OLDER PEOPLE AND NUTRITION
Dementia and its relationship with food Stephanie Ragdale
Stephanie Ragdale, Admiral Nurse, Central Manchester, Manchester Mental Health and Social Care Trust Email: [email protected]
T
here are currently about 800 000 people in the UK with dementia. With the ageing population this is set to rise to 1.7 million people by 2051 (Alzheimer’s Society, 2013a). A report produced by Alzheimer’s Disease International (Prince et al, 2014) highlighted that while malnutrition is common in people with dementia (20–45% of people with dementia living in the community will experience clinically significant weight loss in the course of 1 year), the reasons for this are not yet fully understood—although it is known that malnutrition is avoidable.
Nutrition in the elderly
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While the physiology of the large and small intestines is largely unaffected by age, functions of other gastrointestinal processes do deteriorate (D’Souza, 2007). For example, a reduction in the sense of smell and taste can lead to malnutrition due to these senses playing an important role in the choice of food (Nigam and Knight, 2008). Nutritional status in the elderly is also affected by psychosocial factors, such as isolation, heavy use of medication and lengthy hospital stays (Brownie, 2006). Dementia can further reduce nutritional intake as a result of the behavioural and physical symptoms of the disease (Hargreaves, 2008). It is worth noting that there are certain mineral deficiencies that can mimic dementia symptoms, such as a lack of vitamin B12, so, once treated, the symptoms will abate (Sutcliffe, 2001). A study conducted by Clarke et al (2004) found the prevalence of vitamin B12 deficiency to be about 1 in 20 among people aged 65–74 years and 1 in 10 or even greater among people aged 75 years and above. Holley (2013) acknowledges that signs and symptoms may not be evident in mild-tomoderate cases of malnutrition. With this in mind, current recommendations suggesting early intervention for those at risk (Wilkinson and McLeod, 2008) are very relevant.
What is dementia? Dementia is a syndrome—a collection of related symptoms that affect the brain. These may include loss of memory, language difficulties, altered judgement, periods of confusion and changes in mood and personality (NHS Choices, 2014). Dementia is the result of lost connections in the brain through illness or injury (Wayne et al, 2014).
Nutrition, July 2014
It involves a loss of brain cells, and while we all lose these as we get older, in dementia it is catastrophic (Sutcliffe, 2001). While dementia is commonly linked to older age, it does not solely affect older people, neither is it predestined (Kennard, 2005). National Institute of Health and Care Excellence (NICE) and Social Care Institute for Excellence (SCIE) (2007) identify that the experience of the diagnosis of dementia is challenging, not only for the person diagnosed with dementia, but also family members and health-care professionals. Many carers find that their own health suffers due to the social isolation and physical and emotional stress that caring for someone with dementia can cause (Wood and Watson, 2000). Alzheimer’s Society (2014) acknowledge that a Mediterranean diet rich in unsaturated fatty acids and consisting of a high intake of cereals, fruits, fish, legumes and vegetables lowers the health risks associated with vascular dementia and increases levels of protein in the brain, which protect neurones from the oxidative damage associated with Alzheimer’s disease. Eggs and oily fish are high in vitamin D, which may also reduce the risk of developing dementia (Alzheimer’s Society, 2012).
Types of dementia There are over 100 diseases that come under the umbrella of dementia (Alzheimer’s Australia, 2014). The most common forms of dementia are Alzheimer’s disease, vascular dementia, dementia with Lewy bodies and frontotemporal dementia (Alzheimer’s Disease International,
Abstract
This article provides an overview of dementia and how it relates to nutrition. It examines the evidence for food and nutrition preventing, causing and treating dementia. The article highlights how malnutrition can affect the individual with dementia. The remainder of the article provides an in-depth, focused discussion on the difficulties people may experience in the community in relation to food and eating and the impact this has on family caregivers, with recommendations for achieving optimum nutrition.
KEY WORDS
w Dementia w Nutrition w Carer w Treatment w Eating
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OLDER PEOPLE AND NUTRITION
Disease progression and nutrition Knott and Kenny (2012) emphasise that the speed of progression varies greatly from person to person and also depends on the type of dementia. Alzheimer’s Society (2013a) highlights that, during the course of Alzheimer’s, the chemistry and structure of the brain changes. Early symptoms include lapses in memory and word-finding difficulties. Those with Alzheimer’s generally show a steady decline during the course of their illness (Sutcliffe, 2001). Vascular dementia can have a sudden onset, such as after a stroke, or over time, following a series of small strokes, which causes damage to the brain (Sutcliffe, 2001). Symptoms may be similar to those in Alzheimer’s disease; however, people will also experience difficulty concentrating and communicating and they can feel depressed and anxious (Alzheimer’s Society, 2013a). Unlike Alzheimer’s, the disease may progress in a stepped manner (Alzheimer’s Society, 2011). It is interesting to note that people with front temporal dementia are prone to experience excessive eating and other changes to eating behaviour, such as changes in dietary preference and obsession with particular foods (Alzheimer’s Society, 2013b). With regard to maintaining nutrition, Stanner (2007) identifies that, initially, people with dementia may become less able to shop, cook and prepare food. As the disease progresses, they may lose their ability to eat independently. The Alzheimer’s Society (2013a) highlights that there are currently almost 36 million people worldwide with dementia, with 6 million of those living in Europe and 800 000 living in the UK. The number of people with a diagnosis in the UK who are under 65 stands at 17 000. There are an estimated 670 000 family care-givers in the UK for people with dementia (Alzheimer’s Society, 2012). Keys et al (1986) identified that there was a lower incidence of death related to coronary heart disease in southern European populations, which tend to have a diet low in unsaturated fats. This prompted ongoing research into the benefits of a Mediterranean diet in the prevention of dementia (Alzheimer’s Society, 2014). Prince et al (2014) identify that there is moderate evidence suggesting a positive link between following a Mediterranean diet and a lower risk of dementia. Luchsinger and Mayeux (2004) highlight that very few epidemiological studies have explored the link between nutrients, diet and Alzheimer’s disease, and any findings are inconsistent. However, Barnes and Yaffe (2011) conducted a review that concluded that up to half of all cases of Alzheimer’s disease (and possibly other dementias) may be attributed to potentially modifiable risk factors, including diabetes, hypertension and obesity. These are recognised as diet-related illnesses (Weininger, 2013).
