Eating and drinking well with dementia at home
A guide for home care professionals
Introduction
Welcome to the eating and drinking well guide for people living with dementia at home to support home care professionals. Having good food, nutrition, and hydration is fundamental for everyone to maintain overall health and well-being. We recognise that as dementia progresses, eating and drinking can become more challenging. Therefore, every effort should be taken to ensure that food,drink, and mealtimes at home remain an enjoyable experience and are at the heart of providing person-centered care.
This guide has been adapted from an award-winning Nutrition and Dementia Care Toolkit originally designed for Care Homes (2019) based on research with best practice examples.
The guide has been shaped by input from various stakeholders, including people living with dementia, their family carers, home care professionals, healthcare professionals, the care sector and practice experts, as well as the multidisciplinary project team, all of whom provided valuable feedback.
Also available:
• A handy guide for home care professionals
• A handy guide for family carers and friends
For more details, please visit the project TOMATO webpage: www.bournemouth.ac.uk/tomato
and also the Ageing and Dementia Rersearch Centre webpage: www.bournemouth.ac.uk/nutrition-dementia
There are three sections in this guide. We have retained the colour coding from the person-centred nutritional care model on the next page to help you easily find the information you need.
Section one
This section considers each of the factors with practical advice and suggestions. We have included 'How to' and 'Tips' with practical solutions for eating and drinking for people with dementia, to help home care professionals overcome everyday challenges. Throughout this resource, we have signposted and included links to 'trusted' information and current guidelines.
Section two
This section provides some examples to deliver 'availability of food and drinks' for best practice and useful resources such as menu planning, food and fluid diaries and guidance.
Section three
The third section provides a handy checklist to evaluate your own professional practice at a glance.
This guide does not cover nutritional care in people with advanced dementia. It is important to seek specialist nutritional support at this stage.
We have adapted this guide based on the published model of ‘person-centred nutritional care’ which is underpinned by 6 key factors tailored for home care:
1. Availability of food and drinks
How to accommodate for changes in appetite, food preferences and ability with practical suggestions for modifying food, planning menus and improving the presentation of food.
2. Monitoring and care planning
Spotting the signs of poor nutrition and using validated tools to dentify clients likely to be at risk of undernutrition.
3. Relationship: working together
Practical ways of working together with family members and close friends to improve food and drink intake
4. Enhancing the mealtime experience and activities
Improving the dining environment and mealtime experience practical activities to stimulate appetite, evoke memories and create a sense of purpose.
5. Consistency of care
Improved communication between all those involved with care and the provision and prioritisation of nutrition and hydration.
6. Provision of information
Access to trusted information, training, resources and current guidelines.
Working in partnership with
Section one
Availability of food and drinks
Eating and drinking well
Good food provides us with energy (calories) and essential nutrients (protein, fat, carbohydrate, vitamins, minerals and fibre) that help maintain body functions and safeguard us against illnesses and infections. For a healthy, balanced diet, it’s important to eat a variety of foods in the right proportions to provide the nutrients our bodies need. An unbalanced diet can increase the risk of weight loss, low energy, and poor nutrition (undernutrition). See below for tips on how to spot signs of weight loss.
Why is it important for people living with dementia to eat well?
When people experience unplanned weight loss and a decrease in body mass, dementia can progress more quickly, and the risk of complications like pressure injuries, infections, falls, and fractures also go up.
How to... spot weight loss
• Poor appetite
• Clothes, rings, jewellery, dentures may become loose
• Tiredness, loss of energy, muscle weakness
• Reduced physical performance or ability to perform normal tasks
• Increased risk of falls
• Constipation
• Altered mood and changes in behaviour
• Poor concentration.
Why is it important to drink well?
If someone living with dementia or an older person doesn’t drink enough, they can be at risk of many health conditions. These include problems like reduced cognitive abilities, incontinence, urinary tract infections (UTIs), difficulty passing stool (constipation), feeling more tired, poor oral health, low blood pressure, and an increased risk of falling due to feeling dizzy and confused.
How to... spot dehydration
• At present, there are no validated screening tools to determine dehydration in older adults
• Relying on the support of others to drink is a risk factor
• The best approach is to assume risk of dehydration for people living with dementia.
Why are people living with dementia at risk of weight loss or dehydration?
As dementia progresses, eating and drinking can become increasingly difficult due to various reasons, shown in this diagram:
this can occur due
How much drink should older adults aim for daily?
To stay well hydrated, it’s important to have lots of drinks (water, milk, sugar-free drinks, tea, and coffee) and to choose preferred drinks. Keep in mind that not everyone likes to drink water. It is recommended to aim for about 1,600ml for women and 2,000ml for men per day
Meeting these recommendations may not always be possible for a person living with dementia at home, but any increase in their drink intake is a positive development.
Type of drinking utensil
Teacup 150 ml 11-14 full cups
Glass 200 ml 8-10 full glasses
Mug 250 ml 7-8 full mugs
Pint glass
568 ml 3-4 full glasses
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (A2) The British Dietetic Association (BDA) | Hydration in older adults
How to... encourage eating and drinking well
When someone is eating poorly or losing weight unintentionally:
• Consider making changes to the way the client traditionally eats, providing culturally familiar options
• Ensure any adjustments are appropriate to the person’s changing needs. These may be in response to walking with purpose, changes in sleep patterns, varying levels of physical activity, or unintentional weight loss
• Monitoring: Food and drink diaries may be useful to record and monitor intake for people living with dementia. Actions needs to be taken if people with dementia are not eating or drinking enough (See section 2)
• Fortifying foods (Food Based Approach) is a way of adapting a client’s meals and snacks by adding extra amounts of nutrient dense foods
• Common food items like skimmed milk powder, fortified milk, egg, ground almonds, cheese and Greek yogurt can enrich foods without increasing portion sizes
• In addition to boosting energy, the aim is to promote and prioritise nutrient density.
Fortified milk:
You can add 4 tablespoons (60grams) of skimmed milk powder to 568ml full fat milk. You can use this as a base for making milky drinks or add it to suitable foods.
Tips for fortifying food
Prioritising a food based, nutrient dense approach is always best.
