The importance
of nutrition in the
management of
early Alzheimer’s
disease
Authors
Dr Junaid Bajwa, GP Principal and Board Member of Greenwich Clinical Commissioning Group
Gwen Coleman, Registered Dietitian
Mark Lawton, Consultant Nurse, dementia care
Supported by Nutricia Advanced Medical Nutrition.
Introduction
Among the pledges in the NHS mandate recently announced by Health
Secretary Jeremy Hunt is a commitment to drive up diagnosis rates of
dementia.1 This builds on similar undertakings outlined in the Challenge on
Dementia initiative launched earlier in 2012.2 With hundreds of thousands of
people with dementia currently living without a proper diagnosis,3 these moves
should help improve the management of dementia and early Alzheimer’s
disease.
However, there is a danger that the drive for earlier diagnosis of Alzheimer’s
disease will amount to very little, unless it is matched by an equal commitment
to providing high-quality care to people once they are diagnosed. This care
must be holistic, person-centred and focused as much on adding life to years
as it is on adding years to life.
If there is to be a significant increase in the number of people diagnosed
while in the early stages of Alzheimer’s disease, management and personal
care plans must be formulated that not only take advantage of recent drug
developments, but also include lifestyle interventions such as exercise, mental
stimulation and nutrition.
CONTENTS
Introduction1
The importance of nutrition
1
Nutritional intervention in Alzheimer’s disease
2
Rethinking nutrition and early Alzheimer’s disease 2
Nutrition in Alzheimer’s disease in practice
3
Nutrition and Alzheimer’s disease
4
Nutritional protection
4
Nutritional risk factors
4
Hearts and minds
4
How Alzheimer’s disease may affect nutrition
5
How nutrients may affect Alzheimer’s disease
5
Current practice
6
Characteristics of selected screening tools
6
Recommendations7
Conclusion7
References7
The results of our survey clearly suggest that
while the importance of good nutrition is well
recognised among specialists working with
people with Alzheimer’s disease, the role of
nutritional support is often neglected in the
management of the condition’s early stages.
Diets high in omega 3 polyunsaturated fatty acids (PUFAs), vitamin E,
folate and vitamin B12 have also been linked with a reduced risk of
Alzheimer’s disease.9,10
These diets are largely in line with well-established nutritional advice for the
reduction of cardiovascular risk factors, the prevention of diabetes, obesity
and hypertension. It increasingly appears that what is good for the heart is also
good for the brain. It therefore seems sensible to include nutritional and dietary
measures as early as possible in the management of Alzheimer’s disease.
However, a number of challenges remain in the pursuit of this goal.
1
The very nature of Alzheimer’s disease can also present significant barriers to
obtaining a nutritionally adequate diet. Alzheimer’s disease may be associated
with changes in taste patterns or functional difficulties that interfere with
chewing, swallowing and the preparation of food. Cognitive impairments
can make it difficult to remember or follow dietary advice. Individual social
circumstances - isolation or low income for instance - may also present
difficulties in obtaining an adequate diet. And many people with Alzheimer’s
disease suffer comorbidities, such as depression, hypertension or diabetes,
that may also impact on appetite or require difficult dietary restrictions.
Many of these challenges can be overcome by the involvement of health or
social care staff with specialist knowledge in nutritional intervention. Dietitians
or appropriately trained nursing, medical or social care staff can offer valuable
assistance in obtaining all the nutrients necessary for good general health and
optimal cognitive functioning. This is in line with the National Institute for Health
and Clinical Excellence (NICE) quality standard on dementia which states: ‘An
However, for this to happen, it is essential that health and social care staff are
sufficiently aware of the importance of nutrition in early Alzheimer’s disease and
that those with the condition receive a full nutritional assessment as early as
possible in the progress of their disease. Unfortunately, this ideal appears to
be some way removed from the reality of current practice.