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Treatment Currently, dementia is incurable, and the focus of pharmacological intervention is to delay progression and improve symptoms (Qaseem at al, 2008). It is also important to prevent further damage through the modification of risk factors such as treating high blood pressure, high cholesterol, type 1 diabetes and smoking cessation, while psychological therapies can also help people to cope with symptoms (NHS Choices, 2013).
Vitamins, supplements and dementia Studies have been conducted into the use of vitamins, antioxidants, fatty acids and flavonoids in the treatment of dementia (Engelhart et al, 2002; Dionisi and Calder, 2011; Williams and Spencer, 2012). According to Laditka et al (2012), 15 million Americans use dietary supplements for cognitive health. However, Prince et al (2014) concluded that the evidence verifying a link between micro and macro nutrients and cognitive functioning is insufficient. NICE and SCIE (2007) developed guidelines stipulating that, for middle-aged and older people, vascular and other modifiable risk factors for dementia should be reviewed and treated if appropriate. However, they specify that statins and vitamin E should not be prescribed as specific treatments for the primary prevention of dementia (NICE and SCIE, 2007).
Impact of poor nutrition on quality of life in dementia Everyday life can be difficult for people with dementia (Sutcliffe, 2001). Undernourishment can increase confusion and irritability (Crawley and Hocking, 2011), and a loss of appetite can be very distressing (Lee, 2002). This is also the case for carers of people with dementia, who can find the person’s association with food frustrating and upsetting (Carers UK, 2012). It can leave carers feeling helpless as it appears to be a sign of the inevitable progress of the disease (Lee, 2002). Battison (2004) advises carers that a nutritionally balanced diet may improve listlessness in their relative. While gaining weight will not slow the progress of the disease, it is beneficial as it can alleviate distress (Lee, 2002). People who are poorly nourished become sick more often, and recovery from illness and injury is slower (Alzheimer’s Australia, 2014). It is important to remember that dementia may mask the symptoms of the physical illness (Hope and Pitt, 1998). The unwell are also more likely to have weaker muscles, which could result in poor coordination, making the person less physically able (Crawley and Hocking, 2011). The five main groups of nutrients as identified in Thomas et al (2006) (proteins, carbohydrates, fats, vitamins and minerals) are particularly pertinent to the older person as they promote maintenance and repair of tissue, maintain a healthy gut and support the body’s immune system. Adequate nutrition in all types of dementia may improve
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2014), with Alzheimer’s disease accounting for 62% of all diagnoses (Alzheimer’s Society, 2013b). It is also possible to have mixed dementia, where both Alzheimer’s disease and vascular dementia are present (Alzheimer’s Society, 2013c).
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OLDER PEOPLE AND NUTRITION
physical wellbeing, maximise a person’s functioning and improve their quality of life (Gray, 1989).
Difficulties and solutions in relation to maintaining good nutrition in dementia The UK Database of Uncertainties about the Effects of Treatments (2013) has highlighted that there is a lack of systematic reviews looking at the most effective ways to encourage people with dementia to eat, drink and maintain nutritional intake. This is difficult to comprehend when a study conducted in America found that, over an 18 month period, 85.8% of residents in a nursing home with advanced dementia developed an eating problem (Mitchell et al, 2009). In the early stages of dementia, nutritional risks may be more safety focused—such as the ability of the person to navigate their way to the shops, prepare and cook the food without coming to harm using utensils and the safe storage of food. When addressing these issues it is important not to ‘take over’, which could result in the person feeling undermined (Battison, 2004).
Weight gain Alzheimer’s Society (2013b) acknowledge that weight loss in dementia is far more common than weight gain. However, the person with dementia may forget they have eaten recently as well as eating inappropriate foods. Suggestions for tackling this issue include providing activity to ensure the person is not bored or lonely, reducing isolation through a day centre or luncheon club and encouraging snacking on fruit and vegetables rather than cakes, biscuits and confectionary (Alzheimer’s Society, 2013b). Crawley and Hocking (2011) agree with this guidance, but they also advise that it is important to keep weight issues in perspective, as intervention could be counterproductive if the person eats well, is active and their weight is stable. Being underweight in old age poses a far greater risk to health than being overweight (Caroline Walker Trust, 2004).
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Weight loss Hargreaves (2008) reports the biggest factor in weight loss as a combination of reduced calorie intake and increased energy expenditure due to the numerous symptoms of dementia. People with dementia who wander around can expend large amounts of energy during the day (Stanner, 2007). In this instance it is advisable to keep snacks handy which can be ‘nibbled at will’ (Battison, 2004). Snacks can have the advantage of providing stimulation for those displaying stress-related behaviours (Bonner, 2005).
Assessment For family carers, nutrition can be monitored simply through the use of food diaries (Bonner, 2005), regular weight checks (Thomas et al, 2006) or by calculating the person’s body mass index (BMI) (Crawley and Hocking,
Nutrition, July 2014
2011). It is recognised that it is not always easy to obtain the accurate height measurement required for calculating BMI in older people. Therefore, cut-off weights to indicate that a person is underweight are 57kg or below for men and 50kg or below for women (Crawley and Hocking, 2011). In general, if there is concern that a person is underweight, opinion should be sought from the GP (Crawley and Hocking, 2011). SCIE (2009) highlight that preventative, low-level support in the community and an awareness of nutritional needs by health and social care staff is essential. This is achievable through screening and assessment. The Malnutrition Universal Screening Tool (MUST) is a valid, reliable and easy-to-use tool (BAPEN, 2012) that is suitable for use in the community setting (Caroline Walker Trust, 2004). It is also important to rule out medical conditions that may be contributing to weight loss (Caroline Walker Trust, 2004) and ensure medication is not contributing to a reduced appetite (Crawley and Hocking, 2011).
Fortified diets Fortifying the diet is a beneficial way of increasing weight in someone who has lost their appetite (Caroline Walker Trust, 2004). This can be achieved simply through adding high-calorie ingredients such as full-fat milk, cream, cheese, butter, oil, mayonnaise and yoghurt to meals (Crawley and Hocking, 2011). For example, a single tablespoon of double cream can add an extra 80kcal. Caroline Walker Trust (2004) highlight the importance of ensuring the diet is balanced in all nutrients and not just high in calories. Drinks should also be nutritious, such as milky drinks, fresh fruit juices and smoothies (Caroline Walker Trust, 2004). Brotherton et al (2012) highlight the importance of optimising oral intake through ‘food first’ and advise that oral nutritional supplements be used in addition to the normal diet under dietetic supervision. There is strong evidence that oral nutritional supplementation is effective in increasing weight (Prince et al, 2014).