Breakfast: try fortifying:
• Breakfast cereal with fortified milk, ground almonds, evaporated milk or greek yoghurt
• Bread or toast with spread of preferred nut butter.
Lighter meals: try fortifying:
• Soup with skimmed milk powder, evaporated milk, grated cheese, nut butter, ground almonds
• Sandwiches with preferred nut butter in addition to sandwich fillings, protein rich fillings such as meat, fish, cheese, nut butter.
Main meals: try fortifying:
• Meat dishes with grated cheese, skimmed milk powder, preferred nut butter (e.g., almond, cashew or peanut), or milk-based sauces
• Potatoes and vegetables with milk-based sauces made with fortified milk, grated cheese or add egg to mashed potato
• Puddings with evaporated milk or custard made with fortified milk.
How to... use oral nutritional supplements
• If appetite is poor, a food based approach can be used to meet client’s nutritional needs
Food and mealtimes can remain the highlight of the day for those living with dementia at home. Every effort shoud be taken to make sure that it is an enjoyable experience at the centre of their care.
• Over the counter or prescribed oral nutritional supplements may be used following advice from a Registered Dietitian. These are available as powdered milkshakes, soups or ready to drink products
• It can be helpful to know that oral nutritional supplements do not contain anything which cannot be found in a nutritionally balanced diet
• Oral Nutritional Supplements (ONS) may be prescribed for people who cannot meet their nutritional needs through food alone.
Tips to encourage people to drink well at home
All hot and cold drinks count.
• Water is good, though it may not be some clients’ preference, so consider offering drinks they prefer
• Offer a good variety of drinks at all times of the day during your shift visit. Take care not to offer them too close to mealtimes, as they may make a person feel too full to eat
• Drinks can be served in jugs, small decanters, or dispensers, with ice in summer. Jugs should be kept half full so clients can easily lift it themselves
• Smoothies, milkshakes, ice lollies all count
• Squashes and fruit juice including mini cartons for variety can be useful
• Offer hot drinks such as tea, coffee, hot chocolate - consider serving from the client’s favourite China teapots if suitable
• If applicable to the client’s care package, consider attending themed events such as dementia community group afternoon tea party, tea dances, events or memory café
• Take time to prompt the person living with dementia to drink or make them a drink rather than always asking.
How to... ensure good mouth care
• Assist clients to brush teeth with fluoride toothpaste. This should be done twice daily
• Clean dentures twice daily
• Encourage drinking milk as it is nutritionally rich and ‘tooth friendly’
• Clients’ need to have regular dental checks.
Why is this important for health and wellbeing?
• Ability to help improve taste
• Helps avoid mouth or gum infections
• Helps maintain the ability to eat
• If a client wears dentures, ensure they are properly fitted to prevent discomfort.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (A1) Alzheimer’s Society Dental Care and Oral Health
Planning meal menus
How to... plan a menu
• Review food preferences including old favourites, and family food traditions. Discuss together with the client and their family member or close friends and consider incorporating the food choices in their care plans
• Consider the need for culturally traditional menus based on client’s preferences. These can be a pre-prepared microwave meal ordered online from their local cultural restaurants
• Where suitable, ask family member to explain ingredients of different dishes and try the local foods so you can describe options to clients. You can also suggest this to the senior management team to help arrange this
• Incorporate the dietary needs of the client into menus, e.g., diabetes, gluten free, allergies, vegetarian – ensure there is sufficient choice
• Provide different main options to allow food choice
• Present meals in an appealing way, including pureed food.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (E12) Ready-made and pre-prepared meal options
In providing person-centred nutritional care, menus should take into account cultural, religious and food preferences of clients.
Tips for planning menus at home
Consider some of the following to introduce variety to menus:
Seasonal home-grown food
Offers many nutritional benefits and can also provide a meaningful outdoor activity — especially for live-in carers looking to spend quality time with clients. Herbs, salad leaves, and some vegetables can even be grown on windowsills or in patio containers
Taste changes As dementia progresses, people may prefer stronger tastes, e.g. sweet and sour flavours. Use herbs and spices.
Mealtimes at home
Good communication system
meals
Grazing menus, finger foods and snacks
Breakfast cereals
Set mealtimes don’t work for everyone. Some people may not be able to sit down for long enough to eat a complete meal or may be hungry at unconventional times of day or night or may prefer to eat in a different part of the house e.g. in their own room.
It is important to have a good communication in place with the family carer who buys the food items, so you are able to offer a variety of different meals to your clients. Consider creating a shopping list with cupboard items.
Small manageable meals are less daunting than large quantities of food. Consider offering more frequent smaller meals in place of 3 main meals a day. If you have a short time visit with the clients, maintain good communication with the family carer. In the care notes, record how much food and drink they have consumed.
Grazing menus and snacks can help encourage people with dementia to eat more especially for those who struggle to concentrate and walk with purpose – finger food is ideal, e.g., bowls of chopped up fruit, sausage rolls or bite-size sandwiches.
A variety of snacks could be made available on tables or counters within the care setting.
Breakfast cereals with fortified full fat milk (see page 7 for recipe) to increase nutrient intake – great for grazing menus or night-time meals.
Mini
Dietary requirements and special diets
Diabetes
Dementia can make diabetes management challenging and poorly controlled diabetes can negatively impact on the safety and wellbeing of people living with dementia. However, most people with diabetes can eat the same healthy diet as that recommended for the rest of the older population.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (E5) Guide to Diabetes
• (E6) Diabetes Recipe Finder
• (A9) African, Caribbean and South Asian Food Guide | Healthier You NHS Diabetes Prevention Programme
• (E7) Healthy Eating for the South Asian Community (Diabetes UK) – Recipe Search
Swallowing difficulties (Dysphagia) explained
Dysphagia is the medical term for swallowing difficulties and there is a high prevalence in older people living with dementia at home. As a result, they are at increased risk of undernutrition, dehydration and breathing in food particles (aspiration) which could increase the risk of aspiration pneumonia or severe chest infections.
What are the signs of dysphagia?
1
Difficulty chewing or swallowing
2
Drooling / saliva
3
Pouching / holding food in the mouth
Frequent chest infections / heartburn
Coughing choking at mealtimes 7 8
What you can do
If a person has a swallowing problem, it is crucial to document this and follow your organisation’s protocol for addressing concerns. If in line with the local NHS guidance, the person needs to be referred to a Speech and Language Therapist (SLT) who will recommend any necessary changes that need to be implemented, tailored to the client’s needs.
