Expert: Mary Gordon - 11/1/2011

Question
Mary Gordon: I'd welcome your suggestions and pointers re encouraging my wife (85, 2 years into an AD diagnosis) to eat more. Her appetite, never robust, has declined greatly in the last month. Her daily consumption is now not much more than an Ensure, a couple of glasses of orange juice, and an occasional cookie. She will take a spoonful of mashed potato (or anything else I serve) and then say she doesn't want anymore.

Thanks. (Please excuse me if this issue has already been addressed here. I have not been able to see how one <searches> previous posts by topic. If that can be done, I'd be glad to learn how.)

Answer
Hi S.

Weight loss is very common as Alzheimer's progresses. You should be weighing her regularly and keeping track so you can discuss this with her doctor. Obviously, you don't want her to get too thin and weak as this will increase her susceptibility to illness, and make her prone to falls.

It is always worth checking to make sure there is no obvious underlying health problem and to see if the doctor can steer you to specialist resources to help get more calories into her. A consultation with a dietician and a speech pathologist might be helpful. Speech pathologists are specialists in assessing "dysphagia", which are the swallowing and chewing problems common with neurological damage. A dietician might be able to review her diet and come up with ideas and products that could be helpful. The doctor will also be able to check to see if any medications might be killing her appetite, or if there are medications that might make her hungrier.  

As Alzheimers progresses, it is common for decreases in appetite to occur.  Coordination difficulties cause problems in using utensils and in eating. People with dementia often don't seem to feel hunger or thirst like a healthy person -or if they do feel these sensations, perhaps 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. Loss of sense of smell, means everything tastes like cardboard. Most people will retain the ability to taste sweet things, so adding sweeteners can sometimes make food more attractive to her.  

Some suggestions include
- maintaining as much physical activity as you can for her 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 six small meals can keep the weight on better than larger meals three times a day
- eating with her - sometimes seeing someone else eating can get the person eating themselves,
- preparing familiar and favourite foods - if she has particular things she loves and will eat, let her have it as often as you can. There is no reason she can't eat a particular food a dozen times a week. She won't get tired of it because she won't necessarily recall she's had it often.  
- think creatively. If she will eat more at particular times of the day, such as at breakfast, perhaps first thing in the morning is the time to give her substantial foods like meat and potatoes. Think calories and nutrition first, and convention second.
- precut meat or finger foods as necessary, and make sure the textures of food are appropriate for her. She may need food in a soft or pureed form. She may have trouble with textured or chewy food, or food with mixed textures such as crunchy cereals with liquid milk.
- let her get the food into herself any way that works - for example, let her eat with his hands, or drink soup in a cup - whatever will get it into her.
- give her 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 (she may need to be prompted to chew and swallow or actually hand 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. I'd avoid juice or other sugary liquids.
- 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 she has lots of time to eat (it can be very time consuming to get food into them)
- try to minimize distractions - for example, my mother in law would not eat much in a bustling dining hall, since she kept getting distracted from eating by all the noise and activity. It was as though she would forget she'd been halfway through her meal. She did much better sitting quietly in a private location with just one or two people, where we could keep her focussed on her food longer.
- try and keep things calm, relaxed and pleasant at meal time, since she will pick up on a tense atmosphere and it can make things worse.
- check out various products to see if you can substitute a higher calorie or high nutrition version for a "regular" version, such as an energy bar instead of a cookie.
- keep her sitting up after meals for half an hour after meals  to make sure she has fully swallowed everything.  

Hope this helps. I know this is very challenging. You sound like a very kind, caring husband.

Mary G.