Mental health can be a nutritional problem

Eat and drink enough despite dementia

In the full clinical picture of dementia, different regions of the brain are affected. There are local and situational orientation disorders, psychomotor restlessness, anxiety, language disorders and disorders in the course of standard situations. The patient can no longer interpret feelings such as hunger and thirst (8). The situation at the table is no longer understood, food is no longer recognized as such.


Cognitive disorders can mean that people with dementia have “no time” to eat because they are busy with other things. He is also very easily distracted. The handling of cutlery is forgotten; Knife and fork are sometimes even perceived as threatening. In general, the psychological pace slows down: the sick have difficulty adjusting to new situations, such as a meal. The day-night rhythm is often disturbed (9).


In the further course there are swallowing disorders. In the late stages of Alzheimer's disease, chewing and swallowing are no longer possible because the brain centers that coordinate and control these highly complex processes are destroyed (10).


Alien smell and taste


When eating and drinking, food is perceived with many senses: smell, taste and the feeling of consistency and temperature. Only all this together results in the typical taste. The volatile components of the food get into the nasal and throat areas through the air we breathe, where they bind to specific odor receptors. The stimuli are passed on to the limbic system. In this way, sensations of smell and emotions are brought together.


With increasing age, the olfactory nerves degenerate and the transmission of sensory stimuli is more difficult. The threshold values ​​for individual substances change to different degrees. Since the aroma of a food is composed of many fragrance components, this leads to considerable changes in the perception of smell. These disorders occur in the early stages of dementia and go far beyond the physiological changes in age (10).


The sense of taste remains much longer compared to the sense of smell, but the subjective taste quality changes greatly due to the impairment of smell. This means: For people with dementia, the food looks the same as it used to, but it may taste completely different. This can cause irritation and a feeling of alienation. In addition, there is a considerable loss of quality of life, which can promote malnutrition and malnutrition.


Frequently increased energy requirements


Stereotypical movements such as wiping, moving furniture, standing up, sitting down, screaming and moaning consume a lot of energy. Measurements in a nursing home have shown that restless patients walk around the facility for up to 8 km a day (11). Due to restlessness and mobility, the energy requirement of an Alzheimer's patient can be 3000 to 4000 kcal per day, almost twice as high as that of a healthy peer (8, 13).


In principle, the same dietary recommendations apply to people with dementia as to healthy older people, but the energy supply requires special attention. The trick is to find the required calories and nutrients in small portions, because concentration is often not enough for long meals, especially since it is slower than on healthy days anyway. As a result, food that is dense in terms of energy and nutrients should be offered: full fat instead of lean dairy products, liver sausage instead of salmon ham or double cream cheese instead of cottage cheese. The addition of cream or butter not only increases the energy supply, but also intensifies the taste, which is known to be conveyed via fats. Processed cheese, mascarpone, sugar and syrup also provide plenty of calories. Strong seasoning and appetizing arrangement encourage the desire to eat (8).


In order to ensure an optimal supply of all important nutrients, a varied diet should be aimed for. However, this is sometimes difficult because of the changed taste preferences. The aversion to sour, salty and bitter foods is typical. In contrast, there is a high preference for sweet and very sweet dishes. You can also try to taste savory dishes such as goulash, minced meat or fish sweet, for example with honey, cinnamon and sugar, applesauce or vanilla sauce. A sausage or cheese bread can also be coated with turnip tops or jam (14).


If the required amount of energy and nutrients cannot be ensured through normal food, drinking foods can compensate for the deficits (examples Clinutren®, Fortimel®, Fresubin®). However, they should not be offered with meals as they reduce the appetite for the "real" food. They are recommended, for example, as a late meal or between meals. Since a meal in a tetrapak or in a plastic bottle can irritate people with dementia, it should be served in a familiar container. There are also energy and nutrient concentrates that you stir into conventional dishes (for example caloreenTM, Clinutren® Additions, protein concentrate Fresenius).


Design meals


Meals are important for structuring the day for people with dementia as well as for healthy people. If possible, they should take place in a relaxed atmosphere, with plenty of time and in peace. Then eating and drinking can be a highlight of the day even for people with dementia. It is important that they eat with appetite and joy.


Fixed rituals that provide orientation are helpful. Since people with dementia often do not feel hungry, it can be useful to draw attention to the meal by means of noises (gong, rattling plates) or smells (14). Intense smells arouse appetite and interest: freshly ground and boiled coffee, bread in the bread maker, fresh toast or fried bacon. Some nursing homes take this into account by making the final preparation steps for a meal in the dining room (11).


