The Journal of Nutrition, Health & Aging©
Volume 5, Number 4, 2001
THE JOURNAL OF NUTRITION, HEALTH & AGING©
A NUTRITIONAL EDUCATION PROGRAM COULD PREVENT WEIGHT LOSS
AND SLOW COGNITIVE DECLINE IN ALZHEIMER’S DISEASE
S. RIVIERE*, S. GILLETTE-GUYONNET*, T. VOISIN*, E. REYNISH*, S. ANDRIEU**, S.
LAUQUE*, A. SALVA***, G. FRISONI****, F. NOURHASHEMI*, M. MICAS*, B. VELLAS*
* Department of Internal medicine and Clinical Gerontology, Hôpital la Grave-Casselardit, Toulouse, France. ** INSERM U 518, Toulouse, France. *** Programa Vida Als Anys.
Servei Català de la Salut. Barcelona. / Hospital Sant Jaume, Mataro. Spain. **** Laboratory of Epidemiology & Neuroimaging, IRCCS San Giovanni di Dio, Brescia, Italy.
Correspondence: Bruno Vellas, Department of Internal medicine and Clinical Gerontology, Hôpital la Grave-Casselardit, 170 avenue de Casselardit, 31300 Toulouse, France.
Fax : 33 (0)5 61 77 25 93. e-mail [email protected]
Abstract: BACKGROUND Weight loss is a common problem in patients with Alzheimer’s Disease (AD). It is
a predictive factor of mortality and it decreases patients’ and caregivers’ quality of life. OBJECTIVE To
determine if a nutritional education program can prevent weight loss in AD patients. SUBJECTS 151 AD
patients and their caregivers were enrolled to follow the intervention and 74 AD patients and their caregivers
constituted a control group. METHOD Caregivers in the intervention group followed 9 nutritional sessions of
one hour each, over one year. Caregivers in the control group didn’t follow any sessions but were offered advice
provided in a normal follow-up. Patients weight, nutritional state, cognitive function, autonomy, mood,
behaviour disorders at baseline and at 6- and 12-month follow-up. Caregivers burden, nutritional and AD
knowledge at the baseline and at the 12-month follow-up. RESULTS During the year follow-up, the mean
weight increased in the intervention group (0.7±3.6 kg) whereas it decreased in the control group (-0.7±5.4 kg)
(p<0.05). The nutritional status (MNA) was maintained in the intervention group (0.3±2.6) whereas it decreased
significantly in the control group (-1.0±3.4) (p<0.005). After adjustment for baseline differences between the two
groups (caregiver age, nutritional state, eating behaviour disorders, depression), the weight change between the
two groups was not significant (0.6±0.4 kg vs. –0.6±0. 6kg respectively in intervention group and control group).
However, the percentage of patients with significant weight loss is decreased. The MMSE change became
significant between the two groups: -2.3±0.3 vs. –3.4±0.4 respectively in intervention group and control group
(p<0.05). CONCLUSIONS These results suggest that a nutritional educational program intended for caregivers
of AD patients could have a positive effect on patients weight and cognitive function.
Key words : Nutrition, Alzheimer, intervention, weight loss, education.
Introduction
Weight loss has been reported in patients with Alzheimer’s
Disease (AD) in many recent studies (1,2). This weight loss
occurs from the first stages of the disease - patients forget to
eat, to do shopping -, even before the disease diagnosis (3), and
worsens with the severity and progression of the disease (4).
Indeed, AD leads to a progressive loss of learned behaviours
including the ability to feed oneself (5). Patients with advanced
dementia commonly develop difficulty eating, especially when
they become dependent in all activities of daily living. They
may resist or be indifferent to food, fail to manage the food
bolus properly once it is in the mouth or aspirate when
swallowing. These eating problems lead to weight loss and
frequently lead physicians to use tube feeding that has been
found to be painful, costly and not effective (6).
