Nutrire

Pivi et al. Nutrire (2017) 42:1

DOI 10.1186/s41110-016-0025-7

REVIEW Open Access

Nutritional management for Alzheimer’s

disease in all stages: mild, moderate, and
severe
Glaucia Akiko Kamikado Pivi1,2*, Neusa Maria de Andrade Vieira2, Jaqueline Botelho da Ponte2,
Débora Santos Coca de Moraes2 and Paulo Henrique Ferreira Bertolucci2

Abstract
Alzheimer’s disease corresponds to 50–70% of all dementia syndromes, classified as a progressive
neurodegenerative disease showing diffuse cortical atrophy with three stages of evolution: mild, moderate, and
severe. Behavioral symptoms and memory loss are major manifestations of the disease. Non-pharmacological
interventions are essential to improve the quality of life of these patients. Interdisciplinary assistance is essential
throughout the disease course. Regarding nutrition for patients with Alzheimer’s disease, weight loss and behavioral
changes related to food are major objects of scientific study, as they trigger deterioration of the quality of life of
patients and caregivers. Knowing which nutritional guidelines should be used helps in clinical decisions. The study
of nutrition in dementia is, therefore, critical for patient management.
Keywords: Alzheimer’s disease, Dementia, Nutrition, Oral nutritional supplements, Dysphagia

Background Interdisciplinary assistance by nutritionists, psychologists,

The World Alzheimer Report (2015) estimates that 46
million people worldwide are living with Alzheimer’s dis-
ease (AD) and other dementias, and that this prevalence
will increase to 131.5 million in 2050. In developing
countries, including Brazil, this calculated rate is three
to four times larger than that in developed countries [1].
AD corresponds to 50–70% of all dementia syn-
dromes, classified as a progressive neurodegenerative
disease showing diffuse cortical atrophy with three
stages of evolution: mild, moderate, and severe. Memory
decline, attention, and language impairments may be
seen during the disease course, followed by behavioral
changes that end up spoiling the performance in basic
activities of daily living and problem-solving abilities [2].
Despite the discovery of new treatments, there is no
“cure” to stop or modify the disease course. For this rea-
son, several non-pharmacological interventions are es-
sential to improve the quality of life of these patients.
* Correspondence: glauciapivi@hotmail.com
1
Beira Interior University (UBI/Portugal), Rua: Leandro Dupre, 488 apto: 183,
São Paulo, SP CEP: 04025-012, Brazil
2
Federal University of São Paulo (UNIFESP/Brazil), Rua: Leandro Dupre, 488
apto: 183, São Paulo, SP CEP: 04025-012, Brazil
physical therapists, speech therapists, and other profes-
sionals who can provide appropriate guidance for the
symptoms of these patients is, therefore, essential [3].
Regarding nutrition for patients with AD, weight loss
and behavioral changes related to food are major objects
of scientific study, as they trigger deterioration of the
quality of life of patients and caregivers. The aim of this
review is to show the current methods of nutritional
treatments for patients with AD.
Review of the literature
Nutritional intervention strategies for mildly impaired
patients with Alzheimer’s disease
Currently, in the early stage of AD, the nutritional ap-
proach has focused on two important points: (1) to cor-
rectly orient caregivers and patients regarding
prevention of body weight reductions and (2) to de-
crease synaptic loss [4].
At this stage, the patient feeds alone and important
nutritional modifications are not verified. Management
of the nutritional state is suggested to evaluate any
changes in body weight.

