Alzheimer´s disease (AD) can manifest in various forms, influenced by the symptoms, environment, as well as the personal circumstances of the patient. The families of patients with AD should be well organized, working as a team where each member has a certain role. This is very important, as the patient´s personality, lifestyle and family environment are critical factors that directly influence the course and behavior of the disease. Other pathogenic elements interfere in this clinical process, causing co-morbidity that complicates and shortens the lifespan, and exasperates the caretakers. A fundamental aspect in the nutritional intervention of AD is the maintenance of a healthy diet, assuring the patient eats well and varied.
Modifications of the diet in AD patients
The objective of the strategies commented below are to prevent weight loss or excess, avoid dehydration and common infectious disease (flus and colds), avoid possible bronchial-aspiration as well as the development of ulcers. It is also possible to include changes in textures, as this disease can present dysphagia due to the neuromuscular problems it presents.
It is vital to perform periodic analyses to ensure a correct nutritional state and that an adequate diet is followed (in terms of caloric intake and proteins, mainly), considering age, gender and physical activity. The use of questionnaires such as the Mini Nutritional Assessment (MNA), the Blandford scale, or the Eating Behavior Scale (EBS) seem to be the most efficient to analyze diet behavior, giving specific attention to this disease. The energetic and macronutrient intake should be the same as a healthy adult, adapting it to each individual´s needs. It is important to not forget the possibly essential role certain micronutrients can play (vitamin E, C, selenium, among others) due to their antioxidant function, supporting the immunological response of the patients.
In order for the nutrient intake to cover the daily requirements, it is necessary for the patient to strictly follow an individualized diet. Generally, the intakes should be fractioned (5-6 meals/day) in small rations, concentrated, varied (assuring vitamin and oligoelement intake) and taking in consideration the presentation of the meals.
Recommendations for the caretakers:
- It is vital to maintain adequate oral hygiene, assuring hydration and humidity in the mouth mucosa and tongue.
- To control the lack of attention while eating, prepare the dishes with bright colors such as rice with vegetables. In order to control compulsive attitudes, use small rations and diced into small pieces. To avoid food retention in the mouth, use juicy recipes or gelatins.
- If the patient is disorientated, it is necessary to implant a routine with regular meal hours and minimize distractions (i.e. do not turn on the TV while eating).
- The patients that walk around frequently can benefit from physical exercise before eating.
- If the patients are rebellious, it is necessary to identify the factors that cause the reaction in order to eliminate them. The caretaker should sit next to the patient, in a non-dominant attitude and using adequate material (unbreakable dishes and utensils, plates with a suction base and plastic utensils to avoid self-harm).
- If the patient has Sundown Syndrome (increased cognitive affection at dusk), turn on the lights before the sun goes down, bathe the patient before dinner, make lunch the largest meal of the day and perform any task that may help maintain the intakes.
- During the meals, decrease anxiety related to uncontrolled drooling or fear of choking. The patient should be seated while eating and the head placed in a correct position to favor deglutition.
- The consistency of the food should be adapted to help chewing and deglutition, avoiding fish spines, bones, hard textures and other properties that can cause choking.
- It is important to not mix foods with different textures, as the patient is not capable of identifying them.
- If there is difficulty in using utensils, prepare meals they can eat with their hands.
- Insist in drinking sufficient water, especially when choking is possible. Avoid drinking at night, and in the case of dysphagia to liquids, use thickeners.
NUTRITIONAL GUIDELINES RECOMMENDED BY ESPEN (EUROPEAN SOCIETY OF CLINICAL NUTRITION AND METABOLISM)
A group of international multidisciplinary experts have developed a series of guidelines. The GRADE system was used to assign the level of scientific evidence, and the final guidelines were accepted after performing a survey to the ESPEN members (European Society of Clinical Nutrition and Metabolism). There are a total of 20 recommendations (Volkert et al. ESPEN guidelines on nutrition in dementia. Clin Nutr 2015, 34: 1052-1073):
- Malnutrition detection should be performed in each individual case. If it is positive, the individual should be intervened and followed to see their progression.
- There should be a strict surveillance and body weight measured regularly in individuals with dementia.
- It is recommended to provide the meals in a pleasant and homely environment.
- It is advisable to provide an adequate nutrition based on the specific needs and personal preferences.
- A proper diet should be provided, as well as the necessary aid in the cases that it is required.
- It is not recommended to regularly use appetite stimulators.
- The caretakers should be trained to ensure they understand the basic concepts regarding nutrition, as well as strategies in relation to dementia and how to intervene.
- Any possible causes of malnutrition should be eliminated whenever possible.
- Diet restrictions should be avoided.
- It is not advisable to use supplements for omega-3 fatty acids, vitamin B1, vitamin B6, vitamin B12, folic acid, vitamin E, selenium, copper or vitamin D in individuals with dementia in order to correct or prevent cognitive deterioration.
- The use of ONS (oral nutritional supplements) are recommended to improve the individual´s nutritional state.
- The use of ONS is not recommended in individuals with dementia to correct or prevent cognitive deterioration.
- It is not advisable to systematically use special medical foods to individuals with dementia in order to correct or prevent cognitive deterioration.
- It is not advisable to use any nutritional product in individuals with dementia in order to correct or prevent cognitive deterioration.
- It is recommended that the decision to use artificial nutrition and hydration in the patients should be based on the general prognosis and preferences of the patients.
- The use of tube feeding for a short period of time in patients with slight or moderate dementia is recommended in cases where a crisis situation with low or insufficient oral ingestion is present, especially when the cause of the condition is reversible.
- The initiation of enteral feeding is not advisable in patients with severe dementia.
- Parenteral feeding is suggested when an artificial nutrition is considered, as indicated in recommendation 16, and if enteral feeding is unadvisable or not tolerated.
- Liquids should be taken by parenteral administration, in a limited period of time when a crisis situation occurs and the individual is taking insufficient amounts of fluid.
- Artificial feeding (enteral, parenteral and liquids by parenteral administration) is not advisable in the terminal stage of life.