In elderly subjects (7), patients with cognitive impairment (8)
and patients with AD (4), weight loss is a predictive factor of
morbidity (infections, skin ulcers…) and mortality and
decreases patients’ and caregivers’ quality of life. Behavioural
troubles such as eating behaviour disorders, associated with
AD, are perceived as a heavy burden by family caregivers who
may be stressed, depressed and socially isolated. The lack of
knowledge, poor skills, immature coping strategies and guilt,
all exacerbate caregiver burden (9,10). Moreover, the emotional
and material caregiver burden has been shown to be a
predictive factor of patient weight loss (11). In this preliminary
study, we have found that caregiver stress was the only risk
factor still associated with weight loss in Alzheimer’s patients
using a multivariate analysis.
A nutritional education program, intended for caregivers, has
been carried out in order firstly to prevent weight loss in AD
patients. In addition, we also studied the effectiveness of the
program on the caregiver burden and knowledge, and on the
patient’s behaviour.
Method
Subjects
All the patients were recruited in day-hospitals or in
Alzheimer Family Associations of three European cities
(Toulouse, France; Brescia, Italy; Mataro, Spain). Patients were
diagnosed with probable Alzheimer’s Disease according to the
NINCDS-ADRDA (12) criteria. All patients lived at home with
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NUTRITIONAL EDUCATION PROGRAM TO PREVENT WEIGHT LOSS
an informal caregiver, could be weighed and had no
intercurrent pathologies. They also had a score of between 2
and 6 on the Global Deterioration Scale (GDS) of Reisberg
(13).
One hundred and fifty-one patients with AD (52 men, 99
women) and their caregivers were recruited to follow the
program from January 1998 to June 1998. Informed consent
was signed by the patient’s caregiver. If the caregiver refused,
they were not entered into the study (neither intervention nor
control). However, 74 AD patients (22 men, 52 women) and
their caregivers already being followed using the same
methodology in the day-hospitals in France and Spain,
constituted a control group, whose caregivers didn’t follow
nutritional sessions. These patients and their caregivers were
offered the care and clinical evaluation routinely provided to
families and patients in a normal follow-up.
Average age at baseline was 77.3 years (SD 8.2) and 75.4
years (SD 7.9) respectively in the intervention and control
groups, with no significant differences between groups. The
caregivers in the intervention group were significantly younger
(60.5±13.1) than those of the control group (64.8±12.9)
(p<0.05). There were significantly more caregivers who were
the patients’ children (49.5%) and less spouses (39.6%) in the
intervention group than in the control group (32.6% children;
61.2% spouses). However, we do not have these data for the
Spanish patients. During the study, eight patients died in the
intervention group and three patients in the control group.
These patients were included in the analysis.
Nutritional education program
In the intervention group, caregivers followed a maximum of
9 nutritional sessions of one hour each, during one year, in
groups of around 10 persons. The first five sessions occurred in
the first month and the last four sessions occurred in months 2,
3, 6 and 12, after the patient and caregiver had enrolled in the
study (Figure 1).
Each session dealt with a particular topic (see Table 1) and
was presented by a dietician or another health professional.
How to enrich food and how to combat eating behaviour
disorders were given particular emphasis. Caregivers had to
attend at least 5 sessions in order not to be excluded. Only one
couple (caregiver/patient) was excluded from the study because
the caregiver had attended less than 5 sessions.
Table 1
Program of nutritional education sessions
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
During the first session, each caregiver received a nutritional
calendar in order to record his weight and those of the patient
monthly. This calendar also contained advice on diet, on how to
weigh, on the importance of maintaining physical activity, and
gave the phone number of the dietician co-ordinator. It was
agreed that the caregiver should phone the co-ordinator if
Figure 1
Study design
296
Consequences of weight loss in AD patients. How
to weigh patients properly and how to record
monthly weights on the nutritional calendar
Coping with caregiver stress : managing patient
behavior (examples of problem-solving), having
recourse to day care, familial and social support,
recreation and relaxation opportunities
How to assess nutritional status with the MNA
tool
Nutritional and food recommendations including
food groups and balanced menus
Tips to increase protein and energy intake and
replace refused food
Eating behavior disorders. Advice for coping with
eating behavior disorders (patient does not want to
eat, eats too small an amount of food, uses fingers
instead of utensils, or chokes on food…)
Practical dietetics
MNA, advice according to results
Final assessment, questions/answers, distribution
of nutritional calendars
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THE JOURNAL OF NUTRITION, HEALTH & AGING©
Data analysis
The intervention and control groups were compared using
Student’s t-test or Kruskal-Wallis for continuous variables and
chi-square analysis for categorical variables as appropriate.