Also, it is important to work with the SLT as the person living with dementia may not wish to or feel comfortable following the SLTs recommendations. You may already be aware of the dysphagia diet food descriptors recommended by SLTs.
Below you will find links to the webpage to learn more about International Dysphagia Diet Standardisation.
6
Sensation of food getting stuck in the throat
4
A hoarse voice ‘gurgly’ wet sounding voice
5
Unexplained weight loss
Initiative framework.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (A10) IDDSI: The International Dysphagia Diet Standardisation Initiative framework
Monitoring and care planning
Monitoring to spot the signs of poor nutrition
It is important to spot and monitor the signs of poor nutrition. Care professionals have a responsibility on a day-to-day basis to ensure clients are eating and drinking well. The most important way to monitor is by regular weighing, observation and reporting any changes in weight.
To spot the signs of poor nutrition, a useful tool like the Patients Association Nutrition Checklist encourages conversation about client’s nutrition. The nutrition checklist was created in 2018 to fill the gap for a userfriendly and simple self-screening tool. The checklist includes four simple, validated questions (shown on the next page) about appetite, weight, and any noticeable changes. These questions can be part of a conversation rather than directed inquiries with the person living with dementia and their family carers and friend. Refer to page 34 (section 2) for how to use the tool.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (M1) The Patients Association Nutrition Checklist (plus section B-D and online version)
• (M5) National Institute for Health and Care Excellence (NICE) | Nutrition Support in Adults
Adapted from: The Patients Association and Health Innovation Wessex.
Relationship: working together
Working together with family members and close friends
Working with family carers and friends is an important aspect of delivering person-centered nutritional care. Family carers and friends often play a vital role in the life of a person living with dementia, whether as care partners, children, extended family members, or friends. They can play a crucial role in ensuring the person’s well-being and safety.
Maintaining a positive working relationship with family and friends can improve the nutritional care outcomes for the person living with dementia. It's about working together - person living with dementia, family carer and the care professional to have a positive impact.
It is important to emphasise that:
• Everyone's contribution is important in providing care centred around the person living with dementia at home. Good communication is essential for achieving this goal
• Maintaining a clear and efficient communication channel with the family carer or close friend responsible for the client's care is vital to ensure consistency in nutritional care
• Family carers and friends can be engaged as allies to identify the person’s life history, as well as their preferences in eating and drinking (likes and dislikes, cultural, and religious) and any ongoing changes in preferences as dementia progresses
• Home care professionals can rely on the support of families and friends, who are often the first to observe changes in behaviour, such as those stemming from loneliness, a sense of loss, bereavement, or depression
Relationship: working together
• Family and friends may be able to assist staff in understanding and managing aspects of the changing behaviour of the person living with dementia that might otherwise be easily misunderstood
• Dementia can be challenging to manage, both emotionally—as individuals may mourn the ‘loss’ of the person they used to know—and practically. Providing care for a loved one with dementia can be time-consuming, stressful, and costly, potentially leading to burnout and other negative outcomes. It’s important to consider the support that could be offered to family carers themselves
• Home care professionals should consider the protocol set by the home care organisation when working with family and friends.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (R1) Working with families, friends and carers - A framework for adult social care employers | Skills for Care
Enhancing the mealtime experience and activities
Understanding life histories
All care professionals should be familiar with their clients’ life histories. Many clients will have had a life history of preparing food, cooking and caring for others. Meals would have been an important part of their daily activities, giving a sense of purpose and feeling of independence and value.
Food preferences
It is important to consider the person-centred needs of the client living with dementia.
Food preferences are influenced by various factors, including:
• Types of food exposed to throughout life time or family influence over time
• Medical conditions such as allergies, effect of medication
• Availability of food, fresh fruit and vegetables from allotments and gardens
• Religious and cultural beliefs
• Economic status and budget allocated to food
• Social interaction and mealtimes.
It is possible to encourage someone to participate meaningfully in the eating and drinking process at home if there is an understanding of their life histories and preferences. People living with dementia may prefer foods that they were familiar with in their past, which could be linked to specific moments in their lives.
Enhancing tjhe mealtime experience and activities
Identifying food preferences
About me and my Eating & Drinking is a simple tool that can be used to record details about the person living with dementia and their specific preferences. It can be completed as early as possible and updated as necessary. It is not a medical document, but the information provided can assist home care professionals and those involved in their care in building a better understanding of the person’s likes and dislikes. About me and my Eating & Drinking is not a medical document. Please only include any details you are comfortable sharing. See below for the link to download a one-page copy and update as needs change.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (E1) This is me® leaflet: Alzheimer’s Society
• (M3) About Me and My Eating & Drinking (Adapted TOMATO – download the one-page version for use)
About me and my eating & drinking
1. What type of foods do you like?
2. What type of drinks do you like?
3. What foods do you dislike?
4. What types of finger foods do you like?
5. Do you have a time-of-day preference for certain foods and drinks?
6. Would you need assistance choosing foods from your home menu?
7. How would you prefer to be assisted to eat and drink?
8. Do you have a special crockery for eating and drinking?
9. Do you require your dentures to eat?
10. Do you need to have your food cut into smaller bit sizes?
11. Do you have difficulties swallowing your food?
12. Does the food texture need to be modified?
13. What special dietary needs do you have?
14. What are your religious and cultural preferences regarding foods and drinks?
About
How to... include food preferences in care plans
Care plans should account for different food preferences:
• Consider timing of meals – main meals at lunchtime may be preferred by older people, but younger people living with dementia may be used to evening main meals
• Sleep patterns vary in dementia - For some people who have little sleep this could impact when food is eaten
• Sweet foods– people living with dementia, in particular Alzheimer’s Disease may prefer sweet foods
• Changing preferences - if food preferences adapt towards salt, spicy and sour flavours, make good use of natural flavour enhancers like herbs, tomato puree, cheese, marmite and spices.
Understanding and enabling the person living with dementia to participate in the mealtime process at home helps maintain functional skills and feelings of independence and personal control.
