, nutritious foods -- such as almond butter and peanut butter; pudding; protein shakes frozen just to the thickness that they'll stay on the spoon; or mashed potatoes (perhaps mashed with other foods your loved one might like, such as cheese, sour cream, onions or scallions, etc)

Think of ways to add calories and nutrients to everything your loved one eats. Make milkshakes with real ice cream plus Carnation Instant Breakfast or protein powder to add nutrients. Try using a high-calorie supplement such as Boost shakes or Ensure Plus, perhaps blended with ice cream. Blend anything you can with bananas and protein power. Make a "breakfast pudding" of bananas, protein powder, wheat germ, heavy cream and a flavored extract, thickened with baby oatmeal dry cereal if it's too runny, or sweetened with seedless "Simply Fruit".


>> Make foods easier and/or more fun to eat.

For example, as discussed in the section above on liquids, thickening drinks and soups, or pureeing solid foods, may make them easier to swallow.

Melted cheese holds the bread together in sandwiches and so does peanut butter. Eating is easier if crusts are removed and the sandwiches are cut into smaller pieces. Scrambled eggs hold together better if you add a little cheese when you cook them... for example, with a low sodium cheese such as lacy swiss.

Serve small portions. For example, cut a sandwich into four pieces. Give your loved one a single piece. When he eats it, act as if he hasn't had a meal yet, and offer another piece. Serve several small meals and snacks scattered throughout the day. Use a small plate -- a large plate can be overwhelming.

Try offering finger foods, which may be more "fun" to eat, easier to handle, or appear to be smaller servings. For example, offer tiny individually wrapped cheeses (monterey jack, string, and cheddar) served with fruit as a snack, or ice cream sandwiches cut into small pieces.

Try to have something sweet to end the meal, such as a favorite fruit, fresh or frozen. Or, start the meal with something sweet. Once the "pump has been primed", the loved one will often go on to eat everything else that is offered.


>> Difficulty swallowing

At some point, your loved one may lose the ability to swallow. Warning signs that your loved one is developing a swallowing problem include:
- Complaining that swallowing is difficult
- Food or saliva leaking from the mouth
- Coughing before, during, or after swallowing foods or liquids
- Choking when eating or drinking
- Increased congestion or runny nose after a meal
- A change in his voice (wet, gurgling, or hoarse voice)
- Retaining food in his mouth or throat
- Resisting being fed too quickly
- Refusing to open his mouth or accept large bites of food.

Another sign of a serious problem is unexplained weight loss, even when your loved one is eating.

If you see signs that your loved one may be losing the ability to swallow, or continues to lose weight even when he is eating, consult with his doctor.