A Practical Guide to Eating and Drinking When Living With Dementia

Some people with dementia experience problems with eating and drinking. This leaflet provides practical information on how to tackle these problems. The advice provided is not a substitute for individual advice from a health care professional such as a Dietitian, Speech and Language Therapist (SALT), General Practitioner (GP), District Nurse or Community Mental Health Nurse (CMHN).

For specific information about difficulties with chewing and swallowing, refer to Dementia Care – A Practical Guide to Swallowing Problems see Living Well with Dementia link.

Common difficulties with eating and drinking

The way dementia influences a person’s life is different for each individual. This is also true for eating and drinking; not everyone will experience the same changes. This guide provides practical advice to help overcome challenges that can occur.

When someone’s eating habits changes or they find it difficult to eat, it can be distressing for the person and for those who care for them. Challenges can occur because:

There may be reduced or limited recognition of hunger and/ or thirst. The person may think they have already eaten or had something to drink, or they may ask for more food when they have recently eaten. It can also mean that a person forgets to take regular food or fluid.
Tasks such as preparing or cooking food may become difficult.
Food preferences may change. For example, the person may prefer sweet foods or spicy foods, which may be different from their previous likes and dislikes.
The consistency of food that can be managed may change due to problems with recognising food, chewing or swallowing.
Cutlery can become difficult to use due to reduced co-ordination or the person may forget how to use cutlery.

Preparing for a meal

Small changes, such as those listed below, can help to make mealtimes more enjoyable, less stressful and may help improve nutritional intake.

Encourage the person to go to the toilet before meals.
Help them to wash their hands or use a hand wipe before eating.
If glasses, hearing aids or dentures are worn, make sure that these are in place for the meal.
Consider using adapted cutlery or cups if the person is struggling to grip standard types. Try wide or chunky handled cutlery and cups.
If additional time is needed to finish meals, provide one course at a time or consider using plate warmers to help keep the food warm.
You may need to offer snacks between meals if a larger meal is too much to manage.
Use contrasting coloured plates. This can help to make food easier to see on the plate. Pastel colours are difficult to recognise. Try to use primary colours (red, yellow and blue) which are recognised for longer by people as their dementia progresses.
Avoid distracting items on the meal table such as vases or lots of condiments.
Avoid patterned table coverings as these can be distracting and reduce focus on the food.
Ensure good oral hygiene. This helps to avoid infections, encourages good gum health and can maximise taste from food

The mealtime experience

While everyone should be encouraged to eat independently, some people may need help. Some suggestions are:

If someone is easily distracted at meal times then seat them at the table as late as possible.
Make sure they are sitting in an upright, supported and comfortable position.
Try to make surroundings as calm and familiar as possible. Loud TV and radio can be distracting for some people, but could be reassuring for others.
When plating up meals, keeping a routine with how foods are arranged on the plate may help.
Sit at eye level or slightly below the person you are assisting. You may find it helpful to sit at one side or slightly in front of them and maintain eye contact.
Talk about the food and drink that you are offering, but try to discourage the person from talking whilst eating because of the risk of choking.
Naming foods and drinks can help trigger memories.
Give enough time to swallow each mouthful before continuing.
If offering pureed meals, keep different foods and flavours separate.

What if foods are being mixed together? (For example, adding drinks to savoury meals).

It can look unpleasant, but it may be that the person is unsure which items should go together. The following may help:

Avoid putting several plates on the table at one time.
Serve one course at a time.
Offer drinks after the meal or small sips during the meal.

What if food is being spilled at meals?

Try using wipe clean table mats and coverings and allow the person to eat as they wish even if this looks messy.
Use a napkin, apron, or small tea towel or hand towel to protect clothing from spillages whilst maintaining dignity.
Encourage the person to eat independently where possible.
Although it may be difficult, try not to comment on the way they are eating as this could be upsetting. Where required, try verbal prompts and, if necessary, provide some assistance.
If using cutlery is a problem, try using a teaspoon or offer finger foods instead. Adapted cutlery is available please see AT Dementia link.
Try using a lipped or high rimmed plate (such as a pasta bowl) to allow food to be moved around easily and reduce spillages. A plate guard may also be useful.