Avoid adding too much salt to food because of its direct impact on increasing blood pressure.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• E2 SCIE: Promoting independence at mealtimes for people with dementia
• (M3) About Me and My Eating & Drinking (Adapted TOMATO one page)
• (E1) This is me® Leaflet: Alzheimer’s Society
Specialist crockery
Eating and drinking are ingrained motor memories. Our brains can naturally recall actions, such as using utensils, cutting food, chewing, and swallowing. For people living with dementia, eating and drinking can be one of the last activities they can still do on their own, so it is crucial to support their independence for as long as possible.
Specialist crockery for enhanced mealtime independence:
• Specialist crockery are made from specific materials and tailored to meet special needs, enhancing mealtime experiences and promoting independence during meals
• There are specialised lightweight glasses, cups, and high-quality melamine plates and bowls created to support people living with dementia. This is especially beneficial for those facing mobility issues, visual impairments, or a tendency to accidentally knock over their plates of food
• The melamine plates also contribute to keeping food warmer for an extended period and are often available in bright colours. This enhances contrast with the food, making it easier for people to see their meals on the plates
• They are designed to facilitate easier manipulation of food, thereby contributing to an improved overall mealtime experience
• Contact your GP for advice. An Occupational Therapist may be able to help, depending on local referral criteria.
Tips for mealtimes
Consider some of the following:
• Encourage independence, e.g. at breakfast serve toast in a toast rack with butter and marmalade in small dishes for clients to serve themselves
• Consider setting the dining table where possible to provide visual cues that it is a mealtime
• Ensure the curtains are open, as good lighting helps with vision and sets the right mood
• Assistance with eating should be provided in a way that is most comfortable and culturally familiar. For example, using hands to eat food instead of knives, spoons, and forks
• Gently guide the client’s hand to assist with eating as dementia progresses, where needed
• Provide positive encouragement to eat and drink more.
Consider specialist tableware (see weblink below):
• Lightweight plates, such as high-quality melamine with a broad rim for a better grip
• Specialised lightweight glasses and cups
• Lipped plates
• Bright coloured plates can help differentiate food (plain blue, yellow, red and green have all been shown to help increase appetite). Colour requirements may vary with different individuals living with dementia
• Use non-slip plain colour placemats
• Weighted handle cutlery or specially adapted.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view (E10) Alzheimer’s Society Online Shop | Eating and Drinking
The eating environment and mealtime experience
Living with dementia means people are not able to make memories, changes to their environment may cause confusion and increase stress levels. This may impact on their willingness to eat and drink and recognition of where to go to eat.
Tips for eating at home*
Consider some of the following:
• Sensory stimulation – smell and sight of food being prepared or cooked
• Consider using bowls with deep sides to help people retain independence, or specialist crockery and cutlery
• Ensure food is visible – good use of colours, plain colour crockery
• Soothing background music – no distractions such as TV, vacuuming or other distracting sounds
• Lighting is important — it can enhance vision and help create the right mood and atmosphere. Keeping the curtains open allows natural light to brighten the space.
• Allow sufficient time for food and drink to be enjoyed
• Provide positive encouragement to eat and drink more
• Provide suitable assistance where required – open packets, discreetly cut up food, pour drinks
• Support people to eat and drink where required
• Encourage family members who are available to participate during mealtimes at home to improve eating and drinking.
*Not all clients might have a dining table. Think about making the environment fit their way of living. Take into account their life stories and the ways they like to eat. A relaxed environment is needed for eating. It’s important to avoid distractions and ensure there are sufficient clues to identify the area as somewhere to eat and drink.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (A15) Dementia Friendly Environments: Kitchens and Dining Rooms
Social interaction during mealtimes at home
Eating and drinking with others can have a positive impact and can greatly benefit clients. Social interaction at mealtime can evoke familiar memories of past mealtime experiences and be an encouragement to prompt eating and drinking. If it suits the client’s situation, consider having lunch or a hot/cold drink at the same time as them. Encourage family members and friends to join clients for meals where this is possible. You can refer family carers and friends to their guide on eating and drinking well with dementia for more information. It is also important to remember that relationships may change according to the stage of dementia or mood and the person living with dementia may prefer to be alone and eat and drink on their own.
How to... consider relationships at mealtimes
• Personal preference - support and enable clients to choose where they would like to sit
• Seating arrangements - dignity and respect should be given to where and how clients choose to sit and have their meals. Some people may choose to eat in ways others may find unusual, such as using their hands to eat main meals
• Where possible, sit with the client to encourage and model ‘copycat’ behaviour
• Eating alone - some clients may choose to eat alone in their favourite area of the house, this choice should be respected
• Support and enable their preference.
How to... manage anxiety during mealtimes at home
• If a client shows signs of anxiety at mealtimes, try to find out why by talking to the family and close friends about past experiences
• Observe signs that may bring on anxiety, such as eating in the dining room at home. If this happens, consider whether a change of environment, like sitting near a window, on a balcony, or in a quiet outdoor space if available, would help.
Respecting and knowing the person with dementia will help with understanding how best to communicate and establish strong relationships.
Participation in activities
All types of meaningful activity can promote a sense of independence and wellbeing, which can have a positive impact on appetite. As much as possible, people living with dementia should be encouraged to get involved through the whole mealtime process such as helping to prepare food, set the table, pull out the chairs or put dishes away. Remember to stay flexible to adapt to any changes. Having undertaken an activity one day, a person living with dementia may suddenly change - they may be unable to do a task they used to do or perhaps just do not wish to do it at that time. Best to work with them and tailor activities to their needs.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (E11) Chair-Based Exercise
Tips for activity to enhance appetite*
Daily tasks:
• Helping to set the table by laying cutlery or napkins
• Clearing away dirty plates
• Washing or drying up
• Placing condiments on tables
• Sandwich making
• Wiping the table provides a sense of routine
• Stirring cake mixes.
Suggestions of other activities:
• Walking in the garden, if possible
• Swaying, dancing, or moving to music
• Stretching exercises
• Chair based exercises.
Conversations around:
• Childhood food
• Growing their own food
• Helping parents prepare food
• Cooking for their family
• Past meals that were special e.g., holidays, key events - birthdays, eating out, favourite locations
• Growing fruit and vegetables
• Trips to local pub, coffee shop, tea rooms, garden centre.