The Patient Experience
Good nutrition is essential for people with Alzheimer’s disease. A healthy,
well-balanced diet is essential to maintaining physical strength and good
general health. It is a valuable source of enjoyment and interaction for people
with Alzheimer’s disease and their carers, and can help those living with the
disease remain engaged and socially active, even as their cognitive abilities
begin to decline.
Several dietary risk factors for Alzheimer’s disease have been identified,
including high intakes of saturated fat,4 raised plasma cholesterol5
and obesity.6 There is also a growing body of epidemiological evidence
suggesting certain nutrients offer protection against the condition.
There appears to be a lower risk and slower progression of Alzheimer’s
disease in people who regularly eat a ‘Mediterranean diet’ high in vegetables
and fish oils.7, 8
Unfortunately, the early signs and symptoms of Alzheimer’s disease often
remain undiagnosed until cognitive decline is significantly advanced.
Even once a patient is diagnosed, the patient’s nutritional status is often not
considered in early disease, with no intervention being made unless there is
an obvious problem such as obesity or overt malnutrition.
integrated approach to provision of services is fundamental to the delivery of
high quality care to people with dementia’.11
The importance of nutrition
There is also increasing evidence that nutrition plays an important role in the
aetiology and progression of Alzheimer’s disease itself. Research suggests
certain macro and micronutrients are involved in the decline of cognitive
function and in the risk of developing Alzheimer’s disease.
Nutritional intervention in
Alzheimer’s disease
“The thing with Alzheimer’s or dementia is that we
appear quite normal; people can’t see our problems.
If patients come into hospital it should be accepted
now that patients are assessed for their cognitive ability,
because it’s only by assessing your cognitive ability, that
you can assess if there’s something wrong with it”.12
It increasingly appears that what is good for
the heart is also good for the brain.
Ann Johnson, who lives with Alzheimer’s disease
Rethinking nutrition and
early Alzheimer’s disease
This report makes the case for a fundamental rethink on the position of
nutrition in early Alzheimer’s disease.
It will:
• Review the evidence on the importance of nutrition in the management
of early Alzheimer’s disease
• Discuss the ideal diet for someone in the early stages of Alzheimer’s disease
• Investigate the role that individual nutrients play in the aetiology of
the disease
• Ask how can we use this knowledge to offer people with Alzheimer’s disease
the very best nutritional support.
We will then look at current practice and the results of a survey, commissioned
for this report, of 1,006 GPs and 100 elderly care specialists involved in the
diagnosis and/or treatment of people with early Alzheimer’s disease.13
The results are discussed further later in this report; however, the findings
suggest that while most specialists recognise the importance of nutrition in
early Alzheimer’s disease, very few offer an effective and comprehensive
nutritional assessment. Only 33 per cent of elderly care specialists routinely
assess diet and nutrition during the diagnosis of early Alzheimer’s disease.
Only 22 per cent of GPs expect nutrition to be routinely assessed as part of
the diagnostic process of Alzheimer’s disease.13
Access to specialist dietetic support is both poor and under-used. Over half
of elderly care specialists and GPs in the survey were unsure of the role that
nutrition might play in the pathology of Alzheimer’s disease.
There appears to be a clear need for greater awareness about the importance
of nutrition in Alzheimer’s disease and for improved knowledge on the part that
nutritional management may play in care of the condition.
We have therefore made a number of recommendations on how current
practice could be improved.
We propose improvements to staff training and access to specialist
dietary services.
We also offer guidance on the kind of dietary and nutritional advice that could
be given to people living with Alzheimer’s disease and their carers.
There is a danger that the drive for earlier
diagnosis of Alzheimer’s disease will amount
to very little, unless it is matched by an equal
commitment to providing high-quality care to
people once they are diagnosed.