Environment Watson (2002) states that the influence of the environment cannot be emphasised enough. It is recommended that it should be free from excessive stimulation and traditional eating habits should be followed. This may include saying a blessing and eating meals at certain times (Bonner, 2005). Providing clear visual and sensory cues can reduce disorientation through embedding information as to the function of the dining space (Prince et al, 2014). Presentation of the food is also important: it needs to be appetising in amount, colour, taste and smell (Caroline Walker Trust, 2004).
Feeding difficulties Watson (2002) identifies one aspect that may cause weight loss as the inability to eat—whether this is through physical disability or loss of intention to eat. Feeding difficulties
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OLDER PEOPLE AND NUTRITION
Table 1. Common difficulties with eating and drinking in dementia and tips for encouraging increased nutritional intake Possible cause Depression Reduced appetite
Forgetting to eat Physical discomfort
Recommendation
Offer small portions regularly throughout the day Provide nourishing and fortified foods e.g. soup with added cream Eliminate medical causes e.g. constipation Encourage exercise to increase appetite
Reduced interest in food/ refusal
Holding food in the mouth or coughing/ choking on oral intake
Eats very slowly
Plays with food Lacks ability to use utensils/ spills food
Change in taste preference
Serve sweet sauces with main meals
Becoming easily distracted
Cook with herbs and spices
Lack of recognition of hunger
Offer additional snacks
Reduce environmental distractions Consider changing mealtimes
Dysphagia is a difficulty commonly encountered which causes significant distress to both carers and patients (Hargreaves, 2008). There are very few studies identifying the incidence and prevalence of dysphagia in individuals with dementia however the consequences of this can be dehydration, malnutrition, weight loss and aspiration pneumonia (Easterling and Robbins, 2008). Tanton (2010) recommends quick identification of feeding and swallowing difficulties and prompt referrals to speech and language therapy for detailed swallowing assessment.
Feeding skills and techniques Physical discomfort
Eliminate medical causes e.g. ill fitting dentures or sore mouth
Swallowing difficulties
Prompt to chew and swallow, stroke the cheek Transition to soft or pureed foods
Forgetting to eat Slowed processing skills
Prompt and, if necessary, assist Allow extra time Use plate warmers to keep food warm Serve one course/item of food at a time
Inability to recognise the food or what to do with it
Use contrasting coloured plates to make food easier to see
Reduced coordination
Use protective clothing and table coverings
Forgetting how to use cutlery
Serve one course/item of food at a time to avoid confusion
Use adapted crockery and cutlery e.g. high rimmed plates and built up cutlery Offer finger foods
can be major care issues, especially in the later stages of dementia (Bonner, 2005) (Table 1).
Promoting independence Being assisted to eat can lead to a loss of self esteem and a sense of powerlessness (Crawley and Hocking, 2011).
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Dysphagia
Feeding a person can be an emotional experience due to the social, psychological and emotional elements attached to food (Hargreaves, 2008) and family carers require reassurance in understanding how to support the person to eat and drink well (Carers UK, 2012). Helping someone to eat must be treated sensitively (Crawley and Hocking, 2011). It should not be assumed that family caregivers are equipped with the knowledge and skills required (Prince et al, 2014) (Box 1).
Conclusion The prevalence of dementia is set to rise, and with the impact this has on the individual with regard to nutrition, further evidence on the mechanisms behind this is required. The nutritional status of the elderly can be impaired, and this is further affected by dementia. There are many types of dementia, and while it is not the only risk factor, our relationship with food throughout our lives may increase the risk of developing certain types of dementia. The speed and progression of dementia varies from person to person and between dementia types. However, at some stage the ability for an individual to maintain their own nutritional needs may decline. While dementia is, at this time, incurable, there is evidence to suggest that certain dietary choices may improve cognitive functioning. Weight loss is a feature of dementia, but with correct identification and intervention it can be controlled. Early involvement on the behalf of the care professional is important, as is support and guidance for the family care-giver to enable the person with dementia to live well. BJCN Alzheimer’s Association, New York City Chapter (2009) Eating and nutrition. http://tinyurl.com/o273zuu (accessed 7 April 2014) Alzheimer’s Australia (2014) Types of dementia. http://tinyurl.com/pc3mrbe
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Difficulty
People should not be robbed of their retained feeding abilities. This can be avoided through tailoring assistance to compensate only for deficiencies (Bonner, 2005), which can be achieved through prompting, placing cutlery into the individual’s hands and offering assistance, possibly by cutting up food (Hargreaves, 2008). Prince et al (2014) identifies that whilst assistive tableware is available these items can lack aesthetic appeal. However they can be essential for helping people to eat independently (Crawley and Hocking, 2011).
