November/December 2023

Eating Disorders and Dementia
By Jennifer Lutz
Today’s Geriatric Medicine
Vol. 16 No. 6 P. 10

Age-Related Changes vs Disordered Eating

Disordered eating is a common occurrence in patients with dementia and can include changes in food preferences and eating habits, decreased appetite, binge eating, an obsessive focus on certain foods, and more. Understanding the difference between age-related changes in eating and dementia-related disordered eating can help clinicians, caretakers, and family members care for people with dementia.

Identifying eating disorders and having an action plan is also important for physical and mental health in this population. At the same time, certain disordered eating can serve as an early warning sign. As pharmacological tools advance in slowing disease progression, catching these early warning signs becomes more crucial.

How Age-Related Disordered Eating Differs From Eating Disorders in Patients With Dementia
Certain dietary patterns, such as the Mediterranean diet, have shown preventive neuroprotective effects, helping slow cognitive decline. At the same time, individual dietary choices and appetite tend to change with age, sometimes making it difficult for individuals to meet their nutrient needs through such patterns. But when are these changes in appetite simply due to age and when are they a warning sign of dementia? Understanding the relationship between eating disorders and dementia could be a very useful early diagnostic tool, says Marliena Aielo, a research fellow in the department of psychology, Università Di Bologna. One way to discern the difference between age-related and dementia-related changes is to look for other signs of dementia, such as behavior changes, Aielo says. These behavior changes could include new difficulties in solving problems, difficulty completing daily tasks (such as using the microwave or oven), confusion with time and place, trouble understanding visual images and special relationships, vocabulary loss, misplacing things (at greater frequency), and withdrawal from work or social activities.1

It’s also important to understand how eating disorders present differently in various forms of dementia. For example, whereas in Alzheimer’s disease (AD), changes such as food preference, appetite, and eating habits tend to get worse in the moderate stages but decrease in the more severe stages, aberrant eating behavior (such as binge-eating or obsessive focus on specific foods) can be a clinically important diagnostic tool for frontotemporal dementia, the most common form of early-onset dementia.2

In healthy aging, a variety of factors influence eating and thus could influence nutrient intake. Social factors such as low-income, social isolation, and a reduction in food preparation can affect food quality and quantity, leading to poor or insufficient nutrition.3,4 A decrease in food consumption can exhibit as weight loss, and physiological changes such as altered circadian rhythms, loss of skeletal muscle mass, and hormonal disruptions can lead to sarcopenic obesity.4 These age-related factors could mask eating disorders; they could also worsen decline and lead to a vicious cycle of deterioration. While it’s equally important to attend to these age-related changes in eating, identifying changes specifically related to dementia (or not) is an important step in improving nutrition.

Unfortunately, brain changes responsible for neurocognitive disorders are often fairly developed before diagnosis. Eating disorders can therefore be another tool in early diagnosis. For patients already diagnosed, an awareness of the link to eating disorders helps caregivers better care for the individual.

Disordered Eating in Patients With AD
Noticing eating disorders in patients with AD may be particularly difficult due to the typically slow progression of the disease. For example, early memory loss could simply affect the types of foods purchased. What appears as simple changes in preference could be an indicator of memory loss, not just changing taste; the most common change in preference is toward sweeter foods. Patients might forget to eat and drink, leading to malnutrition and dehydration. They might also eat multiple times, having forgotten a previous meal. As the disease progresses, patients may have difficulty swallowing, further decreasing food and nutrient consumption.

Poor nutrition could worsen the symptoms of AD and cause unwanted weight loss. There are multiple reasons a person with AD may refuse to eat, and being aware of these could help to find solutions. Someone may not recognize the food on their plate; an old favorite may seem foreign and distasteful. If you don’t remember how much you loved apples, you’re unlikely to eat them. Trouble swallowing could make eating uncomfortable, in which case applesauce would be a better alternative. A decreased sense of taste and smell could also affect appetite.

