Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0MANAGEMENT OF DEMENTIA SYMPTOMS 245Eating Disorders in Alzheimer’s DiseasePaul E. Cullen 1 and Clive Ballard 21Bushey Fields Hospital, Dudley, and 2 Newcastle upon Tyne General Hospital, UKEating disorders are a recognized feature of dementia, whichinclude a preference for sweet foods (11%), increased (21%) ordecreased (22%) consumption and eating non-food substances(3%) and are particularly common in Alzheimer’s disease (AD) 1 .Clinical 1 and subclinical 3 swallowing problems, general dentalhealth and oropharyngooesophageal function are all important.The basic necessity of eating to maintain health, the frustrationthat disordered eating causes to caregivers and the increased riskof institutionalization and death all make this an important topic 4 .A number of rating scales to evaluate psychopathology indementia now include an eating disorder subcategory (e.g.Neuropsychiatric Inventory), whilst other scales have beendeveloped specifically to assess eating disorders in AD 5 .Several neurotransmitters have been linked to eating disordersin AD. Reduced neuropetide Y and norepinephrine are associatedwith anorexia, whilst the action of galanin in the hypothalamus isthought to increase fat intake and impact upon cholinergichippocampal systems.Studies have shown associations between specific brain changesand eating disorders in AD, e.g. hyperorality with widening of thethird ventricle and frontal and occipital lobe atrophy, Klu¨ver–Bucy syndrome features with temporal lobe atrophy 14 and lowbody weight with temporal cortical atrophy 6 . Hyperphagia maybe associated with increased calorific need in patients with motorrestlessness, whilst younger people with more severe dementiawho are not restless may over-eat because they respond to anyfood stimulus, possibly as a manifestation of frontal lobepathology 7 . The European Commission has focused upon weightloss in AD 4 .In practice there is little evidence to inform the management ofthese problems. The best approaches generally involve commonsense and clinical judgement. The most frequent clinicallysignificant problems relate to poor appetite and weight loss. Afirst step is to assess and treat underlying disorders. This may varyfrom assessment of oral health to the pharmacological treatmentof a concurrent depression. Educating care staff and informalcarers about some of the changes in food preference andencouraging flexibility with the content and timing of anindividual’s diet is often an effective remedy 8–10 .Giving a diet with a higher proportion of sweet foods, such asdesserts, chocolate, cakes and biscuits, is a pragmatic approach.This is helpful as it takes pressure off carers to produce a strictlybalanced diet of cooked dinners, which eases the stress ofmealtimes. Other types of difficulty are less frequent, and areprobably best treated after a detailed individual evaluation, usingtechniques such as an Antecedent–Behaviour–Consequence(‘‘ABC’’) diary. Work pertaining to ideational apraxia 11 andattribution theory 12 has contributed to the management of theseproblems. The management of eating disorders in AD raisesimportant ethical issues 13 .REFERENCES1. Cullen P, Abid F, Patel A et al. Eating disorders in dementia. Int JGeriat Psychiat 12, 559–62.2. Horner J, Alberts MJ, Dawson DV, Cook GM. Swallowing inAlzheimer’s disease. Alzheimer Dis Assoc Disord 1994; 8, 177–89.3. Feinberg MJ, Ekberg O, Segall L, Tully J. Deglutition in elderlypatients with dementia: findings of videofluorographic evaluation andimpact on staging and management. Radiology 183, 811–14.4. Riviere S, Lauque S, Micas M et al. European Programme: Nutrition,Alzheimer’s Disease and Health Promotion. Rev Geriat 1999; 24,121–6.5. Tully MW, Matrakas KL, Muir J, Musallam K. The EatingBehaviour Scale. A simple method of assessing functional ability inpatients with Alzheimer’s disease. J Gerontol Nursing 1997; 23, 9–15.6. Grundman M, Corey-Bloom J, Jernigan T et al. Low body weight inAlzheimer’s disease is associated with mesial temporal cortex atrophy.Neurology 1996; 46: 1585–91.7. Smith G, Vigen V, Evans J et al. Patterns and associates ofhyperphagia in patients with dementia. Neuropsychiat NeuropsycholBehav Neurol 1998; 11: 97–102.8. Boylston E, Ryan C, Brown C and Westfall B. Preventing precipitousweight loss in demented patients by altering food texture. J NutElderly 15, 43–8.9. Soltesz KS, Dayton JH. Finger foods help those with Alzheimer’smaintain weight. J Am Dietet Assoc 1993; 93, 1106–8.10. Suski NS, Nielsen CC. Factors affecting food intake of women withAlzheimer’s type dementia in long-term care. J Am Dietet Assoc 1989;89, 1770–3.11. LeClerc CM, Wells DL. Use of content methodology process toenhance feeding abilities threatened by ideational apraxia in peoplewith Alzheimer’s-type dementia. Geriat Nursing 1998; 19: 261–7.12. Fopma-Loy J, Austin JK. Application of an attribution–affect–actionmodel of care-giving behaviour. Arch Psychiat Nursing 11, 210–17.13. Clibbens R. Eating, ethics and Alzheimer’s. Nursing Times 1996; 92,29–30.14. Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer’sdisease. Br J Psychiat 1990; 157, 86–94.