Purposeful walking and becoming distracted at meals

No matter how hard you try, it can be difficult to get someone to eat a plated meal if they are unable to sit down long enough to finish it. The constant movement of pacing or agitation will also burn up extra energy and can contribute to weight loss.
Leave out snacks along the route the person walks or place foods in their hand to prompt them. Try a variety of finger foods (see below).
Try using a ‘Snack-Pack’ to carry round items to snack on, for example, an apron with pockets or walking frame caddy/ basket.
Encourage high energy foods where possible.
Change the environment. Some people will benefit from a quiet environment such as the television or radio being switched off, others may react better to background noise such as soothing music.
If you notice that there are times in the day when the person is more settled, consider changing mealtimes or offer additional snacks at these times.

Finger food ideas:

Sandwiches cut into small squares, triangles or rolled into a sausage shape.
Use high calorie and protein fillings such as egg mayonnaise, tuna mayonnaise meat or fish paste, corned beef, cold meats, cheese or peanut butter.

To vary the taste and texture of sandwiches, try adding the following:

Sweetcorn, peppers, diced cucumber, chopped tomato, relishes, pickles, chutneys or mashed banana.
Fingers of toast with cheese spread or toasted cheese, mashed or sliced boiled egg, jam, marmalade, pâté, meat paste, peanut butter or yeast extract spreads.
Slices of pizza, quiche or garlic bread.
Small sausage rolls, mini scotch eggs, cooked chicken pieces, cocktail sausages or meatballs.
Fish fingers, scampi pieces or fish cakes.
Potato waffles, potato croquettes, chips, roast or boiled potatoes.
Small savoury biscuits, crackers or mini oatcakes with spreading cheese, meat/ fish paste or pâté.
Scones with butter, jam and cream, teacakes with butter, crumpets with butter and honey, jam or syrup, fruit or malted loaf with butter.
Fruit or chocolate muffins, cereal bars, biscuits, individual cake slices, jam tarts, mini fruit pies, bakewell tarts or egg custard.
Ice cream in cones, choc ices, ice pops or ice lollies.
Pieces of fruit or vegetables such as sticks of carrot, slices of cucumber, cherry tomatoes, pineapple chunks, chunks of banana, berries, or mandarin segments.

Taste changes

What if a preference for sweet foods develops?

When you are trying to encourage a healthy diet it can be difficult when a person seems to only want to eat sweet food. With a little planning, sweet and sweetened foods can provide the nutrition needed. To encourage a good variety of foods:

Try naturally sweet vegetables such as carrots, sweetcorn, parsnip, red or yellow peppers or peas. Vegetables provide a wide range of vitamins and fibre for good health.
Use ‘Sweet and Sour’ sauces, sweet chilli sauce, ketchup, chutneys or pickles to naturally sweeten dishes.
ADD a small amount of honey to vegetables or potatoes before serving.
Try adding a little sugar to mince, stew or potatoes, or serve with sweet sauces such as apple sauce, cranberry sauce, or redcurrant jelly.
Fruit could be added to savoury casseroles, for example, lamb and apricots or pork and apple.
If excess weight gain is a problem, try a sweetener instead.
Milk is a good source of protein, energy and calcium, so try encouraging milk based puddings such as rice pudding, mousse, trifle, whipped desserts or ice-cream. Serve stewed, tinned and fresh fruit with custard, evaporated milk, condensed milk or cream. A small amount of maple or golden syrup, jam or honey can be used to increase the sweetness if needed.

What if a food that has been enjoyed for years is now refused?

