Handfeeding is recommended over tube feeding in Alzheimer’s disease. The handfeeding techniques offer an additional sensorimotor cue.
-Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN

In the late stages of Alzheimer’s disease, it’s not unusual for older adults to have trouble eating.  Before the end of life, 85% of people living with Alzheimer’s disease will have trouble eating.

There are many reasons for this, but many stem from the sensory changes that happen with the disease such as changes with smell, taste, vision, and hearing. Other contributing factors may involve chewing their food, swallowing, or they simply lose interest in food. 

Ensuring that anyone with Alzheimer’s eats a healthy meal or eats sufficiently turns into a real practical and emotional challenge for the caregiver. 

In today’s episode of This Is Getting Old, we’ll talk about Alzheimer’s Care: Making Mealtimes Easier. I’ll share strategies that can help you help an older adult to eat more food.


Part One of ‘Helping a Person With Alzheimer’s Disease to Eat. ‘

The first step in understanding is the sensory changes that impact an older adult’s ability to feed themselves. 

These sensory changes are briefly described below:

Smell. Smell is diminished with Alzheimer’s disease. As this disease progresses, people lose their sense of smell. They can’t smell their body odor, they can’t smell if there’s smoke in the house, so they certainly have a hard time smelling food. This change also increases their risk for food poisoning. 

Taste. Have you ever wondered why an older adult with Alzheimer’s disease loves sweet food? Sugar fires up a part of your brain that remains intact throughout the disease. So if we need to put a little bit of sugar on somebody’s food (and adjust their medical regimen accordingly if they have diabetes), to get them to eat more food, we should do that.

For an older adult with Alzheimer’s disease, adding a little bit of sugar to their food could be a good thing because sugar fires up a part of the brain that remains intact throughout the disease.
-Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN

Hearing. If you only have Alzheimer’s disease, you can still hear, but what happens is you lose the ability to use and understand language. It might seem like they can’t hear us sometimes, but the reality is they can’t understand us. 

Vision. A person with Alzheimer’s disease will  lose peripheral vision. With Alzheimer’s disease, vision diminishes from scuba vision, to binocular vision, down to monocular vision.

Touch. The Palmer Reflex returns with late Alzehimer’s disease. The Palmar Reflex is similar to when you put your finger in the palm of a baby’s hand, and they grab it. That reflex comes back very late in this disease, making it difficult for older adults to use utensils, handle cups, and all the things that it takes to feed themselves.


Verbal and Visual Cues To Facilitate Ease in Feeding

When providing care to a person living with Alzheimer’s disease, we already know to give people verbal and visual cues. However, late in the disease, they will have a hard time using and understanding language so what they pick up on is your nonverbal behavior. 

So if you sit down and you’re smiling, or you mimic chewing or whatever it is that you want them to do, that part of the brain remains intact even late in the disease (it’s called “Mirroring”). By using nonverbal cues, you’re a lot more likely to get them to do what you want without using words.  

Part Two of ‘Helping a Person With Alzheimer’s Disease to Eat.’

Modified Hand-feeding Techniques

In helping the older adult eat, the three hand-feeding techniques are Over Hand, Under Hand, and Direct Hand.  You should start with the least amount of assistance you need to provide and save using the Direct Handfeeding technique until last. Unfortunately, what we often see in practice is that people start and stay with Direct Hand. This can create unnecessary debility and dependence on others, rather than supporting self-feeding. 

The first thing you need to know is if the person has“skill finger” ability (your thumb, first and second finger are your “skill fingers” and are needed to manipulate utensils when eating). Based on this information, you can tailor the level of assistance provided and which technique to use. 

Over Hand 

Let’s say we have an older adult who’s pretty much able to feed themselves that they have skill finger ability and need a little help getting the food from the plate to their mouths; start by offering overhand assistance. Place your hand over the person’s and gently guide their hand with the utensil towards their mouth. 

Be careful when you’re doing this to make sure that you don’t hurt their wrist or grab their hand too tight and always help them through the middle of their body. 

Hand-feeding techniques are helpful for other caregiving activities that you may be doing. You can help older adults brush their teeth, comb their hair, and even get dressed; because with the Under Hand technique, we’re doing all the fine motor stuff that they can no longer do because of Alzheimer’s disease.
-Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN

Under Hand

The Under Hand technique works the best for someone who’s lost skill finger ability or doesn’t seem to understand what to do with their utensils. At this point, we can use the Under Hand technique. 

Start by getting into the Under Hand Shake position; what this technique does is it frees up is your skill fingers. The Under Hand technique provides a new, additional sensorimotor cue to maximize the signals that we’re providing. 

Modifications based on Range of Motion Ability

One of the first modifications we can do with the underhand technique is if the person has a partial range of motion. In this case, we need to load the fork or the spoon for them because that’s the part that they can no longer do.

So if a person has very little range of motion, you may need to put their food item into a different container and get very close to them so that they don’t have to move as far to participate in the act of eating. Even with a minimal range of motion, the underhand still provides the cues that might help them to understand that it’s time to eat 

Direct Hand 

The third technique is the Direct Hand technique. You want to save this handfeeding technique for people who aren’t able to participate in the act of eating. It is best practice to put your hand on their shoulder; because they’ve lost peripheral vision and they may not see you sitting there. Even with this technique, you need to make sure that they see the food before it comes towards their mouth. Lifting it into their visual field helps them to know that food is coming, and usually results in them opening their mouth. This often allows meal intake to go more quickly.

Want to Know More?

If you found this video helpful and would like to learn more strategies to improve meal intake, please visit my website at MelissaBPhD.com/shop. I’ve created an online course titled, “Optimizing Nutrition in Dementia Using Supportive Handfeeding”. I’ve adapted this course from my research teaching nursing home staff for family/ friend caregivers to teach you these skills. 

This course teaches you the most recent evidence-based information we have for managing mealtimes in dementia – and you may even find it helpful for doing other care activities like combing someone’s hair, brushing their teeth, or helping them to get dressed.  

You can use the Coupon Code TIGO20 to get 20% off the course!

You can also find other videos related to Alzheimer’s disease on my YouTube Channel (MelissaBPhD) and this website under podcasts + blogs.



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About Melissa:

Melissa Batchelor, PhD, RN, FNP, FGSA, FAAN. I am a nurse, nurse practitioner, nurse educator and nurse researcher with over 25 years of experience in the aging and long-term care healthcare space. You can visit my website at MelissaBPhD.com to learn more about me, how you can work with me directly,
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