To study the effect of the intervention on the parameters
(weight, MNA, MMS...), an analysis of variance (ANOVA)
with repeated measurement was used. This effect was studied
without adjustment, then with adjustment of the baseline values
which differed between the two groups (control/intervention).
The statistical results are presented as mean ± standard
deviation for the analysis without adjustment, and as
mean±standard error for the analysis with adjustment.
Results
Characteristics of the population at the baseline are shown in
the Table 2. There was no difference between the two groups
for weight, autonomy, behaviour, cognitive function and
disease stage. However, the patients of the intervention group
had significantly more eating behaviour disorders, more
depression symptoms, and had poorer nutritional status. The
weight and MNA score changes during the study in both groups
are shown in Figure 2.
Intervention (n=151)
Weight (Kg)
MNA
Blandford scale
MMSE
Reisberg
ADL
IADL
Cohen-Mansfield
Cornell
Age (Caregiver)
Zarit (Caregiver)
62.7±11.1
22.9±3.7
3.1±3.6
15.4±7.1
4.4±1.0
4.4±1.7
32.8±11.5
51.1±17.6
9.0±5.9
60.5±13.1
32.2±12.1
Control (n=74)
61.6±13.1
24.3±2.9***
2.1±3.3***
15.4±6.1
4.7±0.8
4.7±1.6
31.3±10.0
47.2±16.7
5.0±5.0***
64.8±12.9*
30.6±17.6
* p<0.05; *** p<0.005 between the two groups (Student T test except for Reisberg, ADL,
Cornell, Blandford : Kruskal-Wallis test)
Figure 2
Weight and MNA changes over the study, in control and
intervention groups (before adjustment)
Time
Follow-up
The patients’ characteristics (both groups) were followed for
one year, with a six-monthly evaluation (M0, M6, M12)
(Figure 1). The nutritional status was evaluated using the Mini
Nutritional Assessment (MNA) (14). Cognitive function was
followed using the Mini Mental State Examination (MMSE)
(15). Autonomy was assessed with the Activity of Daily Living
(ADL) (16) and the Instrumental Activity of Daily Living
(IADL) (17) scales. Mood was measured with the Cornell scale
(18) and behaviour disorders with the Cohen-Mansfield
Agitation Inventory (CMAI) (19).
Eating behaviour disorders were assessed using the
Blandford scale (5) at baseline and at the end. Weight was
recorded monthly on the nutritional calendar for the
intervention group. Caregivers were asked to weigh patients
and themselves wearing light clothing, without shoes. In the
control group, the patients weight was measured as in a normal
follow-up, i.e. every six months in the day-hospital.
The material and emotional caregiver burden was assessed at
baseline and at the end using the Burden Interview (BI) of Zarit
(20). Nutritional and AD knowledge(21) of the caregivers were
also performed at the baseline and at the end, in the
intervention group only. The nutrition knowledge questionnaire
(22) contained 27 items which required yes/no answers.
Table 2
Baseline characteristics of the population
Time
patient lost 2 kg or more with respect to the patients initial
weight. In this case, the medical team, the dietician or the
general practitioner could evaluate nutritional status and
possible eating behaviour disorders in order to provide
nutritional care.
* p<0.05; *** p<0.005 between intervention and control group, Student T Test
The mean weight increased in the intervention group
whereas it decreased in the control group. The difference
between the two groups was significant between the baseline
(M0) and the end (M12) of the study (0.7±3.6kg vs.
–0.7±5.4kg, p<0.05). The intervention had an effect on the
nutritional status between M0 and M6 and between M0 and
M12. Indeed, the difference in MNA score between the two
groups was significant between M0-M6 (0.4±2.5 vs.
–0.55±3.34, p<0.05) and M0-M12 (0.3±2.6 vs. –1.0±3.4,
p<0.005) respectively in the intervention and the control group.
The changes in the other parameters are shown in Table 3.