People can experience changes in the food they prefer. This can be due to a change in the way flavours are recognised as well as a reduction in the number of taste buds. Strong flavoured foods, spicy foods or foods previously disliked may now be enjoyed. If strong flavours are preferred or tastes change:

Keep an open mind. Don’t exclude any food and try a range of foods until you find out what that person enjoys now. Keep a list of current preferences and try foods again from time to time.
Try adding additional spices, herbs, onion, garlic, chilli, pepper, lemon juice or Worcestershire sauce to give dishes enhanced flavours.
Offer table sauces, chutney, pickles and relishes, vinegar, mustard, salad dressings or tomato ketchup.

What if the person is struggling to finish meals?

You may notice that the person you are caring for no longer finishes the food on their plate. This can happen for a lot of different reasons. The suggestions below may help.

Allow extra time for meals as needed.
Serve one course at a time to keep food warm.
Prompts such as giving verbal advice or placing the cutlery or cup in the person’s hand can help. Prompting also helps to maintain dignity and independence. Over time it may be necessary to assist with eating.
Dish up a small amount of food. Once eaten, a further portion can always be served.
Consider offering three smaller meals on a tea-plate with 2 to 3 snacks in between rather than three main meals.
Consider plate warmers or insulated cups to keep food and drink warm for longer.
When people with dementia are eating together, for example, on a ward, in a care home or at a lunch group, avoid removing plates until everyone is finished. Removing plates early can be seen as a signal to stop eating.

Adding extra energy and protein

People found to be at risk of malnutrition and people who are burning a lot of energy from activity need a diet that is high in calories (energy) and protein. To boost the calorie and protein content of the diet, follow these tips:

Have nourishing meals and snacks every day.
Encourage three smaller meals and 2 to 3 snacks each day rather than three large meals.
Encourage food at times when the person eats best. For example, some people eat better as the day goes on, whereas other people find that they eat better in the morning.
Avoid low calorie, reduced fat or reduced sugar foods unless advised otherwise by your health professional.
Include nourishing drinks.
Replace one or two cups of tea or coffee with nourishing drinks.

Nourishing drink ideas:

Make hot chocolate, malted drinks or milky coffee using full fat milk. Be careful with hot drinks. Using insulated cups with lids will reduce the risk of injury for someone who paces a lot.
Milkshakes made with full fat milk, cream and ice cream are popular.
Fresh fruit juices such as orange, apple, cranberry, grapefruit or pineapple are a good source of vitamins, especially vitamins A, C and E. Some diluted blackcurrant drinks are also fortified with vitamin C and can be useful to include.

Fortify meals and snacks

Fortifying is the addition of high calorie and high protein ingredients into food.
You can ADD extra butter or margarine, grated cheese, soft cheese or cream to potatoes, soups, sauces or vegetables to add extra calories without increasing the volume.
Spread jam, honey, marmalade and butter thickly on bread, toast, scones, crumpets and pancakes.
ADD extra sugar to puddings, cereals or hot drinks if taken.
Use whole milk or cream in cereals, sauces, puddings and drinks.
ADD jam, syrup or honey to porridge, custard, rice pudding or semolina.
Fortify full cream milk by adding two tablespoons of milk powder to one pint and use as normal on cereal, in sauces and drinks. This will help to ADD energy and protein.
If your friend or relative has lost a lot of weight and/ or they are underweight, arrange an appointment for the person to see their GP or nurse to see whether a referral to a dietitian is necessary.

Overeating

Weight can be difficult to control when a person forgets that they have already had a meal. Being told you have already eaten can be distressing for the individual and can be a challenge for those who care for them. The following tips can help:

Try dividing the original meal portion into two smaller portions. When food is requested the second time around give the second portion.
Alternatively, serve small portions of the main dish (fish, meat, poultry or vegetarian option) and starchy foods such as potatoes, rice, pasta or bread. Fill up the majority of the plate with salad or vegetables which are low in energy.
Offer snacks such as fruit or light yoghurt as an alternative to an extra meal.
Make ice-lollies with sugar free or diet drinks. These can then be offered as a snack or a second dessert.
If a meal has already been eaten, offer a drink instead. Try lower calorie drinks such as water, tea or coffee with sweetener (optional) and diet, sugar-free or reduced sugar flavoured water, cordial, or fizzy drinks.
Limit the amount of high calorie snacks kept in cupboards or rooms, such as biscuits, crisps and chocolate.