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Pivi et al. Nutrire (2017) 42:1
Regarding synaptic loss, the evolution of the know-
ledge on the pathophysiology of this disease has allowed
the correlation of a protective factor for impaired neu-
rons in AD. Countries that have dietary patterns charac-
terized by high consumption of fish, fruits, and
vegetables (foods that usually offer larger amounts of an-
tioxidants and polyunsaturated fatty acids) have lower
incidence of dementia [5].
A similar result was found in a prospective cohort
study in New York where 2148 elderly without dementia
followed for 1.5 years in order to verify the relationship
between the intake of food groups (variation related four
nutrients: saturated fatty acids, vitamin E, vitamin B12,
and folic acid) and the risk of AD development found
that when the action of these nutrients are evaluated in
isolation to prevent AD there is no evidence of a pro-
tective effect, but when they are considered together,
there is evidence that increased consumption of nuts,
fish, tomatoes, poultry, cruciferous vegetables, fruits,
vegetables, leafy dark green, lower intake of dairy lacteal
products high in fat, and red meat may contribute to the
decrease in AD development, demonstrated that the
consumption of food sources of polyunsaturated fats,
folic acid, and vitamin E should be encouraged at all
stages of life [6].
There is evidence that encouraging consumption of
specific nutrients, such as choline, docosahexaenoic acid
(DHA), eicosapentaenoic acid (EPA), and uridine mono-
phosphate, can boost neurogenesis and also contribute
to synaptic improvement in AD [7].
Choline is a micronutrient from the group of water-
soluble B vitamins, synthesized by the human body. Usu-
ally, the exogenous intake of choline is performed in the
chemical form of phosphatidylcholine that apparently
has the ability to cross the blood–brain barrier [8].
When used as a drug, it is in the bioavailable form of
citicoline in which its main functions treat cerebrovascu-
lar disease origin, among them dementias. Important
systematic literature review conducted to verify the ef-
fects of citicoline in attention and memory of elderly
with cognitive disabilities found that in the short and
medium time of use, beneficial effects are found, but it
is emphasized that there is a need to develop further
studies of longer duration of follow-up for real evalu-
ation of the choline about memory and attention [9].
However, another systematic literature review con-
ducted in order to verify the effects of this nutrient at
different stages of life that addressed from pregnancy to
adult phase, demonstrated that choline may have posi-
tive effects on cognition in any of these ;life steps since
it is supplemented in high amounts. Due to lack of stud-
ies on this subject, there is still no consensus of the
exact amount of choline to be supplemented in cases of
dementia [10].
Page 2 of 6
DHA is an important fatty acid with key roles in cellu-
lar homeostasis and in the formation of cell membranes.
Another function regards participation in neurogenesis
and neural integrity. Since its consumption is recom-
mended for patients with dementia, its main food
sources are fish, algae, and krill (crustacean). It is known
that nutrient intake imbalances of DHA can result in
cellular dysfunction [11–13].
Jicha and Markesbery (2010) [14] reported that the
DHA concentration in patients with mild cognitive im-
pairment (MCI) and AD is decreased in the hippocam-
pus and in the cerebral cortex, highlighting the
importance of this nutrient.
Randomized, double-blind, placebo-controlled trials
designed to investigate the potential effect of DHA were
conducted in the USA, following 485 individuals with 55
years presenting Mini Mental State Examination scores
over 26 and logic memory (Weschler Memory Scale III)
baseline score 1. Participants were randomly assigned to
900 mg of DHA for 24 weeks and found that supple-
mentation with DHA is associated with better scores of
immediate and late verbal recognition. This study also
found that serum levels of DHA in the plasma of supple-
mented individuals doubled, demonstrating its import-
ance for the improvement of memory and health as a
whole [15].
To establish what test or exams are to be used to ver-
ify the efficiency of consumption of the nutrients may
have a protective action on cortical morphology, Pistol-
lato et al. (2015) [16]. By review of the literature, it was
indicated that neuroimaging can be a useful instrument,
in this regard, because it detects changes in the cerebral
cortex. But, the authors related that in addition to the
images, there is a need to apply neuropsychological bat-
teries and examine biochemical blood of specific param-
eters of these nutrients because all these measures when