*While certain activities mentioned above may be more suitable for live-in carers, it is important to encourage all care professionals to explore ways of promoting simple forms of activities with clients. It is also important to make sure the activity meets the abilities of the client - break it down into several components so they can become involved at different levels.
Sense organs
As dementia progresses, the decline in the ability to taste, smell, and see foods can significantly affect the capacity to recognise and derive pleasure from meals.
Taste Vision Hearing Touch
As we age, it can get harder to recognise flavours due to changes in our taste buds. We also produce less saliva while eating. Sensitivity to sour, bitter, and salty tastes reduces, whereas sensitivity and enjoyment of sweet tastes can remain the same or increase. This can impact on food preferences and many people living with dementia will prefer sweet foods or want to add increased salt to foods.
Vision or eyesight deterioration is common and often leads to reduced peripheral vision, making it challenging to see objects to the side. Someone living with dementia may have problems with visuospatial skills which means difficulty judging distance and the depth and size of objects (like a plate of food). Additionally, there may be a loss of detail perception and a thickening lens that causes objects to appear cloudy. Consider their sensory needs (e.g. clean eyeglasses) to enjoy the meal experience and make sure they are comfortable.
Smell
Please avoid adding too much salt to food because of its direct impact on increasing blood pressure.
Tips to stimulate the senses
• Use of aromas and spices, herbs and other foods to evoke memories
• Sounds such as waves crashing or bacon sizzling to prompt reminiscence
• Food tasting – fruit, cheese, vegetables, smoothie and milkshake samples
• Use of natural flavour enhancers to stimulate the senses at mealtimes – spices, herbs, tomato puree, parmesan cheese, low salt soy sauce. Use especially with pureed meals
• Make food look appealing – presentation is important
• Encourage good oral hygiene
• Switch between different foods – taste buds and odour sensors can become saturated quickly making it difficult to continue tasting the same foods
• Use brightly coloured crockery to clearly identify food.
Consistency of care
Circle of support
There can be a large ‘circle of support’ around the person living with dementia outside home care provision including family carers, healthcare professionals, speech and language therapists, dietitians and nurses. It is important that all staff supporting the person living with dementia to know the person they care for, understand their individual needs and preferences and respect their choices. You can refer family carers to the guide on eating and drinking well with dementia for more information.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (C1) Skills for Care: Dementia
• (R2) Dementia and carers: workers resources| Skills for Care
Consistency of care
Tips for consistency of care
Better communication across the ‘circle of support’:
• It is not helpful to view people living with dementia as ‘sufferers’
• Everyone involved in their care must, first and foremost, see the person —the man, the woman, the father/grandfather, the mother/ grandmother, the former teacher, or the former chef—who happens to have dementia
• Understand behaviours that challenge, it can sometimes serve as a way some clients communicate their unmet needs
• Prioritising eating and drinking as a central part of their care.
Training, information and support for care professional to:
• Prioritise nutrition and hydration
• Direct to relevant services and resources
• Acquire dementia core skills, education and training
Record and share key information life history:
• Nutritional needs
• Food and drink preferences
• Occupation.
Communication
Good communication is the foundation of a strong relationship. It involves expressing oneself, being listened to, and being understood. As dementia progresses, communication skills become increasingly difficult for both the individual with dementia and their family carers and friends. Likes and dislikes may change over time, so it is important to communicate about food preference.
How to... communicate well, verbally
• Use simple language as appropriate
• Say who you are or reintroduce yourself. Sometimes you might have to say so more than once; if so, be patient, do it calmly, and with reassurance
• Say what you are doing so your actions are not a surprise
• Ask if you can help or if they can help you (but you take the lead)
• Keep sentences short and to the point. Draw on their preferences. Instead of asking “Do you want tea or coffee?” consider asking, “Would you like a cup of tea now?” (See About Me and my Eating & Drinking)
• Simple choice during mealtime: too many choices can be confusing
• Don’t raise tone of voice or be patronising
• Speak clearly and at a relaxed pace as information may take longer to understand and process –speaking quickly may cause distress
• Allow plenty of time to respond – 10 seconds is not unusual.
How to... communicate well, non-verbally
Gaining attention:
• Approach the person such that they can see you
• Acknowledge their presence
• Before assisting with eating and drinking, try to have the person’s attention
• Make eye contact and ensure the person is able to see what is about to happen
• Distractions can get in the way – TV, other conversations.
Body language:
• Try to be calm and unhurried to show that you are focusing attention – moving quickly or showing agitation may cause confusion
• Use ‘objects of reference,’ like showing a cup or glass to enable them to choose a hot or cold drink. Also, consider using pictures to indicate mealtime and provide options for them to choose from.
• Provide reassurance – if appropriate, hold the person’s hand to help focus on what is being said.
Listening:
• Listen even when they are not speaking by observing their body language.
• Allow the person to express their feelings about food
• Be patient and allow the person to eat and drink how they wish
• Listen and show care and understanding
• Be patient and offer encouragement if someone has difficulty finding correct words.
Provision of information
Sourcing trusted information
Every section of this guide including availability of food and drinks, monitoring and care planning, relationships, enhancing the mealtime experience and activities, consistency of care and this section (provision of information), plays a vital role in providing person-centred nutritional care for people living with dementia at home. We have compiled a webpage with links to useful information from credible sources, as mentioned in this guide, to help you get started.
To learn more, visit these websites:
• Project website - www.bournemouth.ac.uk/TomatoPOI
• British Dietetic Association (BDA) - https://www.bda.uk.com
• British Nutrition Foundation (BNF) - https://www.nutrition.org.uk
or call:
• Alzheimer’s Dementia Support Line - 0333 150 3456
The internet can be very helpful, but there is also a great deal of conflicting advice out there. So, who can you trust? Always look for evidencebased information from a trusted, credible sources such as government agencies, universities, charities and nutrition journals.
The British Dietetic Association (BDA) and the British Nutrition Foundation (BNF) offer up-to-date, evidencebased information from reputable sources regarding nutrition and hydration. On the BDA website, you can find Food Fact Sheets specific to adults and older adults, covering various topics such as identifying and treating malnutrition and dehydration, associated health problems, diets, probiotics and gut health, as well as supplements.