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OLDER PEOPLE AND NUTRITION
(accessed 3 March 2014) Alzheimer’s Disease International (2014) Types of dementia. http://tinyurl.com/ nj8zw2c (accessed 3 March 2014) Alzheimer’s Society (2011) The progression of Alzheimer’s disease and other dementias. http://tinyurl.com/3je6uab (accessed 11 March 2014) Alzheimer’s Society (2012) Am I at risk of developing dementia? http://tinyurl. com/8njgj3t (accessed 1 March 2014) Alzheimer’s Society (2013a) Dementia 2013 The Hidden Voice of Loneliness. http:// tinyurl.com/n39jxzx (accessed 13 February 2014) Alzheimer’s Society (2013b) Eating and drinking. http://tinyurl.com/pz7olnm (accessed 12 March 2014) Alzheimer’s Society (2013c) Types of dementia. http://tinyurl.com/kgg4v2v (accessed 3 March 2014) Alzheimer’s Society (2014) The science behind the headlines: how to reduce your risk and other popular topics. http://tinyurl.com/ojscosr (accessed 11 March 2014) BAPEN (2012) The ‘MUST’ Report. Malnutrition Advisory Group, Redditch Barnes E, Yaffe K (2011) The projected impact of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol 10(9): 819–28. doi: 10.1016/ S1474-4422(11)70072-2 Barnet and Chase Farm Hospitals (2009) Feeding issues and dementia. Leaflet, Dietetic Department. http://tinyurl.com/nq577dy (accessed 9 June 2014) Battison T (2004) Caring for Someone with Memory Loss. Age Concern England, London Bonner C (2005) Reducing Stress-related Behaviours in People with Dementia. Jessica Kingsley, London Brotherton A, Holdoway A, Mason P, McGregor I, Parsons, Pryke R (2012) Managing Adult Malnutrition in the Community. http://tinyurl.com/o9a2rgq (accessed 13 March 2014) Brownie S (2006) Why are elderly individuals at risk of nutritional deficiency? Int J Nurs Pract 12(2): 110–18 Carers UK (2012) Dementia and nutrition. http://tinyurl.com/l3plgyr (accessed 13 February 2014) Caroline Walker Trust (2004) Eating Well for Older People. Wordworks, London Clarke R, Grimley Evans J, Schneede J et al (2004) Vitamin B12 and folate deficiency in later life. Age Ageing 33(1): 34–41 Crawley H, Hocking E (2011) Eating Well: Supporting Older People and Older People with Dementia. http://tinyurl.com/khzozgy (accessed 3 June 2014) Dionisi F, Calder PC (2011) Omega 3 fatty acids for the treatment of dementia and cognitive impairment (Protocol). Cochrane Database Syst Rev 2011(2): CD009002. doi/10.1002/14651858.CD009002/full D’Souza AL (2007) Ageing and the gut. Postgrad Med J 83(975): 44–53. doi: 10.1136/pgmj.2006.049361 Easterling CS, Robbins E (2008) Dementia and dysphagia. Geriatr Nurs 29(4): 275–85. doi: 10.1016/j.gerinurse.2007.10.015 Engelhart MJ, Geerlings MI, Ruitenberg A et al (2002) Dietary intake of antioxidants and risk of Alzheimer’s disease. JAMA 287(24): 3223–9 Gray G (1989) Nutrition and dementia. J Am Diet Assoc 89(12): 1795–1802 Hargreaves T (2008) Nutritional issues for people with dementia. Nurs Residential Care 10(3): 118–22 Holley C (2013) What are the signs and symptoms of malnutrition? http://tinyurl.com/mn93xeb (accessed 9 April 2014) Hope T, Pitt B (1998) Management of dementia. In Butler R, Pitt B, eds. Seminars in Old Age Psychiatry. The Royal College of Psychiatrists, London: 87–101 Kennard C (2005) Is dementia age related? http://tinyurl.com/kxdvnqy (accessed 1 March 2014) Keys A, Mienotti A, Karvonen MJ et al (1986) The diet and 15-year death rate in the seven countries study. Am J Epidemiol 124(6): 903–15 Knott L, Kenny T (2012) Memory loss and dementia. http://tinyurl.com/ nw9tkml (accessed 11 March 2014) Laditka JN, Laditka SB, Tait EM, Tsulukidze MM (2012) Use of dietary supplements for cognitive health: results of a national survey of adults in the United States. Am J Alzheimer’s Dis Other Demen 27(1): 55-64. doi: 10.1177/1533317511435662 Lee E (2002) In your Own Time: A Guide for Patients and their Carers facing a Lasting Illness at Home. Oxford University Press, Oxford Luchsinger JA, Mayeux R (2004) Dietary factors and Alzheimer’s disease. Lancet 3(10): 579–87 Mitchell SL, Teno JM, Kiely DK et al (2009) The clinical course of advanced dementia. New Engl J Med 381(16): 1529–38. doi: 10.1056/NEJMoa0902234 NHS Choices (2013) About dementia. http://tinyurl.com/m8fhr9x (accessed 1 March 2014) NHS Choices (2013) How is dementia treated? http://tinyurl.com/noy2pjk (accessed 10 March 2014) NHS Grampian (2012) Dementia Care: Support with Eating and Drinking. NHS Lanarkshire. http://tinyurl.com/ldd4wgf (accessed 9 June 2014) National Institute for Health and Care Excellence (NICE), Social Care Institute for Excellence (SCIE) (2007) Dementia: A NICE–SCIE Guideline on Supporting People with Dementia and their Carers in Health and Social Care. The British Psychological Society, Leicester. http://tinyurl.com/kxjzryt (accessed 3 June 2014) Nigam Y, Knight J (2008) Exploring the anatomy and physiology of ageing: 3— the digestive system. Nurs Times 104(33): 22–3 Prince, M, Albanese, E, Guerchet M, Prina M (2014) Nutrition and Dementia: A
Nutrition, July 2014
Box 1. Techniques for helping someone to eat w Make sure glasses, dentures and hearing aids are being used w The person being assisted should be in an upright position w Sit at eye level of the person being helped and immediately in front of them, maintaining eye contact
w Offer bitesize amounts w Allow time for the person to swallow between mouthfuls w Use verbal prompts in a gentle tone, e.g. ‘open your mouth’, ‘chew’ or ‘swallow’
w Consider a person’s likes and dislikes w Take time
Review of Available Research. Alzheimer’s Disease International, London Qaseem A, Snow S, Cross T Jr et al (2008) Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 148(5): 370–8 Social Care Institute for Excellence (2009) Nutritional Care and Hydration. http:// tinyurl.com/peef9u7 (accessed 3 June 2014) Stanner S (2007) Older people with dementia: eating and drinking healthily. Nurs Residential Care 9(1): 18–21 Sutcliffe D (2001) Introducing Dementia. Age Concern England, London Tanton M (2010) Developing a screening tool and training package to identify dysphagia in all settings. Nurs Times 106(15): 18–20 Thomas S, Mengham H, Cooper J et al (2006) Eating for Health in Care Homes, 2nd edn. The Royal Institute of Public Health, London UK Database of Uncertainties about the Effects of Treatments (2013) What are the most effective ways to encourage people with dementia to eat, drink and maintain nutritional intake? http://tinyurl.com/nyqujpm (accessed 13 February 2014) Watson R (2002) Eating difficulty in older people with dementia. Nurs Older People 14(3): 21–26 Wayne M, White M, Smith M (2014) Understanding dementia: signs, symptoms, types and treatment. http://tinyurl.com/6aqkyu (accessed 1 March 2014) Weininger J (2013) Nutritional disease. http://tinyurl.com/khxl6pp (accessed 12 April 2014) Wilkinson T, Macleod S (2008) Strategies to improve nutrition in elderly people. Best Practice Journal 15: 8–15 Williams RJ, Spencer JPE (2012) Flavonoids, cognition, and dementia: actions, mechanisms, and potential therapeutic utility for Alzheimer disease. Free Radic Biol Med 52(1): 35–45 Wood J, Watson P (2000) Working with Family Carers. Age Concern England, London
KEY POINTS
w Identify those at risk of malnutrition w Support individuals to make healthy lifestyle choices in order to reduce the risk of dementia
w Promote balanced diets in those living with dementia to improve their quality of life
w Work collaboratively with dietitians, speech and language therapists and GPs to improve and maintain nutritional status
w Provide family caregivers with information and reassurance in order to increase their confidence
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Dementia and its relationship with food Stephanie Ragdale
Stephanie Ragdale, Admiral Nurse, Central Manchester, Manchester Mental Health and Social Care Trust Email: [email protected]
T
here are currently about 800 000 people in the UK with dementia. With the ageing population this is set to rise to 1.7 million people by 2051 (Alzheimer’s Society, 2013a). A report produced by Alzheimer’s Disease International (Prince et al, 2014) highlighted that while malnutrition is common in people with dementia (20–45% of people with dementia living in the community will experience clinically significant weight loss in the course of 1 year), the reasons for this are not yet fully understood—although it is known that malnutrition is avoidable.