used together can express more accurate results.
Available in the Brazilian and European markets, a nu-
tritional compound was registered as Fortasyn Connect®,
containing EPA/DHA, uridine, choline, phospholipids,
vitamins E, C, B complex, and selenium. This product is
marketed as dietary supplement Souvenaid® and was de-
veloped specifically to work in the formation of more
phospholipid structures in the brain; it appears to influ-
ence the increase of dendritic spines and synaptic pro-
teins in the growth of neurites, which are important for
the formation of synapses [17, 18].
A 12-week study was performed to analyze memory
improvements by the action of this nutritional com-
pound, finding that after daily supplementation patients
showed improvements in delayed memory [18].
Scheltens et al. (2012) [19] also studied the efficacy of
this dietary supplement in 259 patients with mild AD,
without use of any cholinesterase inhibitors for 24 weeks;
Pivi et al. Nutrire (2017) 42:1
130 patients received supplementation and 129 were
only monitored for neuropsychological test results. The
group of supplemented patients had improved memory
performance by the neuropsychological test battery
(NTB), concluding that the adoption of this supplement
as part of treatment can improve memory in mildly im-
paired patients with Alzheimer’s disease. Extended re-
sults for another 24 weeks concluded that patients with
AD can safely tolerate this product for 48 weeks [20].
Souvenaid® was initially developed with the purpose of
maintaining or restoring synaptic function in the early
stage of AD but, due to the nature of its compounds, its
use has already been extended to study rats with induced
spinal cord injury. It was found that supplementation
led to protection of the spinal cord tissue with increased
neuronal and oligodendrocyte survival and preservation
of axonal integrity [21].
So far, these are the most studied points of the nutri-
tional approach for mildly impaired patients. The con-
sensus is that most studies in nutrition are developed to
contribute to treatment and quality of life of patients.
Nutritional Intervention strategies for moderately
impaired patients with Alzheimer’s disease
For moderately impaired patients, significant behavioral
changes are seen that affect feeding and often result in
an insufficient supply of nutrients for maintenance of
nutritional status. Distraction, passivity, refusal of food,
difficulty chewing or swallowing food, and increased
mealtime are some of the symptoms [22].
For these reasons, feeding time can result in conflicts
for the caregiver because supervision or task orientation
is needed, which is more burdensome than only prepar-
ing food and leaving the patient alone. This care during
the meals along with the supervision of all activities of
daily living of patients brings fatigue and often exhaus-
tion to caregivers [23].
Orientation to the caregiver at this stage is essential to
encourage the adoption of specific strategies for the ex-
perience which is significant for both the social engage-
ment and the nutritional acceptance of the elderly [24].
A Swedish study was undertaken to properly train
caregivers in relation to food; among its results, the bet-
ter the interaction of the patient with the caregiver, the
greater the food intake [25].
In patients with apraxia, the movement to fill the
cutlery and drive them to the mouth is difficult. The
use of hands in this case is considered as a means to
allow greater independence in feeding time. Finger
foods are also oriented in order to achieve a greater
caloric intake [26].
Making verbal or gestural guidance, indicating the
meal time and how the patient should proceed is essen-
tial, since it helps in visual agnosia, which is manifested
Page 3 of 6
in dementia, preventing the recognition of food and cut-
lery combined with forgetfulness of not knowing how
use them. Touching the patient or making hand-in-hand
aids are effective at the beginning of the meal [27].
All these measures are orientated to caregivers in
order to prevent weight loss, commonly found in all
stages of dementia. There are several explanations for
weight loss. One is the presence of cognitive and behav-
ioral disorders that patients have, such as exacerbated
agitation, for example [28].
It is important to note that the use of multiple
medications, adopted for the treatment of AD and
also their behavioral symptoms, increase the risk of
adverse effects on the gastrointestinal tract (nausea,
vomiting, diarrhea, loss of taste, smell, and appetite)
that can harm food intake and also contribute to
weight loss of these patients [29].
There is also evidence that weight loss may be dir-
ectly related to the morphological impairment of the
brain, which is caused by the disease. A significant
association of low body weight with atrophy of the
