Expert: Mary Gordon - 11/12/2009

Question
Hi Mary,
My 87 year old dad has had AD for 9 years.  He does not recognize us most of the time, hardly any communication, occasionally something coherent will come out and amaze us.  He now has started grunting all the time. He is totally incontinent.  His appetite is really pretty good, he can drink but only by using a straw.  However my concern is he has started losing weight even though he eats. He is in a wheel chair due to an amputation from poor circulation.  He is down to 111 lbs.  Is this weight loss a beginning of the end?  Should we be taking him to the Dr to see if there is an underlying cause of the weight loss?  My 82 year old mother still cares for him at home-she is the most remarkable woman.  Thank you in advance for your help.

Answer
Sadly, Cindy, the weight loss is very typical in later stage Alzheimer's. It's heart breaking to see them wasting away. It is always worth checking with the doctor to make sure there is no obvious underlying health problem and to see if the doctor can steer your mother to specialist resources to help her get more calories into him.

As Alzheimers progresses, it is common for decreases in appetite to occur.  Beside loss of appetite, brain impairment also contributes to difficulties in using utensils and in chewing and swallowing. They often don't seem to feel hunger or thirst like a healthy person - or if they feel these sensations, they don't associate them with food and drink. Some of the appetite loss may be because it's common for them to lose most of their sense of smell, so food is less appealing and has less flavor.

Some suggestions include
- maintaining as much physical activity as you can for him to stimulate appetite
- providing regular meals and snacks that follow a routine (i.e. have a specific schedule with 3 meals and 3 snacks, for example).
- try more frequent smaller meals and snacks - sometimes that can keep the weight on better than larger meals three times a day
- eating with him - sometimes seeing someone else eating can get the person eating themselves,
- preparing familiar and favourite foods - if he has particular things he loves and will eat, let him have it as often as you can
- think creatively. If he will eat more at particular times of the day, such as at breakfast, perhaps first thing in the morning is the time to give them dinner foods.
- precut meat or finger foods as necessary, and make sure the textures of food are appropriate for him. He may need food in a soft or pureed form. He may have trouble with textured or chewy food, or food with mixed textures such as crunchy cereals with liquid milk.
- let him get the food into himself any way that works - for example, let him eat with his hands, or drink soup in a cup - whatever will get it into him.
- give him utensils that are easy to hold (they make spoons etc. with big grips for people who have limited fine coordination),
- as coodination deteriorates, offer direct assistance (he may need to be prompted to chew and swallow or actually fed)
- many choices of food on a plate can confuse an impaired person - try serving one part of the meal at a time (one thing at a time on a plain plate, since even a pattern can be confusing.  
- consider vitamins or food supplements (i.e. Boost, Ensure etc.) given after a meal. If these are given before a meal, they can kill appetite
- make every calorie count - if the person is drinking a lot of juice, it can kill their appetite for more nutritious fare
- add calories to food by adding cream, butter or other fats. The point is to get the calories and nutrition into them - and that is more important than cholesterol counts!
- make sure he has lots of time to eat (it can be very time consuming to get food into them)
- try and keep things calm, relaxed and pleasant at meal time, since he will pick up on a tense atmosphere and it can make things worse.
- keep him sitting up after meals for half an hour after meals  to make sure he has fully swallowed everything.  

Your mother might want to ask the doctor to send her for a consultation with a dietician and a speech pathologist to assess his diet and make suggestions. Speech pathologists are specialists in dysphagia, which are the problems with chewing and swallowing that the neurological damage causes.

Hope this helps.

Mary G.