The BNF provides free access to webinars and information on various health conditions, life stages, and sustainable diets.
Provision of information
Section two
Spotting the signs of poor nutriton by encouraging conversations
The nutrition checklist
There are two versions of the Patients Association Nutrition Checklist– one for clients and family carers or close friends to use, and another for staff, including home care professionals.
Adapted: The Patients Association and Wessex Academic Health Science Network (Wessex AHSN) 2018.
Be sure to accurately record changes and follow your organisation's protocol to guide the next steps. Where appropriate, prioritising food-based approach can help the client eat well and meet their needs. It is important to work with family carers and friends to ensure that any additional nutritional support is consistent. After spotting risks of undernutrition, appropriate action should be taken to manage any changes in weight. Further assessment and appropriate referrals may be needed for specialist advice. It is helpful to monitor and keep an eye on the person’s progress over time.
Visit www.bournemouth.ac.uk/TomatoPOI to access the full checklist (plus section B-D) and view:
• The Patients Association Nutrition Checklist (pdf and online version)
• A potential risk of undernutrition due poor eating and drinking may be identified if the client answers yes or don’t know to one or more questions as stated above
• The checklist also provides guidance to practical nutrition advice and signposting to relevant information and resources to help those likely to be at risk (See Section B for more details).
Food and drink diaries
By carefully observing and documenting the food and drink the person living with dementia has had, it becomes possible to identify eating patterns, including preferences, likes, dislikes, and preferred mealtimes on a daily basis.
Recording mealtime behaviours at home is valuable. Based on this information, care plans can be adjusted, and appropriate interventions can be implemented accordingly.
Observation
Food left uneaten or refused
Poor drink intake
Moves around with a purpose during mealtimes
Difficulties chewing or swallowing
Difficulty using cutlery or drinking utensils
Distracted from eating
Holds food in mouth or doesn’t open mouth
A drink chart or diary can be used if the amount of drinks the clienr has appears to be low or if they have symptoms of a urine infection. When a client is not having sufficient amounts of drinks, it is crucial to review the existing drink provision and make individual changes accordingly.
Clients may need reassurance that drinking more will not worsen incontinence.
Possible intervention
• Discuss food preferences
• Check texture and consistency of food
• Offer smaller portions and assist with eating if necessary.
• Encouraging prompts – make a drink rather than asking
• Offer a variety of different drinks.
• Ensure mealtimes are calm – no distractions
• Provide finger/ bite sized food that can be eaten ‘on the go’.
• Use verbal cues as a reminder
• Ask the GP to refer to a Speech and Language Therapist (SLT).
• Use verbal cues and show correct use
• Offer finger food or cut food into smaller pieces.
• Ensure mealtimes are calm – no distractions
• Make sure they have everything needed for the meal – glasses, dentures, been to the toilet
• Use verbal or manual cues – place cutlery into hands
• Sit together and model eating.
• Use verbal cues to chew or open the mouth
• Offer smaller amounts of a variety of foods
• Gently massage the cheek or touch the lips with a spoon.
Sample food and fluid diary
Name
Special diet
e.g. dysphagia
modified texture,* coeliac, diabetic, vegetarian
Assisted feed
Yes / No
Fortified Yes / No
Risk of malnutrition Risk of dehydration
Has choking been identified as a risk? Yes / No
Check assessment in care plan
Date Time Food / quantity (including supplements)
00.00 – 07.00 Snacks
07.00 – 12.00
Breakfast / midmorning snack
All food consumed should be recorded accurately, e.g. 1 slice, 2 scoops, 1 teaspoon, 1 tablespoon, ½ portion, ¼ portion etc.
* for dysphagia diet remember to include descriptor. Pureed food must be described in full and any food supplements must be recorded.
A mug holds approx. 250ml and a glass 200ml
12.00 – 17.00
Lunch / midafternoon snack 17.00- 24.00
Evening meal / supper / snack
Comments/actions
For example: If fluid intake is less than 1.5 litres – what action is needed to increase fluid intake tomorrow? If portions are too large, offer 5 smaller meals a day.
Encouraging eating and drinking well
Examples of how to fortify foods
For clients at risk of undernutrition, it is important that food and drinks contain as much energy (calories), protein and other nutrients as possible.
How to increase nutrient content through fortifying foods:
• Add nutrient dense foods such as egg, cheese to increase nutrient content see examples below)
• Include nutritious drinks to increase nutrient intake –such as milk-based drinks and fortified soups with nutrient rich ingredients.
Food based approach - practical ways to prioritise a nutrient dense diet if someone is losing weight unintentionally.
(1 egg; varied sizes)
Dried skimmed milk powder (1 tablespoon; 15 grams)
Preferred nut butter e.g. almond or peanut (1 tablespoon; 15 grams)
Grated cheese (1 tablespoon; 10 grams)
Soya protein powder (1 tablespoon full; 14 grams)
Mashed potato, porridge, custard
Mashed potato, porridge, milk based soups, rice pudding, custard
Porridge with whole milk, vegetable soup
egg with whole milk, potatoes, vegetables, baked beans
Fruit bowls, porridge, curries, butternut squash or lentil soup
Consider enhancing meals with some of these foods to increase nutrient content.
E.g. mix 2 tablespoons of skimmed milk powder into a bowl of soup for extra nutrients.
Examples of nutrient dense snacks
Preferred nuts e.g. almond or peanut (1 handful; 40grams)
Greek yoghurt (1 tub; 150 grams)
Falafel (2 mini balls; 22grams)
Presenting the egg whole or cutting it into quarters
The needs of the person living with dementia, soft nut bars could be an alternative
Using appropriate cutlery to enable independence or assist where needed
Offer a drink alongside to help with swallowing
You can add 4 tablespoons (60grams) of skimmed milk powder to 568ml full fat milk. You can use this as a base for making milky drinks or add it to suitable foods.
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (A21) Creating a fortified diet recipe book: How
• (A22) Spotting and treating malnutrition
Suggestions for snacks and drinks
Some of the sugary snacks and drinks may not be suitable for someone with diabetes and those with swallowing problems.
Savoury
Drinks
Some of the sugary snacks and drinks may not be suitable for clients with diabetes.