2
Nutrition in Alzheimer’s disease in practice
In November 2012 a detailed survey13 was carried out to investigate
the practice of 100 specialists in elderly care in the UK. All of the survey
participants were involved in the diagnosis of Alzheimer’s disease and fell
into one of the following categories:
• A psychiatrist with a subspecialty in old-age psychiatry
• A geriatric medicine specialist with a subspecialty in old age psychiatry
• A general internal medicine specialist with dual accreditation in old
age psychiatry
83%
83 per cent of elderly care specialists feel the importance of nutrition
in Alzheimer’s disease is to maintain general good health compared
with 6 per cent who believe nutrition has a therapeutic benefit.
The results showed that:
89%
53%
Almost 9 out of 10 (89 per cent) elderly care specialists think it is
important to educate people with Alzheimer’s disease about a
healthy diet.
5 out of 10 elderly care specialists are unsure of
the role nutrition might play in the pathology of
Alzheimer’s disease (53 per cent).
Nutrition and Alzheimer’s
disease
Epidemiological studies have produced a growing body of evidence to
suggest that nutrition plays a key role in the development and progression of
Alzheimer’s disease. A number of nutritional and dietary factors have been
identified that may increase the risk of Alzheimer’s disease or protect
against it.
The dietary pattern approach – our growing knowledge of how individual
nutrients affect Alzheimer’s disease has given us a valuable insight into how
these specific elements in the diet influence progression of the condition.
However, putting this information into practice is complicated by the fact that
humans rarely consume individual nutrients in isolation. Normal diets contain
complex combinations of nutrients that are likely to have a range of synergistic
effects.14 This has led to an approach known as ‘dietary pattern’ analysis, in
which nutrients are investigated in the various combinations in which they
usually occur. These ‘patterns’ or combinations appear to have a stronger
impact than the individual nutrients themselves.9
People living with Alzheimer’s disease have
been shown to have relatively low levels
of certain nutrients in their bodies despite
eating a normal diet.
Raised plasma cholesterol
B12
Nutritional protection
64%
33%
64 per cent of elderly care specialists think that there is good evidence
linking vitamin B12 with good cognitive function.
Only one-third of elderly
care specialists routinely
assess diet/nutrition during
the diagnostic process
for suspected Alzheimer’s
disease.
29%
Less than a third of
elderly care specialists
have access to a
dietitian for people
with early Alzheimer’s
disease (29 per cent).
22%
Mediterranean diet
Many of the nutrients listed below, which have been found to offer a
protective effect against Alzheimer’s disease, occur in abundance in the
typical Mediterranean diet. Diets which contain high levels of fish, fruit,
unsaturated fatty acids, vegetables rich in anti-oxidants and moderate
amounts of wine, are associated with a reduced risk and slower
progression of Alzheimer’s disease. 7, 8
Omega-3 PUFAs
It has been known for a number of years that diets high in omega-3
PUFAs may reduce Alzheimer’s disease risk. One recent study found
that a diet rich in omega-3 PUFAs, vitamin E and folate, reduced the risk
of Alzheimer’s disease by 40 per cent in those subjects who adhered
best to the diet compared with those who adhered the worst.9
Antioxidants
20%
f those elderly care specialists who don’t routinely assess diet and
O
nutrition, 1 in 5 (20 per cent) of them have never considered nutritional
assessment, while others don’t think it is relevant.
Antioxidants, whether obtained through the diet or in the form of vitamin
E and vitamin C supplements, have been shown to offer a measure of
protection against Alzheimer’s disease.10 It is thought that these vitamins
help protect the ageing brain from the oxidative damage associated with
pathological changes in Alzheimer’s disease.
B vitamins
It is known that inadequate intakes of B vitamins can cause a rise in
plasma homocysteine, which is a risk factor for the development of
Alzheimer’s disease.15 B vitamin supplementation has been shown to
slow brain atrophy in people with high baseline homocysteine.16
Wine
1 in 5 elderly care specialists do not think diet, weight or BMI are
relevant to the diagnostic process of early Alzheimer’s disease
(22 per cent).