What if constipation is a problem?

It is important to encourage good bowel health as constipation can reduce appetite and contribute to increased confusion and agitation. Foods high in fibre help to bulk up stools and make them softer and easier to pass. Try:

Adding extra vegetables into recipes. You can also ADD beans and pulses into meals such as soups, casseroles and stews.
Serving meals with plenty of vegetables. Try side salads or vegetables in a savoury sauce.
Offering desserts containing fruit. Stewed fruit, dried fruit or chopped fresh fruit can be served with yoghurt, custard or cream.
Serving breakfast cereals with fruit, for example, sliced banana or dried fruit.
Offering snacks such as high fibre cereal bars, a handful of dried fruit, digestive or oat based biscuits, or multigrain or seeded crackers. Using wholemeal breads and cereals, for example, Weetabix, Shreddies, bran flakes or porridge.
If fibre is being increased, this should be done gradually to avoid discomfort and excess wind. At the same time fluids should also be increased. Aim for at least 8 to 10 cups of fluid each day which will help to make stools easier to pass.
If constipation is still a problem, seek advice from a GP, Practice Nurse or District Nurse.

What if fluids are a problem?

In general, 8 to 10 cups of fluid (1 ½ - 2 litres or 4 pints) should be included everyday to keep well hydrated. On hot days, when sitting in centrally heated areas or if there is an infection present, try to encourage an extra 1 to 2 cups. Poor hydration can contribute to constipation, increase feelings of tiredness, increase risk of urinary infections, reduce concentration and ADD to confusion.

Offer small amounts of fluid frequently, about half or ¾ a cup at a time if larger amounts are not being taken.
Use flavoured ice-cubes (made with juices) or ice-lollies to ADD extra fluids.
Place the cup in the person’s hand as a prompt if needed.
If someone has a familiar or regular cup that they prefer, try to encourage its use.
Remember fluids include soup, tea, coffee, fruit juices, jelly, cordials, diluted or fizzy drinks and water. A variety can help to maintain interest in drinking.
Try smoothies made by blending soft fruits with juice, milk or yoghurt and adding cream or ice cream.
Offer moist foods, for example, meat with gravy, casseroles, fish with sauce and desserts served with custard or sauce.
If you are unable to be there to prompt the person to take fluids, try making up a jug or bottle of juice or flask of tea or coffee and place it within reach. If other Carers such as relatives, friends or care services are visiting, cold drinks can be left in the fridge and visitors asked to offer these.

Oral care

Establishing a good relationship with the dentist in the early stage of the disease can help the person become familiar with the dental practice and the staff. This will help to make it less frightening and confusing as the disease progresses. Let the dentist or dental practice staff know about the person’s condition before a consultation.

If the person you care for is having high sugar food or supplements, this can increase the risk of tooth decay. It is important to maintain good mouth and tooth care for as long as possible to minimise the risk.

If you are able to maintain tooth care easily, the following is advised:

Brush teeth twice a day using a fluoride containing toothpaste.
Never brush teeth straight after a meal as it can damage them, especially after consuming fruit, fizzy drinks, wine or any other food that contains acid. Instead, wait an hour after a meal before brushing teeth to give saliva a chance to neutralise the acid.
A glass of milk or cube of cheese after a sugary meal/ snack can also help neutralise the acid.
If possible, sugary drinks or high calorie supplements should be drunk in one go rather than being sipped over a longer period.
Let the dentist know about the consumption of a high sugar diet so preventative treatments can be considered, for example, a high fluoride toothpaste or fluoride or Chlorhexidine varnish.
Ask your GP and pharmacist for sugar free versions of medication as some can be high in sugar or sticky, for example, cough mixture.
Some medications can cause a dry mouth. Artificial saliva may be available from your GP. A Dentist or pharmacist can also help.
If manual dexterity decreases, an electric toothbrush or toothbrush with an adapted handle may help maintain independence.
If dentures are worn, ensure they fit comfortably. Consider using denture fixative to keep them secure during the meal.
If dental problems arise, speak to the dentist as soon as possible.