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NUTRITIONAL EDUCATION PROGRAM TO PREVENT WEIGHT LOSS
Table 3
Changes in patients parameters between 6-month and baseline
(M6-M0), end and 6-month (M12-M6), and end and baseline
(M12-M0)
M6-M0
intervention
control
M12-M6
M12-M0
intervention control intervention control
Before adjustment
Blandford
MMSE
ADL
IADL
Cohen-Mansfield
Cornell
-1.2±3.2
-0.4±0.8
1.7±4.5
-0.2±11.5
-0.8±3.5
-1.1±3.1
-0.7±1.5*
1.6±6.3
-0.7±11.9
0.6±4.4*
0.6±3.6 -0.1±3.1
-1.4±2.5 -2.0±2.6 -2.6±3.5 -3.2±3.1
-0.4±1.2 -0.1±1.3 -0.7±1.4 -0.7±1.2
2.2±5.3
2.3±4.1
3.7±6.3
4.4±6.6
-0.2±11.1 2.1±13.4 0.2±13.9 1.7±13.5
0.9±4.1
0.9±3.6 -0.01±4.6
1.5±4.8*
After adjustment (on MNA, Blandford, Cornell, caregiver age)
Weight
MNA
Blandford
MMSE
ADL
IADL
Cohen-Mansfield
Cornell
0.2±0.2
0.3±0.2
-0.3±0.4
-0.05±0.3
0.2±0.3
-0.2±0.2
0.1±0.4
-0.2±0.3
-1.0±0.3
-0.3±0.1
1.6±0.4
0.5±1.0
-0.6±0.3
-1.3±0.4
-0.7±0.1*
2.1±0.7
-1.8±1.6
0.06±0.5
-1.3±0.2
-0.3±0.1
2.3±0.4
0.2±1.1
1.7±0.4
-2.0±0.4
-0.1±0.2
2.2±0.7
0.5±1.7
0.7±0.6
0.6±0.4
0.2±0.2
0.5±0.3
-2.3±0.3
-0.6±0.1
3.7±0.5
1.2±1.2
0.4±0.4
-0.6±0.6
-0.4±0.3
-0.3±0.5
-3.4±0.5*
-0.7±0.2
4.4±0.9
-0.8±1.9
0.8±0.6
* p<0.05, ANOVA with repeated measurement between control and intervention
Symptoms of depression increased significantly more in the
control group than in the intervention group in which they were
stable (M0-M12) and decreased significantly (M0-M6).
Between M0 and M12, dependency in the instrumental daily
living activities and behavioural troubles seemed to increase
more in the control group. Cognitive function seemed to
decrease more in the control group. Lastly, the dependency in
the activities of daily living increased significantly less in the
intervention group between M0 and M6.
The caregiver burden was stable in the intervention group
(Table 4) and seemed to increase in the control group but the
difference between the two groups was not statistically
significant. The caregivers’ nutrition and AD knowledge
increased significantly between the beginning and the end of
the program.
Table 4
Caregivers parameters changes between the end and baseline
(M12-M0)
Intervention Group
Control Group
Before adjustment
Zarit
Nutrition knowledge
AD knowledge
-0.1±7.8
1.7±5.9###
2.8±2.8###
1.9±12.4
-0.3±1.0
1.5±1.7
After adjustment
Zarit
### p<0.005, Student T test
298
After adjustment for baseline differences between the two
groups (caregiver age, MNA, Blandford scale, Cornell scale),
the weight change between the two groups was not significant
despite a difference of 1.2 Kg between the two groups
(p=0.101) (Table 3). However, the increased dependency in
activities of daily living in the control group between M6 and
M0 persisted after adjustment. There was a significant
difference in the change in MMSE from M0-M12 between the
two groups: -2.3±0.3 vs –3.4±0.5 respectively in intervention
group and control group (p<0.05).
Discussion
Weight loss is a common problem in AD and occurs in 44%
of patients11 instead of 13.1% in the general elderly population
(7) and less than 1% in normal and healthy elderly persons
(23). Moreover, it is not confined to patients with severe
disease who are unable or unwilling to eat, but may start earlier
in the course of the disease. Weight loss is not due to an
increase of resting or daily energy expenditure (24,25) but may
be related to pathological changes in the Mesial Temporal
Cortex (26) or otherwise associated with the pathophysiology
of the disease. Up to now, we have not known whether weight
loss could be avoided in subjects with AD. In our study, we
showed that a nutritional education program for caregivers,
could have a positive effect on weight and overall on nutritional
status in patients with AD although the results were not
significant after adjustment. This study was done in patients
with moderate AD, still living at home with a caregiver. We
don’t know if this program could be effective in those with very
severe dementia and living in nursing home.
