Nutritional Approaches to Treating Patients Living With Alzheimer’s Disease and Chronic Wounds

As of 2023, approximately 6.7 million Americans aged 65 years and older are living with Alzheimer’s disease (AD),¹ and this number is expected to increase as the population ages. While chronic wounds are not always the first thing that comes to mind when discussing the AD population, an overlap is seen between AD/dementia and the development and healing of wounds.

AD AND DEMENTIA

AD is a progressive and ultimately fatal disorder in which certain types of nerve cells in particular areas of the brain degenerate and die for unknown reasons.² According to the Alzheimer’s Association, about half of all nursing home residents suffer from AD or a similar neurodegenerative disorder.³ Other terms often used to describe this clinically complex loss of memory/judgment and personality changes include dementia and senile dementia of the Alzheimer’s type.

Dementia is an umbrella term used to describe a variety of diseases that cause a decline in thinking, one of which is AD. Although the progression of AD will vary between patients, it usually has an early, mid, and late stage. As the stage of the disease advances, the clinical complications also follow a progressively worsening course. Eating and feeding difficulties often are present by mid stage and pose a risk of malnutrition and dehydration unless addressed effectively. Malnutrition will surely impact the body’s ability to heal a wound, so prompt intervention is necessary. Because AD and dementia are not curable, the treatment of nutritional problems focuses on effective symptom management.  

AD AND THE WOUND CONNECTION

The clinical characteristics of AD make these patients vulnerable to developing wounds and can make healing an existing wound more challenging. Some of the commonly encountered issues include mobility problems, agitation or restlessness, communication challenges, medication side effects, and feeding issues, including unintended weight loss, dehydration, and swallowing problems.

Wound care guidelines do not specify any different nutritional treatments for people with cognitive deficits. However, many proven feeding strategies can address issues faced by patients with AD and cognitive deficits. All wounds require the proper mix of both macronutrients and micronutrients to build new tissue, plus an adequate amount of fluids. It often is frustrating and time-consuming to feed patients with AD. Therefore, it is necessary to employ compensatory strategies to address the specific problem at hand to ensure adequate nutritional substrate to fuel the wound healing process.

THE DINING ENVIRONMENT

It is important to keep the environment for eating as simple as possible, minimizing any distractions. Patients 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.

Here are some helpful suggestions:

• Avoid using patterned tablecloths and placemats
• Minimize noise during the meal (eg, shutting off the television during the meal so patients can concentrate on the meal)
• Play soothing music during meals if this calms patients (an individual preference)
• Take steps to remove items that can cause confusion, such as mirrors and lighting that produces shadows
• Place patients in the same seat for each meal in order to develop a routine

COMMUNICATION DURING MEALS

Verbal cues, praise, and mimic techniques may help to encourage proper meal intake. Verbal cues may include reminding patients to lift the eating utensil, to chew, and to swallow. AD 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 serves to reinforce this behavior and make the meal more pleasant.

Often patients may forget the physical action needed to eat, so it sometimes helps to act out lifting the fork to the mouth and then to demonstrate a chewing motion. Hand-over-hand techniques also are valuable in prompting the desired action. Communication during meals is an important nutrition strategy that needs performed with patience and gentleness.

HOW TO DEAL 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. In the long-term care setting, these behaviors may disrupt others in the dining room, so it is imperative to manage these problems immediately.

When patients spit or throw food, it is best to seat these individuals off to the side or in the corner of the dining room. Screaming sometimes is 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 too 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 some patients have more difficulty dining with others, it is very important that the health care team continue to encourage socialization. Without regular interaction with others, withdrawal and isolation may occur. Eating nonedible items can pose a safety problem, so it is necessary to remove all toothpicks, doilies, centerpieces, inedible fruit peels, napkins, and food packages 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 patients to remain in the dining room for an extended period, have the tray completely set up before seating them. 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. The Table illustrates finger food substitutions for regular menu items. Foods that patients can keep in a pocket or purse can provide extra calories between meals. Nursing stations can stock finger foods and hand them to patients as they pass by. The use of a variety of high-calorie, high-protein oral nutrition supplements between meals can provide the additional calories and protein needed for healing.

PROBLEMS WITH CHEWING AND SWALLOWING

Many patients with AD suffer from swallowing disorders such as dysphagia. Swallowing problems also may occur because of dental problems or simply a fear of swallowing. Dental problems—such as cavities, gingivitis, or tooth sensitivity—warrant a dental consultation. Sometimes dentures that need refitting are the cause of chewing and swallowing problems.

A consultation with a speech-language pathologist (SLP) can provide the proper diet consistency. Modification of both food and fluids can provide the safest texture to minimize aspiration. The SLP and registered dietitian nutritionist (RDN) can individualize the diet prescription to provide the optimal diet texture for each patient.

It also is possible to modify fluid viscosity. Often, it is difficult to swallow thin liquids because they do not form a cohesive bolus that the tongue can manipulate and position properly for swallowing. For this reason, the use of straws in beverages often is restricted for patients with AD. Many commercial products are available to thicken beverages. It is necessary to avoid foods that do not have a consistent texture 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 patients, family members, and staff on these compensatory strategies.

For patients with wounds and swallowing difficulties, a dysphagia-specific product is available to enhance collagen synthesis and nitric oxide production to support the healing process. Expedite™ Cup (Medtrition, Lancaster, PA) contains a blend of highly concentrated collagen dipeptides (prolyl-hydroxyproline [PO] and hydroxypropyl glycine [OG]) and L-citrulline in a 2-ounce gelled cup. The small volume, coupled with the gelatin consistency, makes this easy for patients with AD and/or dysphagia to consume, and it is the first such available product specifically for this patient population.

END-OF-LIFE ISSUES

Unfortunately, despite the very best efforts to keep patients well nourished, many with AD still suffer from unintended 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. It is important to hold discussions about nutrition support before it becomes a medical necessity or an emergency, followed by thorough documentation in the medical record of the patient’s and family’s wishes. 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 pros and cons, are warranted in a caring atmosphere.  

PRACTICE POINTS

A multidisciplinary team of health care professionals must work together to ensure the best nutritional outcomes for patients with AD and wounds. At a minimum, this team includes the RDN, the occupational therapist, the SLP, the social worker, the nursing staff, the pharmacist, the physician, and the patient and family. Patience, understanding, compassion, and a little creativity in removing the barriers to good meal intake will help practitioners become more successful in maintaining adequate nutritional parameters for their patients for as long as possible, so they can obtain the proper fuel they need for building new tissue to heal wounds.

1. Rajan KB, Weuve J, Barnes LL, McAninch EA, Wilson RS, Evans DA. Population estimate of people with clinical Alzheimer’s disease and mild cognitive impairment in the United States (2020-2060). Alzheimers Dement. 2021;17(12):1966-1975. doi:10.1002/alz.12362

2. Alzheimer’s Association. What is Alzheimer’s disease? Accessed August 7, 2023. https://www.alz.org/alzheimers-dementia/what-is-alzheimers

3. Alzheimer’s Association. 2023 Alzheimer’s Disease Facts and Figures. Accessed August 7, 2023. https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf

Nancy Collins, PhD, RDN, LD, NWCC, FAND, is a wound care-certified, registered dietitian nutritionist based in Las Vegas, NV. Dr. Collins is well known for her expertise in the complex relationship between malnutrition, body composition, and tissue regeneration. To contact Dr. Collins, visit her website at www.drnancycollins.com.