Maintaining independence at home

If the person you care for lives alone, the following services and independent living aids may help the person stay well nourished while remaining relatively independent.

Mealtime prompts

If forgetting to eat or struggling to find items in the kitchen is a problem, you may need to consider the use of a prompt.
A simple prompt such as a sign or notice in the kitchen may help the person find food, equipment, crockery and cutlery. Try using a picture as well as wording to help the person understand the purpose of the notice.
Verbal prompts can be given using message machines, texting or calling the person, or through using a telecare service.

For more information about prompts, telecare and other assistive devices, speak with your social worker or Occupational Therapist.

Food storage

As the dementia progresses, the person may not only forget to eat but may lose the ability to identify foods that are out of date or have gone off. If you can only shop once per week the following can help limit the risks:

Throw away out of date items before you go shopping.
Move products with a shorter shelf life to the front.
Look for items with a long shelf life.
Consider longer life products, for example, UHT milk, tinned fruit, tinned meats.
Buy small individual portions of perishable foods, for example, mini cheeses, individual milk puddings, chilled meals for one.

Shopping and meal delivery services

If the person you care for has difficulty cooking and/ or shopping, the following services may help:

Cooked meals are available for a daily fee through your local Meals on Wheels service.

Ready meals can be kept in the fridge or freezer and used as required. Your local supermarket may have a good selection or you may wish to use a frozen meal delivery service, such as:

Wiltshire Farm Foods
Oakhouse Foods

In addition to their meal delivery service, Oakhouse Foods have a range of groceries that can be purchased and delivered with the meals. The drivers may be able to assist with putting the food away, but ask for this specifically when ordering.

Online shopping may be an alternative, but someone might need to be present to help sort and store the food once it has been delivered.

What to do when a person with dementia is admitted to hospital

At some point during the progress of their dementia, the person you are caring for may have to go into hospital. Hospitals can be unfamiliar and confusing, especially for a person with dementia. Ensuring that the hospital staff “know” the person can be very helpful to make their stay as comfortable as possible.

Most hospitals have procedures in place to obtain information to provide appropriate care for patients with dementia. You may be asked lots of questions which can seem quite daunting and intrusive, but all information will be handled in a confidential manner. If you are unsure why they are asking certain questions you can ask them questions too!

A number of hospitals have specialists working within the area of dementia. Ask if your friend or relative can be referred to them during their stay.

Eating and drinking in hospital

Food forms a central part of daily life and in hospital this is no different. Providing information on usual eating habits can help the staff caring for your friend or relative to provide familiar meal patterns and familiar foods to encourage dietary intake.

Useful information that can help:

Do they need assistance to eat or drink?
Can they use cutlery or do they prefer finger foods?
Are dietary aids used, such as specialist cutlery or crockery?
Do they have preferred cutlery or crockery that they use at home?
Does food need to be cut into pieces?
Do they wear dentures to eat?
Do they wear glasses?
Do they have swallowing difficulties? Is a soft or pureed diet required?
Do they require thickened fluids?
Do they have any special dietary requirements or preferences, such as following a vegetarian diet or having certain foods in accordance with religious or cultural beliefs?
What is their appetite usually like?
Do they need help to choose food from a menu?
What foods do they like and dislike?

Food preferences can change as dementia progresses, so it is a good idea to make a note of these changes from time to time.

A ‘This is Me’ form (A personal profile to support people with dementia going into hospital) is available on the Alzheimer’s UK website which can be completed and provided to the hospital team for their information.

With special thanks to the Coventry and Warwickshire Dietic Department for the use of information from the ‘Dementia Care - A Practical Guide to Eating and Drinking’ March 2014