Nutrition in the elderly
© 2014 MA Healthcare Ltd
While the physiology of the large and small intestines is largely unaffected by age, functions of other gastrointestinal processes do deteriorate (D’Souza, 2007). For example, a reduction in the sense of smell and taste can lead to malnutrition due to these senses playing an important role in the choice of food (Nigam and Knight, 2008). Nutritional status in the elderly is also affected by psychosocial factors, such as isolation, heavy use of medication and lengthy hospital stays (Brownie, 2006). Dementia can further reduce nutritional intake as a result of the behavioural and physical symptoms of the disease (Hargreaves, 2008). It is worth noting that there are certain mineral deficiencies that can mimic dementia symptoms, such as a lack of vitamin B12, so, once treated, the symptoms will abate (Sutcliffe, 2001). A study conducted by Clarke et al (2004) found the prevalence of vitamin B12 deficiency to be about 1 in 20 among people aged 65–74 years and 1 in 10 or even greater among people aged 75 years and above. Holley (2013) acknowledges that signs and symptoms may not be evident in mild-tomoderate cases of malnutrition. With this in mind, current recommendations suggesting early intervention for those at risk (Wilkinson and McLeod, 2008) are very relevant.
What is dementia? Dementia is a syndrome—a collection of related symptoms that affect the brain. These may include loss of memory, language difficulties, altered judgement, periods of confusion and changes in mood and personality (NHS Choices, 2014). Dementia is the result of lost connections in the brain through illness or injury (Wayne et al, 2014).
Nutrition, July 2014
It involves a loss of brain cells, and while we all lose these as we get older, in dementia it is catastrophic (Sutcliffe, 2001). While dementia is commonly linked to older age, it does not solely affect older people, neither is it predestined (Kennard, 2005). National Institute of Health and Care Excellence (NICE) and Social Care Institute for Excellence (SCIE) (2007) identify that the experience of the diagnosis of dementia is challenging, not only for the person diagnosed with dementia, but also family members and health-care professionals. Many carers find that their own health suffers due to the social isolation and physical and emotional stress that caring for someone with dementia can cause (Wood and Watson, 2000). Alzheimer’s Society (2014) acknowledge that a Mediterranean diet rich in unsaturated fatty acids and consisting of a high intake of cereals, fruits, fish, legumes and vegetables lowers the health risks associated with vascular dementia and increases levels of protein in the brain, which protect neurones from the oxidative damage associated with Alzheimer’s disease. Eggs and oily fish are high in vitamin D, which may also reduce the risk of developing dementia (Alzheimer’s Society, 2012).
Types of dementia There are over 100 diseases that come under the umbrella of dementia (Alzheimer’s Australia, 2014). The most common forms of dementia are Alzheimer’s disease, vascular dementia, dementia with Lewy bodies and frontotemporal dementia (Alzheimer’s Disease International,
Abstract
This article provides an overview of dementia and how it relates to nutrition. It examines the evidence for food and nutrition preventing, causing and treating dementia. The article highlights how malnutrition can affect the individual with dementia. The remainder of the article provides an in-depth, focused discussion on the difficulties people may experience in the community in relation to food and eating and the impact this has on family caregivers, with recommendations for achieving optimum nutrition.
KEY WORDS
w Dementia w Nutrition w Carer w Treatment w Eating
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OLDER PEOPLE AND NUTRITION
Disease progression and nutrition Knott and Kenny (2012) emphasise that the speed of progression varies greatly from person to person and also depends on the type of dementia. Alzheimer’s Society (2013a) highlights that, during the course of Alzheimer’s, the chemistry and structure of the brain changes. Early symptoms include lapses in memory and word-finding difficulties. Those with Alzheimer’s generally show a steady decline during the course of their illness (Sutcliffe, 2001). Vascular dementia can have a sudden onset, such as after a stroke, or over time, following a series of small strokes, which causes damage to the brain (Sutcliffe, 2001). Symptoms may be similar to those in Alzheimer’s disease; however, people will also experience difficulty concentrating and communicating and they can feel depressed and anxious (Alzheimer’s Society, 2013a). Unlike Alzheimer’s, the disease may progress in a stepped manner (Alzheimer’s Society, 2011). It is interesting to note that people with front temporal dementia are prone to experience excessive eating and other changes to eating behaviour, such as changes in dietary preference and obsession with particular foods (Alzheimer’s Society, 2013b). With regard to maintaining nutrition, Stanner (2007) identifies that, initially, people with dementia may become less able to shop, cook and prepare food. As the disease progresses, they may lose their ability to eat independently. The Alzheimer’s Society (2013a) highlights that there are currently almost 36 million people worldwide with dementia, with 6 million of those living in Europe and 800 000 living in the UK. The number of people with a diagnosis in the UK who are under 65 stands at 17 000. There are an estimated 670 000 family care-givers in the UK for people with dementia (Alzheimer’s Society, 2012). Keys et al (1986) identified that there was a lower incidence of death related to coronary heart disease in southern European populations, which tend to have a diet low in unsaturated fats. This prompted ongoing research into the benefits of a Mediterranean diet in the prevention of dementia (Alzheimer’s Society, 2014). Prince et al (2014) identify that there is moderate evidence suggesting a positive link between following a Mediterranean diet and a lower risk of dementia. Luchsinger and Mayeux (2004) highlight that very few epidemiological studies have explored the link between nutrients, diet and Alzheimer’s disease, and any findings are inconsistent. However, Barnes and Yaffe (2011) conducted a review that concluded that up to half of all cases of Alzheimer’s disease (and possibly other dementias) may be attributed to potentially modifiable risk factors, including diabetes, hypertension and obesity. These are recognised as diet-related illnesses (Weininger, 2013).
