M

illie was everyone's favorite patient. Her Alzheimer's disease didn't prevent her from asking every person she encountered, "How are you today?" She must have asked this question over 100 times every day as she circled the nursing home. From the moment she awoke, she would walk through the east wing into the west wing, through the dining room, and back into the east wing. She followed the same circular path--around and around and around--for hours each day. Millie was a very happy and friendly patient...until mealtime arrived. Trying to coax Millie to sit in the dining room and await her meal tray was quite a challenge. It was an argument that usually ended in frustration for all involved. And it also usually ended before Millie consumed enough calories to fuel all that walking.

Alzheimer's Disease and Dementia
       Alzheimer's disease (AD) is a progressive, ultimately fatal disorder in which certain types of nerve cells in particular areas of the brain degenerate and die for unknown reasons.1 According to the Alzheimer's Association, about half of all nursing home residents suffer from AD or a similar disorder. Other terms often used to describe this clinically complex loss of memory and judgment and personality changes include dementia and senile dementia of the Alzheimer's type (SDAT). Dementia is actually an umbrella term used to describe a variety of diseases that cause a decline in thinking,2 one of which is AD. Although the progression of AD will vary from patient to patient, it usually has early, mid, and late stages. As the stage of the disease advances, the clinical complications also follow a progressively worsening course. Eating and feeding difficulties are often present by mid stage and pose a risk of malnutrition and dehydration unless addressed effectively. Since there is no cure for AD and dementia, the treatment of nutritional problems focuses on prompt symptom management.

The Dining Environment
       The environment for eating should be as simple as possible and minimize distractions. Residents with AD often are confused and may become distracted very easily, so it is best to clear the clutter and keep the table settings basic. Patterned tablecloths and placemats should be removed. Noise should be minimized, and the television should be off to allow concentration on the meal. If soothing music calms the patient, it can be played during meals, but this is an individual preference. Mirrors can often be confusing as can lighting that produces many shadows. Steps should be taken to remove these items. The resident should be seated at the same seat for each meal in order to develop a routine.

Communicating During Meals
       Verbal cues, praise, and mimic techniques may all be utilized to encourage proper meal intake. Verbal cues may include reminding the patient to lift the eating utensil, to chew, and to swallow. These patients often chew and chew and chew but forget to swallow. Cues to "swallow now" and "take another bite" may help to encourage better meal consumption. Praise for following the cues and eating well serve to reinforce the behavior and make the meal more pleasant. Often patients may forget the physical action needed to eat, so it may be useful to act out lifting the fork to the mouth and then to demonstrate a chewing motion. Hand-over-hand techniques are also valuable in prompting the desired action. Communication during meals is an important nutrition strategy and should be done with patience and gentleness.

Dealing with Behavioral Problems
       AD often causes personality changes and may bring on disruptive mealtime behaviors, such as spitting food, throwing food, screaming, agitation, repetitive questions, delusions, and eating nonedible items. These behaviors may disrupt others in the dining room, so it is imperative to manage these problems immediately. If a patient spits or throws food, it is best to seat him off to the side or in the corner of the dining room. Screaming can be a sign of pain or anxiety, so it is important to look for clues as to what triggers this behavior. Perhaps the dining room was very busy and noisy, or it appeared crowded because of mirrors and shadows cast by the lighting. Identification and removal of triggers may help to minimize these types of behaviors. Even though it might be more difficult for some patients to dine with the others, it is very important that the healthcare team continue to encourage socialization. Without regular interaction with others, withdrawal and isolation may occur. Music therapy or light chair exercises are two techniques that may help curb disruptive behaviors.3 Eating nonedible items can be a safety problem, so all toothpicks, doilies, centerpieces, inedible fruit peels, napkins, and food packages should be removed from the dining area and meal tray.

Pacing and Wandering
       Excessive pacing can increase caloric needs, so it is important to serve nutrient-dense foods. If it is difficult to get the patient to remain in the dining room for an extended period of time, have the tray completely set up before seating the patient. Finger foods are a common intervention for patients who refuse to remain seated but are willing to eat on the go. Finger foods also are helpful for patients who can no longer manage utensils. Table 1 illustrates finger food substitutions for regular menu items. Foods that can be kept in a pocket or purse can provide extra calories between meals. Nursing stations can stock finger foods and hand them to the patient as they pass by. The use of a variety of medical nutrition supplements, such as Ensure (Ross Products, Columbus, Ohio) or Boost (Mead Johnson Nutritionals, Evansville, Indiana), can provide extra calories between meals as well.

Chewing and Swallowing Problems
       Many patients with AD suffer from swallowing disorders, such as dysphagia. Swallowing problems may also be the result of dental problems or simply a fear of swallowing.
       Dental problems, such as cavities, gingivitis, or tooth sensitivity, warrant a dental consultation. Maligned dentures are also often the cause of chewing and swallowing problems, in which case a refitting is necessary. A consultation with a speech-language pathologist (SLP) should be obtained in order to provide the proper diet consistency. Both food and fluids can be modified to provide the safest texture to minimize aspiration. Food texture modifications include pureed, ground, chopped, and soft. A speech therapist and registered dietitian (RD) can individualize the diet prescription in order to provide the optimal diet for each patient. Fluids can range from a nectar consistency to a pudding consistency. Often, thin liquids are difficult to swallow, because they do not form a cohesive bolus that the tongue can manipulate and position properly for swallowing. For this reason, the use of a straw in beverages is often restricted for patients with AD. Many commercial products are available to thicken beverages. Foods that do not have a consistent texture should also be avoided for the same reason. These foods include cottage cheese, dry cereal with milk, and chunky soups. Many different techniques are available to overcome swallowing problems, such as stroking the side of the throat to elicit a swallowing response, tucking the chin, and proper seating position. The SLP can provide detailed education for the patient, family members, and staff on these compensatory strategies.

End-of-Life Issues
       Unfortunately, despite the very best efforts to keep our patients well nourished, many with AD still suffer from involuntary weight loss as the disease reaches its end stage. The decision on whether to utilize tube feedings is a very personal decision that requires careful consideration. Discussions about nutrition support should be held before it becomes a medical necessity or emergent situation. Thorough documentation in the medical record of the patient and family wishes should be completed. The debate on the use and effectiveness of tube feedings in end-stage diseases continues not only from an ethical standpoint but also from a medical standpoint. Frank discussions of all the evidence, both pro and con, are warranted in a caring atmosphere. The next issue of ECPN will examine the evidence on both sides of this important discussion.

The Team Approach
       A multidisciplinary team of healthcare professionals must work together in order to assure the best nutritional outcomes for patients with AD. At a minimum, this team includes the RD, the occupational therapist, the speech therapist, the activity coordinator, the social worker, the nursing staff, the pharmacist, the physician, and the patient and family. Only with patience, understanding, compassion, and a little creativity in removing the barriers to good meal intake will we be successful in maintaining adequate nutritional parameters for as long as possible. With proper planning and open communication, hopefully, we will be better prepared for the end stages of this fatal disease. There are many more ideas, solutions, and support groups available on the internet. Table 2 lists several resources that are available to keep this discussion ongoing.