A pleasant preparation ritual is the serving of an aperitif such as liqueur, sweet sherry or pepsin wine. This also has the positive effect of stimulating the appetite and digestion. If grace has been a lifelong habit of a person, it should be retained, even if it may no longer be understood and only serves as an impulse to start the meal.


Visual and perceptual disorders require good lighting in the dining room and clear color contrasts between dishes, tablecloths and dishes (8, 13). If the patient is neither hungry nor hungry, or recognizing the food, colors and shapes can at least arouse interest.


Familiar and desired dishes are more important than "healthy" food. You should also be pragmatic and flexible with regard to the number and composition of meals. The focus is on the patient's abilities and needs.


Sticking to three main meals does not make sense if the patient refuses to do so. Why not offer a hearty hot breakfast and then just four small meals? For many, breakfast is the most important meal of the day because they are still fit and in good mental health in the morning. In the evening, the ability to concentrate is often exhausted and eating becomes more difficult. For people with very nocturnal dementia, a nocturnal snack between meals can be welcome and have a calming effect.


Food and drinks must not be too hot, as many sick people do not see rising steam or a hot cup as a warning signal and are therefore easily burned. Since moderate heat is usually perceived as beneficial, it can help to warm up juices, desserts or cakes.


The consistency of the food is also important. Nuts in desserts or mushrooms in sauce can cause confusion or even be perceived as a threat (13).


Eating together helps


Meals with people with dementia are often challenging and sometimes stressful for healthy people. Perhaps it helps to see the time of eating or feeding together as a therapeutic time in which the patient is stimulated physically, sensory, emotionally and socially and thus encouraged (14).


The table should be set for everyone present so as not to unsettle the patient (13). Everyone should sit down together and start eating. It can make sense to put the spoon or fork in the patient's hand and initiate the movement by carefully guiding the arm. It is usually beneficial if the caregiver sits across from the patient, makes frequent eye contact and communicates with him predominantly non-verbally. For example, licking your fingers, smacking your lips with pleasure or rolling your eyes signals the delicious taste of the food and arouses the patient's interest.


Since attempts at persuasion create irritable moods, people with dementia should not be asked whether they would like to eat or drink this or that. Filling up the plate, handing out a drink or a bite to eat is more skillful, accompanied by idioms like “It tastes delicious! Try it! ”Or“ We haven't eaten that in a long time ”. Positive words and sentences that instill confidence are useful, for example: "Bon appetit!", "Very good!", "We'll have a good time!" Or "As with nuts" (13).


In the case of advanced disease, the person eating with you often has a role model function. So that the patient does not forget the course of action when eating, he needs a counterpart whose behavior he can imitate. It is important to closely observe the patient's gestures, to synchronize movements with him and not to disturb him by abrupt changes. The patient must concentrate strongly in such situations and must not be distracted by questions, loud noises or parallel actions.


If he refuses the meal or ends the meal after a few bites, you shouldn't exert any pressure, but try again in five to ten minutes with the same or a different dish. If the patient is unlikely to recognize the caregiver, it is important to awaken their memories with familiar smells (perfume, deodorant spray) and endearing words.


When feeding, the food should, if possible, be administered by guiding the patient's hand (arm) in order to trigger the opening of the mouth reflexively. The caregiver should sit next to him. If you refuse to open your mouth, smearing a tasty liquid on your lips will often help. If people with dementia forget to swallow, they can be stimulated by brushing their throat. The thumb and forefinger touch the skin of the neck on both sides of the esophagus with light pressure (12, 13).


Note the eating biography


Everyone associates formative memories with certain foods, dishes and smells. They arouse feelings of well-being, security or a festive mood. But traumatic experiences can also wake up. People who suffer from dementia today have mostly experienced war and times of need. Certain foods such as "good" butter, wheat groats or potatoes are particularly important to them. You may also be concerned that the food will not be enough if the servings are small. Conversely, a full plate can trigger the fear of not being able to pay for the meal (9, 14).


The defining phase of the eating biography is usually, but not always, childhood. Knowing the eating and drinking biography is important in order to be able to offer people familiar and pleasant dishes and to be able to structure the course of the meal in a simple manner. Sayings like "There is enough for everyone!" Or "Today everything is free" can encourage people to eat.


Food and drink can appeal to emotions and build a bridge to past life. Perhaps a memory of beautiful experiences can be awakened and the patient can feel like the person he used to be for a while (9). If he can no longer provide any information himself, you could ask family members or friends of the same age:


Did the sick person live in the country or in the city earlier?

Was there a hot or cold dinner?

What did you drink with your meal?

What was there on Sundays or on holidays?

What did he particularly like as a child?

What were his culinary delights as an adult?

Were aperitifs common?

How did you celebrate yourself?

Has he experienced famine?