Toasted crumpets and cheese
Hummus and bread sticks
Cheese and biscuits
Samosas, pakoras, bhajis
Spanish omelette or frittata
Mini pancakes with cream cheese topping and smoked salmon
Sweet
Malt loaf
Flapjack
Tub of custard
Hot chocolate with fortified milk Milky coffee
Hot malted milk
Yoghurt drinks
Fruit smoothies
Milk shake
Planning menus
Menus should be carefully planned to consider the diverse cultural, religious, and food preferences of clients. These preferences should be respected. For instance, some clients may not eat beef or pork, or drink alcohol based on their religious beliefs.
Tips for menu planning
• Start with a conversation: Ask about food likes, dislikes, routines, and cultural or religious needs. Understand how and when the person prefers to eat. Encourage independence where possible
• Flexible meal planning: Base plans on familiar foods and what is easily available. Keep shopping lists adaptable to changing preferences and availability
• Provide options: Offer meals that suit individual needs, e.g. soft or texture-modified foods, finger foods, fortified, diabetic-friendly, vegetarian/vegan, and culturally appropriate dishes
• Involve the person: Support involvement in food choices where appropriate to promote independence, dignity and autonomy
• Coordinate with family carers and friends: Work together with family carers and friends. Consider the support needed with shopping, deliveries, or local access to food
Food presentation
• Food safety: Ensure safe kitchen practices. Consider food storage, temperatures, and expiry dates. Use the freezer wisely – if a client favours a particular dish, make in a large batch and freeze in individual portions
• Plan within budget: Use affordable, nutritious ingredients. Consider cost, food delivery, access to shops and support with buying food
• Consider food presentation and portion sizes: Meals should be appetising and served in suitable portions to encourage eating
• Celebrate special occasions: Include birthdays, anniversaries, and cultural events in meal planning to bring enjoyment and connection.
Maintain flexibility with food choices - some people may change their minds on their previous choice.
Presentation is essential, especially for someone living with dementia, so remember to take time to make food look appealing.
Frequent servings of smaller meals
Consider offering frequent, smaller meals, especially when dealing with a small appetite. It can be less overwhelming for the person if small, manageable portions are served rather than large quantities of food.
Colour
Two or three colours on a plate are more interesting than just one. Would you want to eat poached fish in a white sauce with boiled potatoes and cauliflower? Probably not! Now add parsley to the sauce, roast the potatoes and serve with broccoli and carrots – much more appealing! Make sure each food is clearly visible on the plate.
Portion and plate size
Balance
Choose foods that offer variety and contrast and think about different textures (for those not on a texture modified diet). Serve soup with crunchy croutons, crisp vegetables with noodles or roast potatoes with cauliflower cheese.
A variety of different shapes also adds to the presentation – meatballs, new potatoes and carrots cut into rounds are all similar shapes. Why not change the potatoes for mash and grate the carrots?
Present food on the right size plate. If the plate is too small, food can appear messy and too much to eat, if it’s too large it may look insufficient.
Foods with modified texture
Presentation is essential for foods with modified texture. Any meal that is blended together will end up looking the same – brown, sloppy and unappetising. Always remember to blend foods separately and make use of piping bags, food moulds and shaped cutters.
The International Dysphagia Diet standardisation Initiative framework
To meet treatment standards, the correct texture must be provided, as outlined in the International Dysphagia Diet Standardisation Initiative (IDDSI) framework (see below). This should also include consideration of eating and drinking with acknowledged risk.
Visit www.bournemouth.ac.uk/TomatoPOI to view
• (A10) IDDSI: The International Dysphagia Diet Standardisation Initiative framework
Finger food and grazing menus
Finger foods, which can easily be eaten by hand, are a great alternative to meals presented on a plate and can prolong independent eating and maintain dignity. They are perfect for those who find it difficult to use cutlery (with arthritic hands or tremors) or no longer recognise the purpose of cutlery.
Grazing menus are ideal for someone who is unable to sit still to eat, finds it difficult to concentrate or has a tendency to walking with purpose – why not consider providing a lunch box with separate sections for eating ‘on the move’? Or leave snacks and drinks out in a place where someone goes to when walking with purpose. Remember to follow food safety regulations and don’t leave food out which can become contaminated.
Tips for serving finger foods
• Use foods that are easy to hold
• Serve in bite-size chunks
• Choose foods that are moist and not too dry
• Serve at room temperature
• Provide a variety of different foods to ensure good nutritional balance*
• Pack foods into a lunch box or paper bag
• Make sure food looks colourful and appealing
• Provide drinks that are easy to hold – two handled mugs, use straws, small cartons, frozen drinks
• Provide wipes or flannels to clean hands
• Finger food may not be suitable for someone with swallowing difficulties.
* It is possible for a finger food or grazing menu to meet the nutritional requirements of clients. Fibre and folate may be in shorter supply, so take care to include foods containing these nutrients - cereal bars, broccoli, green beans, asparagus, wholegrain bread, fruit and vegetables.
Food safety
Food safety is paramount. All care professionals should have basic food safety training to ensure extra care is taken when dealing with food to reduce the spread of harmful bacteria.