In our intervention, we didn’t improve eating behaviour
disorders (evaluated by the Blandford scale) but we improved
weight and nutritional status. We taught caregivers eating
behaviour management techniques to minimise the effects of
problem patients behaviour and we can hypothesise that
caregivers didn’t prevent eating behaviour disorders but they
knew how to respond to patients nutritional disorders (without
using tube feeding). The participants in the intervention group
certainly had better nutritional intake.
Weight loss was shown to be accompanied by a greater
deterioration in those aspects of dementia explored by the
MMSE and EHD scales (11). Conversely, it seems that weight
gain is a protective factor against mortality and is associated
with a slower progression of the disease (4). In our study, we
showed that progression of cognitive deterioration, evaluated
by the MMSE, could be slowed by a education program
targeted on prevention of weight loss. These results are
consistent with many studies that have found relationships
between nutritional intake, in particular vitamins C, E, B12, B9,
and cognitive function (27,28,29).
The mood of patients in the intervention group was also
improved early in the study (M0-M6) as was the nutritional
status evaluated by the MNA. Two hypotheses could be
considered. Firstly, the caregiver may be more self-confident,
The Journal of Nutrition, Health & Aging©
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THE JOURNAL OF NUTRITION, HEALTH & AGING©
may take better care of the patient, and consequently the patient
may feel good. Secondly the patient may be better nourished, as
confirmed by the MNA score, he may have less deficiencies in
vitamins, in particular in B group vitamins. Now, deficiencies
in vitamins B, in particular vitamin B9 and B12, have been
shown to be linked with mood in elderly patients and with
behavioural and psychological symptoms in patients with AD
(30).
Caregiver intervention programs can improve caregiver
knowledge, quality of life for the caregiver and decrease
caregiver burden. The works of Brodaty (31) and Mittelman et
al. (32) confirm the effectiveness of such interventions. Our
nutritional education program improved significantly caregivers
knowledge on nutrition and AD. But, it didn’t reduce
significantly caregiver burden. However, caregivers reported
being more relaxed when faced with behavioural problems,
especially feeding problems. They knew better how to respond
to patient behaviour. Our impression is that a group of around
10 participants for each session is good. Participants felt
confident and free to express themselves and enjoyed sharing
difficulties. The confidence that was established between the
co-ordinator and the participants enabled the caregivers to ask
frequently for nutritional and other advice.
We concede that our recruitment procedures may have
introduced a sampling bias such that caregivers in the
intervention group may have been more receptive to training
and more eager to treat eating problems and avoid weight loss,
thereby limiting the generalisability of the results. However,
patients and caregivers from both groups were very similar as
regards severity of dementia, living place and agreement to
participate in follow-up. It seems that patients in the
intervention group had a relatively poorer nutritional status and
more eating behaviour disorders compared to the control group
at baseline. We could expect a greater loss of weight in this
group than in the control group. We felt that a truly randomised
study was likely to be refused by the participants.
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In conclusion, this study showed that a one-year nutritional
educational program, simple to carry out, could have a positive
effect on weight, nutritional status and mood, and also slow the
cognitive decline in patients. By giving nutritional information
and support to families, it is possible to improve the patient’s
global state of health. It is therefore important to assess the
nutritional status and to follow the weight in patients, while
giving support to caregivers.
Acknowledgement: We thank Dr. Margarita Llado, of the Sant Jaume Hospital of
Mataro, coordinator of the study in Spain, for her practical help.
Key points: • A nutritional educational program intended for caregivers of AD patients
improved caregivers knowledge on nutrition and AD. • The nutritional education program
could have a positive effect on AD patients weight and nutritional status.• Progression of
cognitive deterioration has been slowed by the education program targeted on prevention
of weight loss.
Funding/Support: This program took part of a European Health Promotion program and
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person acting on its behalf is liable for any use made of this information.
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