3
Nutritional risk factors
Moderate consumption of wine has been associated with a lower risk of
developing Alzheimer’s disease.17
High serum total cholesterol has been shown to be an independent risk factor
for a number of neurodegenerative disorders including Alzheimer’s disease.5
In particular, high cholesterol has been linked with the development of the
brain plaques that are associated with Alzheimer’s disease. However, the
relationship between high cholesterol and Alzheimer’s disease appears to be
complex and trials using cholesterol-lowering drugs in Alzheimer’s disease
have, so far, proved disappointing.18
Saturated and trans fatty acids
Diets that include a high intake of saturated or trans-unsaturated
(hydrogenated) fats, found mainly in animal fats, have been shown to increase
the risk of Alzheimer’s disease. In one study of 815 people aged 65 years
or older, none of whom had Alzheimer’s disease at the outset, 131 had
developed the disease four years later.4 The researchers found that those with
the highest levels of saturated fat intake had 2.2 times the risk of developing
Alzheimer’s disease compared with those with the lowest levels. The risk also
increased with the consumption of trans fats.
Obesity
People who are obese in middle age have been shown to be twice as likely to
develop dementia compared with those of a more healthy weight.6 This study,
which followed 1,500 elderly subjects for an average of 21 years, also found
that high cholesterol and high blood pressure in midlife raised the Alzheimer’s
disease risk by up to six times.
Hearts and minds
For many years healthcare professionals have been offering dietary advice
specifically aimed at reducing cardiovascular risk factors such as obesity, high
cholesterol and hypertension. More recently it has become clear that what is
good for the heart is also good for the brain.19 A low fat, high-fibre diet with
plenty of fruit, fish and vegetables is likely to offer as much protection against
dementia as is does against cardiovascular disease.20 This is good news for
healthcare professionals who have limited time to assess their patients and
offer practical, meaningful advice. Alzheimer’s disease-focussed dietary advice
does not mean re-writing the rule book. In many cases it will mean simply
expanding on what healthcare teams should already be doing for the general
good health of their patients.
4
How Alzheimer’s disease
may affect nutrition
Even in the early stages of Alzheimer’s disease the symptoms of the condition can
present significant barriers to obtaining a nutritionally adequate diet.21 Alzheimer’s
disease is often associated with changes in taste patterns or, in the later stages,
functional difficulties that interfere with chewing, swallowing and the preparation of
healthy food.
Cognitive impairments can make it difficult to remember or follow dietary
advice. Individuals’ social circumstances - isolation or low income for instance
- may also present difficulties in obtaining an adequate diet.
Many people with Alzheimer’s disease suffer comorbidities, such as dental
problems, depression, hypertension or diabetes that may have their own
impact on appetite or require difficult dietary restrictions. Lack of exercise may
also lead to a loss of appetite.
Many of the nutritional challenges of Alzheimer’s disease can be overcome
by the involvement of health or social care staff with specialist knowledge in
nutritional intervention. Indeed, professional guidelines, including those from
NICE22 and the Royal College of Nursing,22 stress that care plans for people
with Alzheimer’s disease should be person-centred and include nutritional
management.
Dietitians or appropriately trained nursing, medical or social care staff can offer
valuable assistance in obtaining all the nutrients necessary for good general
health and the best possible cognitive functioning.
The Kennedy Cycle
The biochemical pathway for
synthesising new neuronal membranes23
Phospholipids
Choline
Alzheimer’s disease focussed dietary advice
does not mean re-writing the rule book.
In many cases it will mean simply expanding
on what healthcare teams should already
be doing for the general good health of
their patients.
How nutrients may affect
Alzheimer’s disease
One of the key features of early Alzheimer’s disease is the loss of synapses24
- the connections within the brain that allow the transmission of electrical or
chemical signals. Loss of synapses is associated with the loss of memory.25
Because people with Alzheimer’s disease are losing synapses more rapidly
than would otherwise be expected, they have a higher requirement to
synthesise new ones.
