Friday, July 9, 2010

How to manage Alzheimer’s patient who refuses to eat?

What should be done when a patient refuses to eat? What does this behavior mean? We will review on what can be done by the caregivers to improve the situation in relation to the Alzheimer’s patients.  

Dementia progress

Functional Assessment Staging (FAST) scale is used to determine dementia progression. Patients progressing through the various stages will ultimately reach the point when they refuse food and fluids. In addition to helping clinicians determine the progression of a patient’s dementia, the FAST scale also helps you understand certain behaviors, such as refusing to eat, that patients exhibit. Let’s look at the scale again:
*Levels 1–5: Patient experiences increasing forgetfulness, inability to perform complex tasks, and needs assistance with dressing.
*Level 6: Patient needs help with bathing and toileting, and is unable to control bladder or bowels.
*Level 7: Patient experiences inability to form intelligent speech, inability to ambulate without assistance, and requires total care.

For clinicians, determining the cause of the problem should be paramount. Does the patient have difficulty chewing or swallowing due to the disease process? Does the patient pocket or spit out food or have problems with aspiration? Are there other medical problems developing such as infection or constipation? This detective work is necessary to determine whether the patient’s loss of interest in food is caused by advanced depression or an inability to interpret the sensation of hunger.

Families become very distressed when their loved one refuses to eat. Our instincts tell us to provide nutrition to people who are ill. Food is symbolic of life and of love and of caring. But when a patient reaches the final stages of dementia, the body can no longer metabolize food, and food can stay in the digestive tract, causing nausea and vomiting. Certain food (especially meat) may not taste or smell good and may be difficult to chew. This is an expected progression, usually seen in the final stage of the FAST. Ultimately, the patient may prefer only liquids, and then nothing at all. When the patient is nearing the end of life, allowing him or her to refuse food is one of the hardest decisions facing families and clinicians, but it is the kindest thing we can do.

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Families need to refocus on what is really happening in advanced dementia. The Alzheimer’s Association provides wonderful resources to help families cope with and understand the changes they observe, particularly about eating. Providing adequate food and fluids during the various stages can be especially challenging to the family and the caregiver. Offering small meals that contain soft, sweet and cold foods seems to appeal to these patients. Ultimately, the disease process itself leads to reduced food and fluid intake partly due to declining perceptions of smell and taste, the inability to feed oneself, and feelings of loss of control and depression. Further, patients “may refuse to eat because of physiological or behavioral conditions, or they do so because they are at the end of life.”

While having the non-resolvable problems with eating disorder close at the end of life of the Alzheimer’s patient cannot be address, unless artificial nutrition applied, the problem is manageable on the most stages of the AD.  

General guidelines

  • Talk to the doctor. Sometimes poor appetite is due to depression, which can be treated. Your loved one also may be suffering from a treatable disorder—such as heartburn, constipation, diarrhea, nausea, or sore mouth—that may be affecting his or her eating.
  • Monitor medications. Some medications interfere with appetite. Read about the side effects of any medications that the Alzheimer's patient is taking. Discuss with the doctor the lack of interest in eating; you may need to change a medication. Make sure that the person gets enough liquids with their food, as dry mouth may be a side-effect of some medications.
  • Don't force feed. Try to encourage the person to eat, and try to find out why he or she doesn't want to eat (not hungry, the food is cold or doesn't taste good, etc.).
  •  If the Alzheimer's patient does not like the person who is feeding them, they may not feel like eating. Try a different caretaker for the feeding process.
  • Try giving the patient little spoonfuls, and sing short, funny rhymes to get them to eat. Get the person to smile so that the mouth opens, and then slip a little food in their mouth. Or put a bit of the food on the person’s lips so that they open their mouth wider. But, remember to treat the person as an adult, not a child. Don't punish the person for not eating.
  • Serve small, frequent meals and snacks.
  • Walking or participating in other light activities can help stimulate the appetite. Even a simple exercise can make a person feel hungrier: The hungrier the person feels, the more likely they are to eat.
  • Consider finger foods that are easy to handle and eat.
  • Adaptive equipment, such as plate guards or silverware with specially designed handles, is available for individuals who have difficulty holding or using utensils.
  • Monitor chewing and swallowing. Chewing and swallowing difficulties can develop as Alzheimer's progresses. If necessary, give instructions on when to chew and when to swallow. Keep the person upright for thirty minutes after eating so that they don’t choke.

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Meal guidelines

  • Serve beverages after a meal instead of before or during a meal so that the person does not feel full before starting to eat.
  • Plan meals to include favorite foods.
  • Use your imagination to increase the variety of food you're serving. Prepare meals that offer different textures, colors, and temperatures.
  • Reduce distractions in the eating area.
  • Avoid foods that are too hot or too cold, as these may be unpleasant to the patient.

Snack guidelines

  • Don't waste your energy preparing foods that provide little or no nutritional value (such as potato chips, candy bars, sodas, and other snack foods).
  • Choose high-protein and high-calorie snacks.
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Dining guidelines

  • Make food preparation an easy task: Choose foods that are easy to prepare and eat.
  • Make eating a pleasurable experience, not a chore: Liven up meals by using colorful place settings; play background music during meals.
  • Use colorful garnishes such as parsley and red or yellow peppers to make food look more appealing and appetizing.
Later Stages Feeding

In the later stages of Alzheimer's, the person can no longer swallow food and may choke on food. Swallowing problems can lead to pneumonia because the patient may inhale food or liquid into the lungs.

Begin feeding only liquids to the patient when the time is right - In the later stages of Alzheimer’s, the person can no longer process solid foods.

At the end stage of Alzheimer’s or another terminal illness, the patient’s organ systems begin to shut down and the lack of desire to eat or drink is the usual result. In the final days or hours, starvation or dehydration are not a problem and not a cause of suffering

Sources and Additional Information:
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