As a carer you will want to make sure that the person for whom you are caring eats a healthy, well balanced diet. Depending on the individual and the progress of the dementia, mealtimes can be pleasant, with the person thoroughly enjoying the food or they may be extremely stressful times for both of you.
If there is a problem, these notes may help you to find possible causes and remedies:
Possible physical factors
The progress of the disease: The disease cannot be cured, so you will have to help the person more and more at meal times.
Over-eating or an insatiable appetite: can also be a symptom of the disease.
Try giving as many as six small meals a day, rather than three large meals.
Give healthy snacks such as fresh fruit (cut into pieces), raisins and dried fruit.
You might have to lock away foods that the person tends to eat too much of, or that are fattening.
Do not leave the person alone in a room with food unless it is for her/him.
Try to distract the person with activities, walks etc.
The appetite may also be because the person has forgotten that s/he has just eaten. Try to distract the person but if that doesn’t work, give a healthy snack.
On the other hand, the person may just forget to eat or even hide away the food that has been given. If the person lives alone, this would be time to consider other living arrangements.
Chronic illness: can make people feel generally weak and too tired to feed themselves. This might happen only now and again, when you can give the person something light to eat. If this continues, however, it may be necessary to take the person to the doctor or clinic.
Generally feeling unwell, is ill or has an infection: Having looked after the person, you will soon know when s/he is not well. Take the temperature, although elderly people sometimes do not have a high temperature, even though they are ill. If possible, smell the urine and check its colour. If the urine smells like fish or has an abnormal smell and looks cloudy (not clear), the person most likely has a urinary tract infection, which will need medication, and you should give plenty of fluids.
Pain: If a person can’t tell you that s/he is in pain, a good indication is to watch the face and hands. When in pain, people usually pull a face and hold the painful area. If the cause of the pain is unknown, it will be necessary to take her/him to the doctor.
Dry mouth: is commonly caused by medication, especially psychiatric medication, and makes both chewing and swallowing almost impossible. Do not serve food that is dry and ensure that there is always water available during meals.
Sores in the mouth, cavities in the teeth: check the mouth and if necessary take the person to the dentist.
Ill-fitting dentures: take the person to the dentist.
Cannot see what s/he is eating because of changes in vision/cataracts: watch the person walk. Does s/he tend to walk slowly and hold onto things? Does the person look very closely at things? When last were the person’s eyes tested? If sight is a problem, it’s a good idea to visit the optician.
Side-effects of medication e.g. difficulty in swallowing, drowsy, too tired to eat: when last was the medication reviewed? Has the medication been changed or is s/he on new medication? Sometimes, new medication can make the mouth dry, but this might improve. The side effect might also be a stiff jaw or difficulty in swallowing. If you suspect that medication is the cause, it will be necessary to take the person to the doctor.
Does not feel hungry: There are times when we do not feel like eating but this feeling does not last and, by the next meal, we are ready to eat. Let the person eat as little as s/he wants. If the person is still not eating at the next meal there could be another reason. Don’t wait for mealtimes – allow the person to eat when s/he becomes hungry.
If the person is under-eating, try giving a glass of juice, wine or sherry (if alcohol is permitted) before the meal. This might make the person feel hungry.
Tempt her/him with milkshakes, egg flips, ice cream or a favourite pudding such as bread- or rice pudding.
Make sure the person is getting enough exercise to help increase the appetite.
Prepare favourite foods
Use supplement drinks such as Ensure, Complan, Sustagen, etc
If feeding the person, try to give all or most of one food on the plate before moving on to the next. Maybe the sudden change in texture and flavour is confusing
Mix ice cream in with the other foods if this will encourage the person to eat
Make sure the person is in a comfortable position, as upright as possible. Do not stand. Sit at the same level as the person.
Check with the doctor about the use of vitamin supplements and any weight loss.
Constipated: When last did the person pass a stool? Two bowel movements or fewer per week is considered constipated. Try natural remedies first such as prune juice, raisins, figs and boiled beetroot, before buying something to treat the constipation.
Jaw muscles not working properly/chewing problems: This is noticeable if the person has trouble chewing or even opening her/his mouth. The doctor or a speech therapist can confirm if this is a problem and tell you the best way to serve the food (e.g. semi-solid or liquidised) or to use substitute feeds such as Ensure. You can try the following:
- Make sure the person is in a comfortable position, as upright as possible. Do not stand. Sit at the same level as the person
- Avoid sticky food such as bananas, peanut butter and white bread
- Avoid food that has a tough skin
- Moisten the food with gravy or a sauce
- Serve chopped, soft foods such as scrambled eggs, cottage cheese, yoghurt, chopped chicken, mashed potatoes and gravy. Avoid ‘loose’ food such as rice, which is difficult to control in the mouth and tends to ‘hide in corners’ and get under dentures
- Offer small bites, one at a time
- Try light pressure on the lips or under the chin to get the chewing going
- Tell the person to “Chew now” and “Swallow now”
- Demonstrate the chewing motion
Decrease in sense of smell and/or taste: this may be due to medication side effects or ageing. Try adding flavour to the food with more salt or different spices. Provide bottled sauces such as tomato, Worcester, barbecue etc at meals. It may be necessary to remove them once a choice has been made, if the person is likely to use them repeatedly.
Depression: is a psychiatric illness and needs to be treated. One of the symptoms can be over- or under-eating. Once the person is on medication, the appetite should return to normal.
Tendency to choke and general difficulty in swallowing: The person might not want to eat in case s/he chokes, which is frightening for both of you. Do not give foods that are hard to chew e.g. popcorn, nuts and raw vegetables.
