Distraction and Wandering. "Some patients have short attention spans. They take a couple of bites and stand up," said Richard Strickland, MD, Geriatrician and Medical Director for four LTC facilities in Dallas. He considers mobility a key issue in eating problems among LTC residents with dementia. For example, it is hard to get a patient who likes to wander to sit down and eat a meal.

Agnes Langan, RN, Director of Nursing, Newton & Wellesley Alzheimer's Center, Wellesley, Massachusetts, finds that the facility's 54 patients with mid-stage Alzheimer's are the most difficult population at meal time. "They can't sit still," she observed, "and they keep getting up and walking away from the dining table."

Loss of Hunger. Patients with Alzheimer's disease often lose or confuse hunger signals. "The mind no longer tells the body it's hungry," said Ms. Langan. A patient may see food and say, 'I just ate,' even though he didn't. The majority of our residents with Alzheimer's disease couldn't care less about food."

Food Recognition. Difficulty in distinguishing color, contrast, depth perception, or spatial orientation makes discerning what is on a plate tricky. "Inability to recognize a food can interfere with eating," pointed out Jennifer Brush, MA, Coordinator of Continuing and Professional Education for Applied Gerontology at Cuyahoga Community College in Highland Falls, Ohio. Impaired language skills compound the problem.

"If you can't ask what [the food] is or say you don't like it, a normal reaction is to spit it out," Ms. Brush said. Even cultural and regional backgrounds, such as preference for certain seasonings, affect food perceptions.

Individual Biorhythm. "Some patients with dementia do not get up early," noted Ernestine Wright, MD, Assistant Medical Director at Stella Maris, Inc., a 450 bed LTC residence in Timonium, Maryland. Since meals are provided at an established time each day, a resident who stays in bed until 11 AM will miss breakfast. "Calorie counts will show that," added Dr. Wright. "Someone in no mood for food may simply announce, 'I don't feel like eating' at 1 PM."

Difficulty Swallowing or Chewing. Food consistency and texture can really make a difference in eating habits. A resident who is not eating as a result of a problem chewing food may need to be shifted to a soft, pureed diet. Unable to feed themselves, patients with late-stage dementia often decrease food intake. Forgetting how to swallow or what to do with food, they simply hold it in their mouths.

Co-morbidities. A patient may have constipation, a urinary tract infection, or dental problems, Dr. Wright explained. "The fact that they stop eating may be a clue, since they may not tell you about a symptom."

External Factors. External factors exert an influence on eating habits as well. Mealtime, noted Dr. Strickland, is "an event-the kind of activity that marks a certain point in the day. The environment, the caregiver's voice, and the dining setting are very important. Is it institutional, with pagers and vacuums heard during meals?" Both he and Dr. Wright find that residents do poorly when the dining room is noisy (this is not true for music, however; see Sidebar). An easily distracted patient might take a bite, but not chew because he or she stops paying attention to the food, instead trying to making sense of all that noise, explained Ms. Brush, a speech/language pathologist who treats patients with Alzheimer's disease.

 

WISH LIST

Experienced LTC staff readily cite nutrition-related areas ripe for improvement in their own facilities. One common complaint is staff training (or the lack thereof) ). "Long-term care is a little like the fast-food industry," noted Dr. Strickland. "There is high turnover, often minimal training (if any), and the expectation of an enormous amount of work in a short period of time. The people serving meals are often changing the sheets." Part-time staff, in particular, may have little idea how to help patients with Alzheimer's disease.

Staff consistency is another area of critical importance to nutritional caregiving. "As the disease progresses, patients need to recognize their caregivers," said Dr. Wright. "A resident who's [been fed by] a staff member for a few months is more likely to accept food." The resident may not recognize the caregiver but somehow realize that he or she is there to assist with eating.

Budgetary constraints are also a concern. In Dr. Strickland's Medicaid-funded facility, the modest budget covers medications, building upkeep, dietary services, and activities. "Private facilities that have higher fees can do much more with their surroundings, dishes, and music," he pointed out. This can certainly affect the eating habits of patients with Alzheimer's disease. Moreover, no one in Dr. Strickland's facility has time to train less-skilled employees to correctly administer food to residents with Alzheimer's disease; some of his nurses who do group case supervision must care for 10 to 15 patients apiece.

At Ms. Langan's facility, only licensed nurses, rehabilitation therapists, or certified nursing assistants can take part in feeding residents with Alzheimer's disease. Despite a good staff ratio, "All the nurses are feeding: me, the assistant director, my supervisor, our activities director, the program director -- for three meals a day," she said. Ms. Langan looks forward to the launch of Massachusetts' forthcoming Paid Feeding Assistance Program, which will train people specifically for mealtime needs.

"In LTC, [staff] are rewarded for how quickly they can get people fed, bathed, etc. It's more quantity than quality," said Dr. Strickland, who wishes his facilities had dietitians on staff. "The bottom line is, you want to provide balanced nutrition, avoiding weight loss and malnutrition. Do you have someone at your institution who can do calorie counts? Can you measure markers of improvement?"

A recent study, testing two simple, affordable approaches to basic dining difficulties, originated with Ms. Brush's work evaluating patients with Alzheimer's disease who have swallowing problems. Noticing that environmental aspects seemed to distract them, she set out to investigate whether dim light and low color contrast affect residents' eating or social functioning. She and her colleagues studied whether environmental factors can be modified to increase food intake in dementia. Working with residents at a nursing home and an ALF, the team made initial discoveries that are easily addressed.