Synapse formation depends on a process known as the Kennedy Cycle.23
The Kennedy Cycle involves a number of nutrients as precursors (uridine,
omega-3 PUFAs and choline) and as cofactors (B-vitamins, phospholipids
and antioxidants).26
However, people living with Alzheimer’s disease have been shown to have
relatively low levels of certain nutrients in their bodies despite eating a
normal diet. Specifically:
• Low brain levels of the omega-3 PUFA docosahexanoic acid (DHA)
are associated with cognitive decline and Alzheimer’s disease27
• Plasma folate levels are reduced in Alzheimer’s disease28
• Plasma vitamin B12, vitamin C and vitamin E levels are reduced in
Alzheimer’s disease29
• Uptake of choline is reduced in the ageing brain30
• Uridine monophosphate synthesis is reduced in people with
Alzheimer’s disease.31
Current practice
Nutritional assessment and screening
There are a number of clinical tools available to assess nutritional status and
screen patients for deficiencies (see Table 1). However, most of these tools
are primarily designed to identify malnutrition. Little, if any, attention is paid
to the effect of the diet on cognitive decline. Moreover, as the results of the
survey make clear, most of these tools are currently used only sparingly, or not
at all. Nutritional assessment tends to take place only when there is an obvious
problem such as malnutrition or obesity; or when the patient’s condition
has advanced to the point where they can’t prepare food, are experiencing
severely diminished appetite, or they have been admitted to hospital.
The Patient Experience
“Marco was first worried...he kept asking me what
the day was, and what we were doing, and endlessly
repeating it, and I was getting cross, as you do, when you
don’t understand…Once we got the diagnosis,
I listened to the doctor very carefully; Marco fell asleep.
It left me feeling confused and alone and totally unsure
about what I could do to help my husband”.12
Kate Harwood – Family carer
Characteristics of selected screening tools32
Tool
Target group
Table 1
Tool comprises
Malnutrition Universal Screening
Tool (MUST)
Adult patients in
hospital, community and
all care settings
3 sections: BMI*, unplanned weight loss, acute disease effect; score and
management plan
Nutrition Risk Screen (NRS)
Adult & child hospital
patients
5 sections: BMI/percentile chart, weight loss, appetite, ability to eat/retain
food, stress factor
Subjective Global
Assessment (SGA)
Adult hospital patients
2 sections: history of: weight loss, dietary intake change,
gastro-intestinal symptoms, functional capacity, disease, physical signs of
wasting, oedema, ascites
Malnutrition Screening Tool
(MST)
Adult hospital patients
3 questions: unintentional weight loss, amount of loss, dietary
intake/appetite
Derby Nutritional Score (DNS)
Adult hospital patients
7 sections: body weight for height, mobility, gastro-intestinal symptoms, skin
condition, appetite and dietary intake, psychological state, age
Mini Nutritional Assessment &
Short Form (MNA SR)
Older adults
6-item initial screen: BMI, recent weight loss, mobility, cognitive/mood state,
appetite and eating. If ‘at risk’, proceed with full 18-item version
Nutritional Risk Index (NRI)
Older adults
16-item questionnaire: medical history, medications, eating abilities, dietary
habits and intake, smoking, weight change
Nutritional Risk Assessment
Scale (NuRAS)
Older adults
12-item questionnaire: medical history, eating abilities, medications,
cognitive/mood state, social habits, weight loss
B-vitamins
anti-oxidants
Uridine
Cofactors
Phosphocholine
CDP-choline
Omega-3
fatty acids
Phosphatidylcholine
New neuronal membrane
Kennedy EP, Weiss SB. The function of cytidine coenzymes in the
biosynthesis of phospholipides. Biol Chem 1956;222:193–214.
One of the key features of early Alzheimer’s
disease is the loss of synapses22 - the
connections within the brain that allow the
transmission of electrical or chemical signals.