Disordered Eating in Patients With Frontotemporal Dementia
The most common form of early-onset dementia, frontotemporal dementia, presents as clinically different variants: behavioral, semantic, and motor impairment. The difference in these variants is a consequence of the localization of neuropathology and relates to different eating disorders.

Behavioral frontotemporal dementia is most linked to aberrant eating behaviors, which can be hard to spot at first but should be on a practitioner’s radar. Hyperorality and dietary changes are reported in more than 60% of frontotemporal dementia patients at initial presentation. Some things to look for include a preference for sweet foods (similar to that seen in AD), overeating, binge eating, and obsessive or compulsive food choices.

A recent study, published in the Journal of Neuropsychology and supervised by Aielo, examined the link between semantic memory, eating disorders, and dementia. The study included patients with frontotemporal dementia, patients with AD, and a healthy control group. Participants were given semantic memory tests and a questionnaire on eating disorders. The scores of these tests were then analyzed in relation to anatomical data, mainly cerebral cortex volume and the volume of white matter tracts.

White matter in the brain is composed of bundles of nerve fibers that put different parts of the brain and the spinal cord in communication with each other; a volume-decrease would indicate fewer nerve fibers.

Study results showed that a higher pathological score for eating disorders coincided with worse performance on the semantic test. These test results also coincided with a decreased white matter volume in brain regions found to be involved with semantic memory and in regions involved in eating behaviors, including the fusiform gyrus. The worse patients performed on these tests, the greater the decrease they exhibited in cortex volume. Decreased volume of white matter tracks suggests errors in communications between parts of the brain, such as the visual and semantic areas, which could be one explanation for disordered eating seen in patients with frontotemporal dementia. The results of this study could point researchers and practitioners toward novel forms of rehabilitation.

“The first step is to repeat this study to see if rehabilitation works,” Aielo says. “The two eating disorders we most often encounter in frontotemporal dementia can be divided into two categories: binge eating and food selectivity,” she says. In patients who exhibit binge eating, the research team believes there could be a link to the loss of inhibitory control. “We could potentially try to see if what works for patients lacking this control also works for patients with dementia,” Aielo says. Future studies could test transcranial direct current stimulation, which has shown some preliminary success as a rehabilitation approach in binge eating.

For people with dementia who exhibit extreme food selectivity, working with food images could be effective. The findings from Aielo and her team suggest this selectivity could be part of a disconnect; patients may no longer recognize the foods on their plates. By using visual stimulation, such as photos in conjunction with food, researchers may be able to help patients retrain their brains to recognize a greater number of foods.

Previous studies and brain imaging have shown significant atrophy in the hypothalamus and in the orbitofrontal region.

Considerations: Modifications for Patients With Disordered Eating
Changes in eating behavior can be particularly challenging for caregivers, especially as they may not identify these behaviors as symptoms. For this reason, one of the first steps in helping patients is raising provider and caregiver awareness. When providers, family members, and caregivers understand eating disorders as a symptom of disease progression, they can approach it with more targeted and tactful measures.

When patients exhibit a loss of appetite, caregivers could present foods that are especially colorful or aromatic; bringing foods to life in this way can help the person connect on various levels (not just through memory). Another approach involves offering smaller meals more often; this tackles the issue of forgotten meals (in both directions) and avoids visually overwhelming the patient with heaps of food. Try a wide variety of foods; just as preferences can change rapidly in childhood, they may do the same in late adulthood, and adapting to these developments can benefit both patient and caregiver. People may also consider liquid diet supplements (like health shakes) and search for options that have a full nutrient profile, being mindful of overloading patients who may have trouble metabolizing certain nutrients (such as those on dialysis) and matching meal replacements with individual needs.

Sometimes changing behavior in dementia can present as anger or outbursts (such as refusing to eat and spitting out food). While these may not be directly related to an eating disorder, they certainly could interfere with proper nutrition. Dementia can be frustrating for the person living through it. They may not like the food but are having difficulty expressing it, or they could be uncomfortable in the environment, have difficulty eating, or be overwhelmed by multiple stimuli. In this situation, caregivers can work to make the patients more comfortable, give them a break from eating, and make sure they’re in a room where they feel secure. After some time has passed and the individual is more relaxed, the caretaker could try offering a different food option. Of course, asking the patients why they don’t want to eat could be helpful. Sometimes, people simply don’t recognize the food being offered, and photos or packaging could help. For example, showing someone the box that cereal comes in or the familiar pudding packing they grew up with could help.