Water is more difficult to swallow than thicker fluids. Try giving milkshakes, egg flips and the thicker fruit juices such as apricot juice.
Soft porridge, preferably served with milk for added nutrition, is also easier to swallow.
Serve liquids at room temperature (unless the person likes warm drinks). Prepare food that is easy to chew. Moisten the food with gravy. Offer small bites, one at a time, and allow plenty of time between each bite. Remind the person to swallow. Check the mouth now and again for food stored in the cheeks.
Cravings: for both salty and sugary snacks. Some medication can cause cravings, e.g. antidepressant medication can cause a craving for sweet things. In this case, try to give healthy sweet or salty foods.
Forgetting what to do next: The person might forget what the next move should be, what the cutlery is used for, or what to do with the food in front of her/him. These moments can be most frightening for that person. Remain calm and show what the next move should be. You may even have to guide the food to the person’s mouth.
Possible emotional factors
Fear and anxiety: is experienced as the person cannot tell you what s/he wants, or is scared of choking or embarrassing her/himself in front of others.
Keep telling the person that s/he is not a nuisance.
Do not rush her/him.
Let the person eat alone, if s/he wants. If in a care facility, seat the person at a table with others who have similar problems.
If s/he does make a mess or spill, say that it is alright and do not make a fuss.
Upset from change in routine: People with dementia need routine. Keep to a regular mealtime schedule. There may be times when you have to change the routine. If so, give warning that you are going to do so, say why you are doing it and what you are going to do. The person might still feel fed up but will accept it more easily if told.
Not given choice: Life is about choice. As far as possible let the person choose when, where, what and how to eat.
Rushed by others: Do not rush her/him. Give enough time to eat the meal. Make it enjoyable for both of you by using it as your time together.
Boredom: Encourage the person to help lay the table and even prepare the food, to some extent.
Sit with the person while s/he eats.
Play music that s/he enjoys.
Maybe the person is bored with the food – try some new recipes or another way of preparing it.
Wants to feed self: Encouraging them to do things for themselves is important when caring for people with dementia. You will, however, have to accept their changing table manners and likes and dislikes. They will be less frustrated if you make it easy for them to feed themselves. It does not matter if they are slow, make a mess or spill. It is more important that they are feeding themselves. Praise them for managing to do so.
Use bowls and cups that are larger than the portion of food, to prevent spilling
Use bowls rather than plates
Put out only the cutlery the person needs
Put one course at a time on the table, to prevent confusion
Use bowls and plates of different colours to the place mat or tablecloth, to help the person see the plate
Use coloured bowls to help the person see the food more easily
Use plates with suction cups on the bottom, or put a damp cloth under the plate, to prevent it from sliding
Do not use plastic utensils as they are too light and may break in the person’s mouth
Bendable straws and cups with lids or spouts may also be useful
Use mugs for soup and stew but use the ones with two handles that are large enough for the person to have a good grip
Get a plate guard that clips onto the side of the plate, preventing the food from being pushed off
Large rubber handles can be bought to cover the handles of cutlery, making it easier to hold and control. A length of rubber tubing can also be cut for this purpose
Serve ‘finger foods’ such as chips, cheese cubes, and pieces of chicken, fresh fruits, vegetables, or small sandwiches. These finger foods are also ideal if the person does not like to sit down to a full meal but prefers to ‘snack’.
Does not like the food: Maybe the person does not like the taste, look or smell of the food. Maybe this is not what s/he wants.
Here we first go back to ‘choices’. Make the food look as attractive as possible. Do not mix the food together. If it is necessary to feed the person, feed one or two items of food at a time and say what is on the spoon or fork.
Serve it with an appetising liquid drink.
Try new and different foods, new recipes.
Responding to your mood: Maybe you are not in a good mood that day, or are worried or sad about something. A person with dementia can pick up moods very easily. If possible, explain why you are feeling as you are.
Too many demands: The person might feel anxious at having been given too many tasks or instructions at once.
If you do need to give instructions, give them one at a time, and let the person finish one thing before going on to the next.
Being asked too many questions: Some carers can make the mistake of trying to talk or be friendly by asking the person questions. Because of poor memory, these questions will only make the person feel anxious and frustrated.
Possible environmental factors
Create a calm, relaxed, friendly environment.
Too much stimulation/activity: Maybe there is too much noise, or movement of people such as in a restaurant, or people leaving and returning to the table. Maybe the music is too loud or not according to the person’s taste and it is irritating.
Not enough stimulation: Could be a boring environment with no music or conversation
Nothing appears to be familiar: People with dementia like familiarity; it goes hand-in-hand with routine. Change the environment and the person becomes anxious.
If you are not eating in the usual place, try to keep the immediate environment as familiar as possible, for instance by using the person’s own placemat, cutlery and crockery.
Sudden noises or movements: can be disturbing.
Too many people: As with too much activity, having too much conversation around the table can be most confusing.
Room temperature uncomfortable: might be too hot or cold.
- If you are worried that the problem is physical, a speech therapist will be able to assist you as they also deal with swallowing disorders. The Department of Speech Pathology and Audiology at the University of the Witwatersrand, tel 011 717 4577, may be able to conduct an assessment and advise you.
- Phone the association of speech therapists, who will give you the names of private speech therapists in your area.
- Visit the Independent Living Centre – phone 011 482 5474 or 021 555 2881 – for useful items such as rubber handles for utensils, plate guards and non-slip place mats.
It is important that you contact the doctor or clinic if you believe that the eating problem could be the result of a physical problem