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Treatment Currently, dementia is incurable, and the focus of pharmacological intervention is to delay progression and improve symptoms (Qaseem at al, 2008). It is also important to prevent further damage through the modification of risk factors such as treating high blood pressure, high cholesterol, type 1 diabetes and smoking cessation, while psychological therapies can also help people to cope with symptoms (NHS Choices, 2013).
Vitamins, supplements and dementia Studies have been conducted into the use of vitamins, antioxidants, fatty acids and flavonoids in the treatment of dementia (Engelhart et al, 2002; Dionisi and Calder, 2011; Williams and Spencer, 2012). According to Laditka et al (2012), 15 million Americans use dietary supplements for cognitive health. However, Prince et al (2014) concluded that the evidence verifying a link between micro and macro nutrients and cognitive functioning is insufficient. NICE and SCIE (2007) developed guidelines stipulating that, for middle-aged and older people, vascular and other modifiable risk factors for dementia should be reviewed and treated if appropriate. However, they specify that statins and vitamin E should not be prescribed as specific treatments for the primary prevention of dementia (NICE and SCIE, 2007).
Impact of poor nutrition on quality of life in dementia Everyday life can be difficult for people with dementia (Sutcliffe, 2001). Undernourishment can increase confusion and irritability (Crawley and Hocking, 2011), and a loss of appetite can be very distressing (Lee, 2002). This is also the case for carers of people with dementia, who can find the person’s association with food frustrating and upsetting (Carers UK, 2012). It can leave carers feeling helpless as it appears to be a sign of the inevitable progress of the disease (Lee, 2002). Battison (2004) advises carers that a nutritionally balanced diet may improve listlessness in their relative. While gaining weight will not slow the progress of the disease, it is beneficial as it can alleviate distress (Lee, 2002). People who are poorly nourished become sick more often, and recovery from illness and injury is slower (Alzheimer’s Australia, 2014). It is important to remember that dementia may mask the symptoms of the physical illness (Hope and Pitt, 1998). The unwell are also more likely to have weaker muscles, which could result in poor coordination, making the person less physically able (Crawley and Hocking, 2011). The five main groups of nutrients as identified in Thomas et al (2006) (proteins, carbohydrates, fats, vitamins and minerals) are particularly pertinent to the older person as they promote maintenance and repair of tissue, maintain a healthy gut and support the body’s immune system. Adequate nutrition in all types of dementia may improve
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2014), with Alzheimer’s disease accounting for 62% of all diagnoses (Alzheimer’s Society, 2013b). It is also possible to have mixed dementia, where both Alzheimer’s disease and vascular dementia are present (Alzheimer’s Society, 2013c).
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physical wellbeing, maximise a person’s functioning and improve their quality of life (Gray, 1989).
Difficulties and solutions in relation to maintaining good nutrition in dementia The UK Database of Uncertainties about the Effects of Treatments (2013) has highlighted that there is a lack of systematic reviews looking at the most effective ways to encourage people with dementia to eat, drink and maintain nutritional intake. This is difficult to comprehend when a study conducted in America found that, over an 18 month period, 85.8% of residents in a nursing home with advanced dementia developed an eating problem (Mitchell et al, 2009). In the early stages of dementia, nutritional risks may be more safety focused—such as the ability of the person to navigate their way to the shops, prepare and cook the food without coming to harm using utensils and the safe storage of food. When addressing these issues it is important not to ‘take over’, which could result in the person feeling undermined (Battison, 2004).
Weight gain Alzheimer’s Society (2013b) acknowledge that weight loss in dementia is far more common than weight gain. However, the person with dementia may forget they have eaten recently as well as eating inappropriate foods. Suggestions for tackling this issue include providing activity to ensure the person is not bored or lonely, reducing isolation through a day centre or luncheon club and encouraging snacking on fruit and vegetables rather than cakes, biscuits and confectionary (Alzheimer’s Society, 2013b). Crawley and Hocking (2011) agree with this guidance, but they also advise that it is important to keep weight issues in perspective, as intervention could be counterproductive if the person eats well, is active and their weight is stable. Being underweight in old age poses a far greater risk to health than being overweight (Caroline Walker Trust, 2004).
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Weight loss Hargreaves (2008) reports the biggest factor in weight loss as a combination of reduced calorie intake and increased energy expenditure due to the numerous symptoms of dementia. People with dementia who wander around can expend large amounts of energy during the day (Stanner, 2007). In this instance it is advisable to keep snacks handy which can be ‘nibbled at will’ (Battison, 2004). Snacks can have the advantage of providing stimulation for those displaying stress-related behaviours (Bonner, 2005).
Assessment For family carers, nutrition can be monitored simply through the use of food diaries (Bonner, 2005), regular weight checks (Thomas et al, 2006) or by calculating the person’s body mass index (BMI) (Crawley and Hocking,
Nutrition, July 2014
2011). It is recognised that it is not always easy to obtain the accurate height measurement required for calculating BMI in older people. Therefore, cut-off weights to indicate that a person is underweight are 57kg or below for men and 50kg or below for women (Crawley and Hocking, 2011). In general, if there is concern that a person is underweight, opinion should be sought from the GP (Crawley and Hocking, 2011). SCIE (2009) highlight that preventative, low-level support in the community and an awareness of nutritional needs by health and social care staff is essential. This is achievable through screening and assessment. The Malnutrition Universal Screening Tool (MUST) is a valid, reliable and easy-to-use tool (BAPEN, 2012) that is suitable for use in the community setting (Caroline Walker Trust, 2004). It is also important to rule out medical conditions that may be contributing to weight loss (Caroline Walker Trust, 2004) and ensure medication is not contributing to a reduced appetite (Crawley and Hocking, 2011).
Fortified diets Fortifying the diet is a beneficial way of increasing weight in someone who has lost their appetite (Caroline Walker Trust, 2004). This can be achieved simply through adding high-calorie ingredients such as full-fat milk, cream, cheese, butter, oil, mayonnaise and yoghurt to meals (Crawley and Hocking, 2011). For example, a single tablespoon of double cream can add an extra 80kcal. Caroline Walker Trust (2004) highlight the importance of ensuring the diet is balanced in all nutrients and not just high in calories. Drinks should also be nutritious, such as milky drinks, fresh fruit juices and smoothies (Caroline Walker Trust, 2004). Brotherton et al (2012) highlight the importance of optimising oral intake through ‘food first’ and advise that oral nutritional supplements be used in addition to the normal diet under dietetic supervision. There is strong evidence that oral nutritional supplementation is effective in increasing weight (Prince et al, 2014).