mesial temporal cortex was observed in patients with
AD, particularly in the region involved in control of
feeding behavior [30, 31].
Another possible explanation for weight loss is based
on the dysfunction caused by low energy consumption
and the sharp state of hypercatabolism of these patients.
It has been suggested that malnutrition can be a factor
in the etiology of dementia and other psychiatric and
cognitive disorders, although nothing has been proven
[32, 33]. This process is worrisome because it generates
decrease in mass and muscle strength resulting in re-
duced functional capacity [34].
To recover weight and maintain a good nutritional sta-
tus, proper nutritional guidelines regarding adoption of
the correct amount of protein and calories needed to re-
cover the patient’s weight are required. The recommen-
dation of the protein intake of the elderly changed; 1.0
g/kg weight per day used to be enough for proper main-
tenance of muscle mass, but now, several studies have
shown that 1.5 g/kg weight per day are required to
maintain a positive nitrogen balance and generate
muscle mass [35].
In most cases, protein and caloric recommendations
are achieved only with the use of dietary supplements,
defined as concentrated sources of nutrients and calories
that should be prescribed to increase the intake of spe-
cific nutrients normally used in addition to the usual
diet of the patient. The use of dietary supplements opti-
mizes the nutritional status and contributes to improve-
ment of the immune response [26].
A recent review, conducted in order to evaluate the
impact of the use of oral nutritional supplements (ONS),
found that the independently supplemented patient has
Pivi et al. Nutrire (2017) 42:1
an average readmission time of 2 to 3 days while patients
that are not supplemented often return to service, stay-
ing 8 to 10 days. This study proves the hypothesis that,
once supplemented, patients tend to have better recov-
ery and shorter stays while decreasing healthcare system
costs [36].
Still in relation to protein-energy supplementation
studies, in Toronto, 34 institutionalized patients with
AD were assessed to check their effectiveness on the
body composition; it was found that after 21 days of
supplementation the body mass index (BMI) had consid-
erably improved [37].
Trelis and Lopez (2004) [38] showed that, despite the
benefits of food supplements, only 11% of outpatients
use them. There are no studies in Brazil that indicate
how much outpatients resort to some sort of supple-
mentation in the diet, but it is known to provide the eld-
erly with low volume, high concentration of calories and
protein, stimulate consumption, and adherence to the
treatment [39].
Stratton and Elia (2007) [40], in a review of the clinical
practice of adopting the use of oral nutritional supple-
ments, came to the conclusion that patients with de-
mentia, both in mild and moderate stages, should make
use of ONS to ensure adequate supplies of energy and
provide essential nutrients to prevent malnutrition and
reduce the formation of pressure ulcers.
A meta-analysis by Alen et al. (2013) [41] stated that
malnutrition is the most prevalent nutritional status in
people diagnosed with dementia and therefore the use of
ONS is indicated by having a positive effect on weight
gain.
Pivi et al. (2011) [42] demonstrated that oral nutri-
tional supplement used for 6 months increased all an-
thropometric measurements (weight, arm, and muscle
circumference), with a positive impact on the body mass
index and improvement of the immune status of these
patients.
The European Society for Clinical Nutrition and Me-
tabolism (ESPEN) in 2015 developed a guideline of nu-
tritional strategies to be taken for patients with
dementias and established that the use of ONS has high
level of evidence; it significantly contributes to the im-
provement of the nutritional status [43]. Despite the use
of ONS being well established, unfortunately in Brazil,
there is no distribution of oral nutritional supplements
for the population. The elderly statute, established by
law, guarantees only the right to food when the elderly
or their relatives do not have economic conditions to
provide their maintenance. The statute also mentions
the right to treatment of full health for the elderly but
does not specify the distribution of dietary supplements
[44]. Nutritional intervention in these cases should be
guided individually and depending on the nutritional
Page 4 of 6
status according to multiple comorbidities, as well as the
biological and psychological changes associated with
aging, functional capacity, and nutritional needs of the
individual in order to provide all the necessary nutrients
and adequate amounts to maintain a good nutritional
state [45].
Nutritional intervention strategies for severely impaired