In Ms. Brush's study, funded by the Extendicare Foundation of Milwaukee, subjects were more hydrated and consumed more calories at its completion. The subjects, 22 women and three men over the age of 70, were randomly selected from an SNF and an ALF. Stage of dementia was not a criterion; however, Ms. Brush described most subjects as "mid-stage" patients with Alzheimer's disease.

Changing nothing except lighting and table arrangement, researchers measured numerous intervention outcomes, using the Communication Outcome Measure of Functional Independence (COMFI) and the Meal Assistance Screening Tool (MAST). They tracked calorie intake for each resident individually, as well as his or her ability to chew or eat independently

Researchers returned to gather postintervention data four weeks after taking baseline measurements (Table). The results included:

• Twenty-three of 25 subjects had increased their caloric intake after lighting and contrast interventions were made

• Nursing home subjects had an average 1,000 calorie in crease during a three-day calorie count (3,277 over three days at baseline to 4,339 at post-test)

• For ALF residents, calories rose from 3,571 at baseline to 4,476
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• Socially, researchers found a statistically significant increase in frequency at which residents engaged in or initiated conversation with a staff member, and how frequently residents answered questions on topic. The COME scores rose from 48 to 61
  
• The MAST scores indicated overall improvement in measures of food intake and functional independence relating to mealtime experiences

Staff members at the ALF, which had more dramatic lighting changes, also told researchers of greater ease in performing their tasks (Figure).

Aging brings changes in visual acuity and performance. An older retina, taking in less light, requires more light than that of a younger person. Research has shown that, with increased contrast, persons with Alzheimer's disease are able to read more quickly and easily.³

In Ms. Brush's study, the assisted living dining room, unmistakably dark, had two main lighting fixtures, each holding two bulbs. Researchers replaced them with four-bulb lighting fixtures. "We added bulbs, turned on the chandeliers, and saw a significant difference."

The researchers, following recommended lighting practices for senior living from the Illuminating Society of North America (New York City), added wall sconces at both facilities to reflect indirect light upward. Ideally, she said, "dining room lighting [should be] evenly distributed."

Ms. Brush's team also tackled table settings. "Some facilities use a white tablecloth, white napkin, and white plate, because it looks elegant, but it's very low contrast and difficult for someone who has any visual problem. One facility had gray table service, with gray trays and white plates. They all blend together, making it hard to find things."

The researchers switched to darker tablecloths. High-contrast table settings -- for example, a white plate on a dark blue tablecloth-provide enough differentiation to make visibility easier on the patient. "It's also important that table coverings have a matte finish and nonglare surface," said Ms. Brush. If the table covering is shiny, like a plastic tablecloth, "sun coming in windows or artificial light can cause glare, which can be blinding to aging residents, whose eyes are much more sensitive to glare."

Figure: Dining room lighting: Mean baseline and posttest lighting in an SNF and an ALF.

Some subtle dining room changes also help psychologically. Dining rooms are often used for other activities as well, so choosing distinct table settings can signal residents to eat at appropriate times. According to Ms. Brush, residents who have dementia need many cues during the day. Seeing that tablecloth and the place settings helps them know what's comingthat it's mealtime."

IMPLEMENTING AFFORDABLE LIGHTING AND DINING CHANGES

Is improving the dining experience of residents with Alzheimer's disease worth the time, effort, and cost? "It's easier to feed someone than to oversee their eating," acknowledged Ms. Langan. However, she said, truly enhancing their dining experience "helps preserve their independence and dignity."

Though improvements generally require a financial outlay, cost is a minor factor. "You don't need an expensive electrical contractor to make these lighting changes," according to Ms. Brush, whose team selected new fixtures and bulbs at Home Depot, at an estimated cost of $300 per facility. "It was easy and cheap." She and other experts offered some advice:

• Install sheer curtains or paper shades to deflect sun glare while letting light in; avoid blinds, which block both glare and desirable sunlight

• Do not use a central chandelier, which will darken the dining room perimeter; residents seated near walls will have dimmer light

• Seat location can have a significant effect; place patients near others with the same level of dementia

• A patient can become confused when told to sit in "his/her" chair; a place card with the resident's name in large clear print may help. So may letting the resident personalize the place card with a picture or make his or her own (with staff or family assistance, if needed)

• Small type, glare, poor light, and colored paper make printed menus hard to read, whereas large black type on white background can be clearer

• Inaccurate menu listings are confusing, so be sure the staff matches the menu to that day's foods

In addition, for food presentation, "Limit the visual challenges and choices," urged Dr. Strickland. "Give the patient one plate with one [type of food] or they'll mix everything together." Ms. Brush added, "For residents who are easily distracted and overwhelmed, a crowded plate is overstimulating."

No technique to improve eating can work for every patient with Alzheimer's disease. "You can't summarize or pigeonhole this population," said Ms. Langan. "Any patient who comes in the door is different." With her extensive experience in the dining room, she offered a parting tip: "Don't get hung up on proper etiquette; Emily Post does not work here."

1. Zgola JM: Care That Works. Baltimore, Johns Hopkins University Press, 1999.

2. Brush J, Meehan R, Calkins M: Using the environment to improve intake for people with dementia. Alzheimer's Care Quarterly 2002; 3:330-338.3. Baucom AH: Hospitality Design for the Graying Generation. NewYork City, John Wiley & Sons, 1996.

Many of these articles appear on the publication's website, which are often password-protected or members-only. For your convenience, I've gathered them on my own website.