Environment Watson (2002) states that the influence of the environment cannot be emphasised enough. It is recommended that it should be free from excessive stimulation and traditional eating habits should be followed. This may include saying a blessing and eating meals at certain times (Bonner, 2005). Providing clear visual and sensory cues can reduce disorientation through embedding information as to the function of the dining space (Prince et al, 2014). Presentation of the food is also important: it needs to be appetising in amount, colour, taste and smell (Caroline Walker Trust, 2004).
Feeding difficulties Watson (2002) identifies one aspect that may cause weight loss as the inability to eat—whether this is through physical disability or loss of intention to eat. Feeding difficulties
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OLDER PEOPLE AND NUTRITION
Table 1. Common difficulties with eating and drinking in dementia and tips for encouraging increased nutritional intake Possible cause Depression Reduced appetite
Forgetting to eat Physical discomfort
Recommendation
Offer small portions regularly throughout the day Provide nourishing and fortified foods e.g. soup with added cream Eliminate medical causes e.g. constipation Encourage exercise to increase appetite
Reduced interest in food/ refusal
Holding food in the mouth or coughing/ choking on oral intake
Eats very slowly
Plays with food Lacks ability to use utensils/ spills food
Change in taste preference
Serve sweet sauces with main meals
Becoming easily distracted
Cook with herbs and spices
Lack of recognition of hunger
Offer additional snacks
Reduce environmental distractions Consider changing mealtimes
Dysphagia is a difficulty commonly encountered which causes significant distress to both carers and patients (Hargreaves, 2008). There are very few studies identifying the incidence and prevalence of dysphagia in individuals with dementia however the consequences of this can be dehydration, malnutrition, weight loss and aspiration pneumonia (Easterling and Robbins, 2008). Tanton (2010) recommends quick identification of feeding and swallowing difficulties and prompt referrals to speech and language therapy for detailed swallowing assessment.
Feeding skills and techniques Physical discomfort
Eliminate medical causes e.g. ill fitting dentures or sore mouth
Swallowing difficulties
Prompt to chew and swallow, stroke the cheek Transition to soft or pureed foods
Forgetting to eat Slowed processing skills
Prompt and, if necessary, assist Allow extra time Use plate warmers to keep food warm Serve one course/item of food at a time
Inability to recognise the food or what to do with it
Use contrasting coloured plates to make food easier to see
Reduced coordination
Use protective clothing and table coverings
Forgetting how to use cutlery
Serve one course/item of food at a time to avoid confusion
Use adapted crockery and cutlery e.g. high rimmed plates and built up cutlery Offer finger foods
can be major care issues, especially in the later stages of dementia (Bonner, 2005) (Table 1).
Promoting independence Being assisted to eat can lead to a loss of self esteem and a sense of powerlessness (Crawley and Hocking, 2011).
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Dysphagia
Feeding a person can be an emotional experience due to the social, psychological and emotional elements attached to food (Hargreaves, 2008) and family carers require reassurance in understanding how to support the person to eat and drink well (Carers UK, 2012). Helping someone to eat must be treated sensitively (Crawley and Hocking, 2011). It should not be assumed that family caregivers are equipped with the knowledge and skills required (Prince et al, 2014) (Box 1).
Conclusion The prevalence of dementia is set to rise, and with the impact this has on the individual with regard to nutrition, further evidence on the mechanisms behind this is required. The nutritional status of the elderly can be impaired, and this is further affected by dementia. There are many types of dementia, and while it is not the only risk factor, our relationship with food throughout our lives may increase the risk of developing certain types of dementia. The speed and progression of dementia varies from person to person and between dementia types. However, at some stage the ability for an individual to maintain their own nutritional needs may decline. While dementia is, at this time, incurable, there is evidence to suggest that certain dietary choices may improve cognitive functioning. Weight loss is a feature of dementia, but with correct identification and intervention it can be controlled. Early involvement on the behalf of the care professional is important, as is support and guidance for the family care-giver to enable the person with dementia to live well. BJCN Alzheimer’s Association, New York City Chapter (2009) Eating and nutrition. http://tinyurl.com/o273zuu (accessed 7 April 2014) Alzheimer’s Australia (2014) Types of dementia. http://tinyurl.com/pc3mrbe
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Difficulty
People should not be robbed of their retained feeding abilities. This can be avoided through tailoring assistance to compensate only for deficiencies (Bonner, 2005), which can be achieved through prompting, placing cutlery into the individual’s hands and offering assistance, possibly by cutting up food (Hargreaves, 2008). Prince et al (2014) identifies that whilst assistive tableware is available these items can lack aesthetic appeal. However they can be essential for helping people to eat independently (Crawley and Hocking, 2011).