As AD progresses, patients may have trouble swallowing, which can make eating both uncomfortable and scary. In this situation, speech and language therapists could be helpful; they can evaluate the patients and present options. A dietitian should also be consulted to create an eating plan that ensures patients meet their specific dietary needs. Focus on foods that are soft and avoid dry foods. Examples of foods that are easier to swallow and nutritionally dense include scrambled eggs, oatmeal, applesauce, yogurt, cottage cheese, soups, baked fish, smoothies, and milkshakes. Foods that are more difficult to swallow should be cut into small, more digestible pieces.

Remember, one of the most important things is identifying foods the patient likes, otherwise they’re unlikely to eat them. It’s also good practice to check the patient’s mouth after meals, making sure there is no remaining food they could choke on.7

In certain cases, selective serotonin reuptake inhibitors have been used to treat behavior symptoms in patients with frontotemporal dementia, including carbohydrate cravings and compulsions.6 The broad focus now is on behavioral intervention, caring for caregivers, and the use of rational drug therapy.

Considerations Toward Food and Quality of Life in Patients With Dementia
Dementia can be a devastating disease for the patient, family, and caregiver. While adequate and proper nutrition is important for health, enjoyment of food and quality of relationships are an invaluable part of quality of life. While dietary patterns such as the Mediterranean diet have shown to be preventive against dementia, there’s little evidence that an ice cream cone or cookie can worsen the condition. Where binge eating is a concern, the patient’s care team can consider detriment to quality of life and discuss pharmaceutical interventions. Rehabilitation depends on each case and should consider the patient’s overall life and preferences. Sometimes, “let them eat cake” could be a very good practice (just not too much and don’t give up on those meal shakes).

— Jennifer Lutz is a freelance journalist who covers health, politics, and travel. She’s written for both consumer and professional medical magazines as well as popular newspapers. Her writing can be found in Practical Pain Management, Endocrine Web, Psycom Pro, The Guardian, New York Daily News, Thrive Global, BuzzFeed, and The Local Spain. In addition to journalism, Lutz works as a strategies and communication consultant for nonprofits focused on improving community health.

References
1. 10 early signs and symptoms of Alzheimer’s and dementia. Alzheimer’s Disease and Dementia website. https://www.alz.org/alzheimers-dementia/10_signs. Accessed September 21, 2023.

2. Fostinelli S, De Amicis R, Leone A, et al. Eating behavior in aging and dementia: the need for a comprehensive assessment. Front Nutr. 2020;7:604488.

3. Porter Starr KN, McDonald SR, Bales CW. Nutritional vulnerability in older adults: a continuum of concerns. Curr Nutr Rep. 2015;4(2):176-184.

4. Locher JL, Ritchie CS, Roth DL, Baker PS, Bodner EV, Allman RM. Social isolation, support, and capital and nutritional risk in an older sample: ethnic and gender differences. Soc Sci Med. 2005;60(4):747-761.

5. Vignando M, Rumiati RI, Manganotti P, Cattaruzza T, Aiello M. Establishing links between abnormal eating behaviours and semantic deficits in dementia. J Neuropsychol. 2020;14(3):431-448.

6. Cipriani G, Carlesi C, Lucetti C, Danti S, Nuti A. Eating behaviors and dietary changes in patients with dementia. Am J Alzheimers Dis Other Demen. 2016;31(8):706-716.

7. Eating and nutritional challenges in patients with Alzheimer's disease: tips for caregivers. Cleveland Clinic website. https://my.clevelandclinic.org/health/articles/9597-eating-and-nutritional-challenges-in-patients-with-alzheimers-disease-tips-for-caregivers. Updated May 23, 2019. Accessed September 21, 2023.