Suggestions for finger foods
Breakfast
Hard boiled egg cut into quarters
Lunch / main meal
Fish goujons, fish fingers or fish cakes
Kebabs
Sliced or cubed roast meat
Chicken drumsticks
Salad - lettuce, cherry tomatoes, cucumber, avocado, beetroot, celery - cut into slices or sticks
Tea / light meal
French toast (eggy bread)
Mini new potatoes or small roast potatoes
Potato waffles or chunky chips
Steamed or raw vegetable batons
Broccoli spears, green beans, asparagus
Sandwiches with variety of fillings Cheese cubes
Bread rolls, chapatis, roti, naan bread, bagels Salad - as above
Spanish omelette or frittata
Tortilla wraps Grilled cheese on toast Paninis
Dessert
Fresh fruit - individually or chunky fruit salad
Snacks
Vegetable batons
Buttered malt loaf or tea loaf
Fresh fruit portions – try with a yogurt dip
Cheese and crackers
Sample template of a weekly menu planner with photos
Monday
Name of food/drink
Tuesday
Name of food/drink
Wednesday
Name of food/drink
Thursday
Name of food/drink
Friday
Name of food/drink
Tofu cubes
Suggestions for shopping list | cupboard items
Tinned vegetables and fruits
Porridge Oats
Dried fruits (raisins, dates, figs, apricots, other mixed dried fruits)
Tea bags or instant coffee (based on preference)
Peanut butter, honey, marmalade and jam
Mayonnaise
Tinned meats, fish and lentils (based on preference) Skimmed milk powder
Tinned custard and rice pudding
Tinned baked beans and sweet corn
Tinned tomato sauce, hot sauces, and spices
Powdered milk sauces, gravy granules
Tinned evaporated milk
Bag of rice, spaghetti, macaroni
Hot chocolate drink powder, Horlicks, milk shake powder (different flavours - banana, strawberry)
Fruit Juice and squash
Wheat meal powder Semolina powder
Suggestions for shopping list | freezer inventory
Frozen vegetables (e.g. broccoli)
Frozen fruits (e.g. mixed berries)
Ready meals/pre-prepared meals
Frozen desserts (fruit crumbles, puddings)
Garlic bread
Frozen finger foods (sausages, fish fingers, samosa etc.)
Taking care of your own wellbeing
As a care professional, it is essential you look after your own health as well as those you care for. Eating well and maintaining a healthy lifestyle can enhance your well-being and enable you to deliver the best possible care.
How to... eat a healthy balanced diet
• Aim for at least 5 portions of a variety of fruit and vegetables
• Base your meals on carbohydrates (potato, yam, rice, grains), choosing wholegrain where possible
• Have some dairy or dairy alternatives (such as soya drinks), choosing lower fat/sugar options
• Eat some beans, pulses, fish, eggs, meat and other proteins (2 portions of fish every week, one should be oily)
• Choose unsaturated oils and spreads; eat in small amounts
• Aim for at least 1,600ml (women) and 2,000ml (men) daily, (7–8 mugs of 250ml)
• Salt or sugar should be eaten less and in small amounts
• For older adults 65 years and over, it is best to focus on eating, drinking, and ageing well. As we age, the body requires more protein, calcium, folate (folic acid), and vitamin B12 for overall health.
Thank you for your dedication to supporting people living with dementia as well as their family carers and friends.
Avoid adding too much salt to food because of its direct impact on increasing blood pressure.
Healthy eating resources
The Eatwell Guide: A simple visual representation which show the proportion of different foods and drinks needed for a healthy balanced diet.
Please note: The reference to the Eatwell Guide here is primarily a guidance for you as a care professional but may not be appropriate for people living with dementia due to their specific needs and underlying problems.
Source: Public Health England in association with the Welsh Governement Food Standards Scotland and the Food Standards Agency in Northern Ireland. © Crown copyright.
The Eating, Drinking and Ageing Well Resource: A public health resource for older adults, providing a practical guide to healthy eating, offering age-appropriate messages, and highlighting the latest evidence on food and nutrition.
Source: The British Dietetic Association’s (BDA) Older People Specialist Group, with support from Friends of the Elderly and the British Geriatrics Society. ©The British Dietetic Association (BDA) 2023- bda.uk.com
To learn more visit www.bournemouth.ac.uk/TomatoPOI to view
• (T2) Eatwell Guide
• (A3) Eating, Drinking and Ageing Well - British Dietetic Association
• (A4) Eating, Drinking and Ageing Well - Easy Read Version - British Dietetic Association
• (T3) African & Caribbean Eatwell Guide
• (T4) Healthy Eating for the South Asian Community (Diabetes UK) – Recipe Search
• (A9) African, Caribbean and South Asian Food Guide | Healthier You NHS Diabetes Prevention Programme
• (A7) Diabetes Recipe Finder
Section three
Checklists
Use
Availabilty of food and drinks
Monitoring and care planning
Acknowledgements
Contributors
Profound appreciation to everyone who contributed towards producing the adapted guides and for supporting the overall TOMATO project.
Patient and Public Involvement (PPI) and Project Steering Group
Thank you to the dedicated TOMATO project PPI Group and the Project Steering Group for their invaluable contributions, which have greatly influenced the development of the study and future direction.
Dr Gladys Yinusa
Post-Doctoral Research Fellow
Bournemouth University and
NIHR DEM-COMM Fellow
NIHR ARC Wessex
Dr Sarah Thomas
Senior Researcher
Centre for Wellbeing & Long-Term Health
Bournemouth University
John Major
TOMATO Public and Patient Involvement lead Lay representative
Helen Knight
Clinical Head of Service for Neurology & Adult Speech and Language Therapy
Leeds Community Healthcare NHS Trust
Professor Jane Murphy
Chief Investigator
Professor of Nutrition
Registered Nutritionist and Dietitian
Deputy Dean for Research
Bournemouth University
Professor Lee-Ann Fenge
Professor of Social Care
Registered Social Worker Bournemouth University
Dr Jane Townson
CEO for the UK Homecare Association (UKHCA) Homecare Association
Caroline Hemmings
Creative Design and Administrative Support Officer Bournemouth University
Professor Claire Surr
Professor of Dementia Studies Director of the Centre for Dementia Research Leeds Beckett University
Professor Gordon Taylor
Professor of Medical Statistics University of Exeter
Dr Michelle Heward
Lecturer in Psychology
Dementia Champion
PPIE-lead Academic Bournemouth University
Dr Daniel Howdon
Senior Research Fellow of Health Economics School of Medicine University of Leeds
Thank you to Alexsa Brooks for her assistance with supporting Caroline Hemmings with the design of this guide.
Collaborating organisations
We recognise and appreciate all the collaborating organisations; Good Oaks Home Care; Home Instead Warrington & Lymm; Home Instead Hammersmith & Chiswick; Love in Care; Westmorland Homecare; and Home Instead Worcester, along with its Cheltenham, Warwick, and associated franchises providing care across the region.
Research participants
A special thank you to the research participants—people with dementia, family carers, home care professionals, and healthcare professionals—for sharing their experiences and feedback, which shaped the adaptation of this home care guide.
Funding
This project (TOMATO) is funded by the National Institute for Health Research (NIHR) [Research for Patient Benefit (award identifier: NIHR203110)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