patients with Alzheimer’s disease
At this stage of the disease, the patient presents severe
anatomical and physiological changes, such as weakness
of oral and/or lingual muscles, making it difficult to
chew; reduction of smell and taste, often caused by the
use of drugs that alter the viscosity and volume of saliva
produced thereby reducing oral sensitivity and ultimately
culminating in dysphagia [4].
Dysphagia is any type of difficulty in the effective pro-
gress of food from the mouth to the stomach through
the interrelated phases, controlled by a complex neuro-
logical mechanism [46].
Proper knowledge of the physiology of swallowing is
essential for the satisfactory progress of food in each in-
stance [47]. Its detection is multidisciplinary as it in-
volves doctors, speech therapists, nutritionists, and
nurses who contribute with their expertise interdepen-
dently to the improvement of the patient in order to
identify clinical signs such as coughing and choking dur-
ing feeding as well as functionality and also the pulmon-
ary complications [48].
Studies by Sato et al. (2014) [49] in patients with AD
found that mortality from aspiration pneumonia is high
in this group, accounting for 70% of causes of death, in-
dicating that they need daily measures to diagnose and
treat dysphagia.
Major consequences of dysphagia include malnutrition
and dehydration caused by inadequate diets due to the
modification of food consistency. In an attempt to adapt
to symptoms, the caregiver often changes the feeding
consistency, adding more water and reducing the caloric
density of the meal [50].
It is up to the speech therapist to determine the safest
food consistency to be adopted, after thorough evalu-
ation by the nutritionist to correct caloric and protein
intake for the indicated consistency. A feature often used
in these cases is the use of thickeners, such as gums and
mucilage that suit the consistency of meals and the con-
tinued use of dietary supplements, which also contribute
to increase the caloric value of the diet also provide sig-
nificant amounts of protein.
A study in Germany with 160 patients with various
forms of dementia and 30 control patients was con-
ducted to evaluate the impact of the recommended
changes regarding food texture for patients with dyspha-
gia. It was found that patients with dementia show signs
Pivi et al. Nutrire (2017) 42:1
Fig. 1 Flow chart of the main nutritional complications and their approaches
of aspiration more frequently with water (35.6%) than
with a slice of an apple (15.1%) or applesauce (6.3%). It
was concluded that patients in severe stages of dementia
benefit from changes in the texture of foods that need to
be constantly monitored [50].
With the development of dysphagia, the risk of pul-
monary aspiration increases and in those cases oral nu-
trition is interrupted by the use of alternative energy
sources, either by nasoenteric tubes (NGT) or percutan-
eous endoscopic gastrostomy (PEG) [51].
The use of enteral nutritional therapy (ENT) is contro-
versial, since there seems to be no real clinical benefit in
terms of survival for patients with dementia [52]. Never-
theless, the number of patients older than 65 years who
underwent PEG in the USA increased exponentially
(15,000 in 1989 to 123,000 in 1995), whereas most of
these patients (60%) have AD or multiple cerebrovascu-
lar lesions [53].
An important study was conducted by Rabenek (1996)
[54] to investigate the mortality of terminal patients in
use of PEG, finding that the average survival after gas-
trostomy placement was 7.5 months.
In Brazil, there are no specific rules under the bio-
ethical and legal points of view regarding the use or
non-use of artificial nutrition therapy in the terminal
stages of the disease; it is up to the professional to indi-
cate ENT and explain the benefits and adverse effects
that its use can cause. In this case, patient autonomy
Page 5 of 6
must be respected, considering that the legal representa-
tive will decide whether this form of nutrition must be
used.
The present literature review included the main nutri-
tional complications and their approaches. The flowchart
in Fig. 1 summarizes the text.
Conclusions
This review presented the general aspects of nutritional
guidelines adopted in each stage of AD. These guidelines
are employed at the Behavioral Neurology Section, Nu-
trition Area of the Federal University of São Paulo, and
were developed after a broad review of the literature; so
far, we have had good results with this protocol, but
more studies in this field are required.
Authors’ contributions
All the authors have contributed to writing this article. All authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 17 June 2016 Accepted: 20 September 2016
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