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(accessed 3 March 2014) Alzheimer’s Disease International (2014) Types of dementia. http://tinyurl.com/ nj8zw2c (accessed 3 March 2014) Alzheimer’s Society (2011) The progression of Alzheimer’s disease and other dementias. http://tinyurl.com/3je6uab (accessed 11 March 2014) Alzheimer’s Society (2012) Am I at risk of developing dementia? http://tinyurl. com/8njgj3t (accessed 1 March 2014) Alzheimer’s Society (2013a) Dementia 2013 The Hidden Voice of Loneliness. http:// tinyurl.com/n39jxzx (accessed 13 February 2014) Alzheimer’s Society (2013b) Eating and drinking. http://tinyurl.com/pz7olnm (accessed 12 March 2014) Alzheimer’s Society (2013c) Types of dementia. http://tinyurl.com/kgg4v2v (accessed 3 March 2014) Alzheimer’s Society (2014) The science behind the headlines: how to reduce your risk and other popular topics. http://tinyurl.com/ojscosr (accessed 11 March 2014) BAPEN (2012) The ‘MUST’ Report. Malnutrition Advisory Group, Redditch Barnes E, Yaffe K (2011) The projected impact of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol 10(9): 819–28. doi: 10.1016/ S1474-4422(11)70072-2 Barnet and Chase Farm Hospitals (2009) Feeding issues and dementia. Leaflet, Dietetic Department. http://tinyurl.com/nq577dy (accessed 9 June 2014) Battison T (2004) Caring for Someone with Memory Loss. Age Concern England, London Bonner C (2005) Reducing Stress-related Behaviours in People with Dementia. Jessica Kingsley, London Brotherton A, Holdoway A, Mason P, McGregor I, Parsons, Pryke R (2012) Managing Adult Malnutrition in the Community. http://tinyurl.com/o9a2rgq (accessed 13 March 2014) Brownie S (2006) Why are elderly individuals at risk of nutritional deficiency? Int J Nurs Pract 12(2): 110–18 Carers UK (2012) Dementia and nutrition. http://tinyurl.com/l3plgyr (accessed 13 February 2014) Caroline Walker Trust (2004) Eating Well for Older People. Wordworks, London Clarke R, Grimley Evans J, Schneede J et al (2004) Vitamin B12 and folate deficiency in later life. Age Ageing 33(1): 34–41 Crawley H, Hocking E (2011) Eating Well: Supporting Older People and Older People with Dementia. http://tinyurl.com/khzozgy (accessed 3 June 2014) Dionisi F, Calder PC (2011) Omega 3 fatty acids for the treatment of dementia and cognitive impairment (Protocol). Cochrane Database Syst Rev 2011(2): CD009002. doi/10.1002/14651858.CD009002/full D’Souza AL (2007) Ageing and the gut. Postgrad Med J 83(975): 44–53. doi: 10.1136/pgmj.2006.049361 Easterling CS, Robbins E (2008) Dementia and dysphagia. Geriatr Nurs 29(4): 275–85. doi: 10.1016/j.gerinurse.2007.10.015 Engelhart MJ, Geerlings MI, Ruitenberg A et al (2002) Dietary intake of antioxidants and risk of Alzheimer’s disease. JAMA 287(24): 3223–9 Gray G (1989) Nutrition and dementia. J Am Diet Assoc 89(12): 1795–1802 Hargreaves T (2008) Nutritional issues for people with dementia. Nurs Residential Care 10(3): 118–22 Holley C (2013) What are the signs and symptoms of malnutrition? http://tinyurl.com/mn93xeb (accessed 9 April 2014) Hope T, Pitt B (1998) Management of dementia. In Butler R, Pitt B, eds. Seminars in Old Age Psychiatry. The Royal College of Psychiatrists, London: 87–101 Kennard C (2005) Is dementia age related? http://tinyurl.com/kxdvnqy (accessed 1 March 2014) Keys A, Mienotti A, Karvonen MJ et al (1986) The diet and 15-year death rate in the seven countries study. Am J Epidemiol 124(6): 903–15 Knott L, Kenny T (2012) Memory loss and dementia. http://tinyurl.com/ nw9tkml (accessed 11 March 2014) Laditka JN, Laditka SB, Tait EM, Tsulukidze MM (2012) Use of dietary supplements for cognitive health: results of a national survey of adults in the United States. Am J Alzheimer’s Dis Other Demen 27(1): 55-64. doi: 10.1177/1533317511435662 Lee E (2002) In your Own Time: A Guide for Patients and their Carers facing a Lasting Illness at Home. Oxford University Press, Oxford Luchsinger JA, Mayeux R (2004) Dietary factors and Alzheimer’s disease. Lancet 3(10): 579–87 Mitchell SL, Teno JM, Kiely DK et al (2009) The clinical course of advanced dementia. New Engl J Med 381(16): 1529–38. doi: 10.1056/NEJMoa0902234 NHS Choices (2013) About dementia. http://tinyurl.com/m8fhr9x (accessed 1 March 2014) NHS Choices (2013) How is dementia treated? http://tinyurl.com/noy2pjk (accessed 10 March 2014) NHS Grampian (2012) Dementia Care: Support with Eating and Drinking. NHS Lanarkshire. http://tinyurl.com/ldd4wgf (accessed 9 June 2014) National Institute for Health and Care Excellence (NICE), Social Care Institute for Excellence (SCIE) (2007) Dementia: A NICE–SCIE Guideline on Supporting People with Dementia and their Carers in Health and Social Care. The British Psychological Society, Leicester. http://tinyurl.com/kxjzryt (accessed 3 June 2014) Nigam Y, Knight J (2008) Exploring the anatomy and physiology of ageing: 3— the digestive system. Nurs Times 104(33): 22–3 Prince, M, Albanese, E, Guerchet M, Prina M (2014) Nutrition and Dementia: A
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Box 1. Techniques for helping someone to eat w Make sure glasses, dentures and hearing aids are being used w The person being assisted should be in an upright position w Sit at eye level of the person being helped and immediately in front of them, maintaining eye contact
w Offer bitesize amounts w Allow time for the person to swallow between mouthfuls w Use verbal prompts in a gentle tone, e.g. ‘open your mouth’, ‘chew’ or ‘swallow’
w Consider a person’s likes and dislikes w Take time
Review of Available Research. Alzheimer’s Disease International, London Qaseem A, Snow S, Cross T Jr et al (2008) Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 148(5): 370–8 Social Care Institute for Excellence (2009) Nutritional Care and Hydration. http:// tinyurl.com/peef9u7 (accessed 3 June 2014) Stanner S (2007) Older people with dementia: eating and drinking healthily. Nurs Residential Care 9(1): 18–21 Sutcliffe D (2001) Introducing Dementia. Age Concern England, London Tanton M (2010) Developing a screening tool and training package to identify dysphagia in all settings. Nurs Times 106(15): 18–20 Thomas S, Mengham H, Cooper J et al (2006) Eating for Health in Care Homes, 2nd edn. The Royal Institute of Public Health, London UK Database of Uncertainties about the Effects of Treatments (2013) What are the most effective ways to encourage people with dementia to eat, drink and maintain nutritional intake? http://tinyurl.com/nyqujpm (accessed 13 February 2014) Watson R (2002) Eating difficulty in older people with dementia. Nurs Older People 14(3): 21–26 Wayne M, White M, Smith M (2014) Understanding dementia: signs, symptoms, types and treatment. http://tinyurl.com/6aqkyu (accessed 1 March 2014) Weininger J (2013) Nutritional disease. http://tinyurl.com/khxl6pp (accessed 12 April 2014) Wilkinson T, Macleod S (2008) Strategies to improve nutrition in elderly people. Best Practice Journal 15: 8–15 Williams RJ, Spencer JPE (2012) Flavonoids, cognition, and dementia: actions, mechanisms, and potential therapeutic utility for Alzheimer disease. Free Radic Biol Med 52(1): 35–45 Wood J, Watson P (2000) Working with Family Carers. Age Concern England, London
KEY POINTS
w Identify those at risk of malnutrition w Support individuals to make healthy lifestyle choices in order to reduce the risk of dementia
w Promote balanced diets in those living with dementia to improve their quality of life
w Work collaboratively with dietitians, speech and language therapists and GPs to improve and maintain nutritional status
w Provide family caregivers with information and reassurance in order to increase their confidence
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