Loss of synapses is associated with the loss
of memory.24
* BMI = body mass index
5
6
Recommendations
References
The results of the survey clearly suggest that while the importance of good
nutrition is well recognised among specialists working with people with
Alzheimer’s disease, the role of nutritional support is often neglected in the
management of the condition’s early stages. We believe this needs to change.
Specifically there is a need for:
1. D
epartment of Health. What does the Mandate mean for people with dementia?
[Online] 2012. Available at: http://mandate.dh.gov.uk/dementia [Accessed
November 2012].
• A raised awareness among staff, carers and people with Alzheimer’s
disease of the importance of nutrition in Alzheimer’s disease and
dementia
• Better nutritional support during the pre-diagnosis stage and the
early stages of Alzheimer’s disease
• Nutritional assessment to be carried out as a matter of course in
suspected Alzheimer’s disease cases
• The development of better assessment tools that focus on the
nutritional value of diet, as well as calorific intake
• Better nutritional training for health and social care staff
• Better access to dietetic support, especially for people with early
Alzheimer’s disease
• Recommended daily intakes to be developed for people with
Alzheimer’s disease to include Omega-3 PUFAS, vitamin E, folate,
vitamin B12 and vitamin B6.
Conclusion
In the UK alone there are more than 820,00031 people living with dementia.
This number is expected to double over the next 30 years; nearly 400,000 of
these people are unaware that they have the condition.
Alzheimer’s disease is a multifactorial condition that requires multidisciplinary
care. In recent years it has increasingly been recognised that this care should
be patient-centred, holistic, and incorporate lifestyle factors such as diet and
exercise, as well as pharmaceutical intervention. It should focus as much on
adding life to years as it does on adding years to life.
The NHS prioritises patient-centred solutions, and provides both guidance
and infrastructure to support people with Alzheimer’s disease from the point of
diagnosis. The NICE quality standards stress the importance of an integrated
multidisciplinary approach to the management of the condition. However, it
appears that important steps at diagnosis, such as nutritional assessments,
are being missed by healthcare professionals. This is due to poor awareness
of the role that good nutrition can play in maintaining physical strength and
brain function.
We believe that implementing the recommendations in this report will help
raise awareness among health and social care staff, as well as providing
them with the tools to offer a more comprehensive nutritional assessment and
better dietary support. This will ensure that nutrition takes its rightful place as a
cornerstone of patient-centred Alzheimer’s disease care from the outset.
3. A
lzheimer’s Society. Increase in number of people diagnosed with dementia: over
400,000 remain undiagnosed, according to Alzheimer’s Society [Online]. Available
at: http://www.alzheimers.org.uk/site/scripts/news_article.php?newsID=1164
[Accessed November 2012].
4. M
orris MC, Evans DA, Bienias JL et al. Dietary fats and the risk of incident Alzheimer
disease. Arch. Neurol. 2003;60(2):194–200.
5. N
otkola IL, Sulkava R, Pekkanen J et al. Serum total cholesterol, apolipoprotein E
epsilon 4 allele, and Alzheimer’s disease. Neuroepidemiology. 1998;17(1):14–20.
6. K
ivipelto M, Anttila T, Fratiglioni L et al. P2-278 Body mass index, clustering of
vascular risk factors and the risk of dementia: a longitudinal, population-based
study. Neurobiology of Aging. 2004;25:S311.
7. S
olfrizzi V, Frisardi V, Seripa D et al. Mediterranean diet in predementia and dementia
syndromes. Curr Alzheimer Res. 2011;8(5):520–542.
8. V
assallo N, Scerri C. Mediterranean Diet and Dementia of the Alzheimer Type. Curr
Aging Sci. 2012.
9. G
u Y, Nieves JW, Stern Y et al. Food combination and Alzheimer disease risk: a
protective diet. Arch. Neurol. 2010;67(6):699–706.
10. Z
andi PP, Anthony JC, Khachaturian AS et al. Reduced risk of Alzheimer disease in
users of antioxidant vitamin supplements: the Cache County Study. Arch. Neurol.
2004;61(1):82–8.
11. N
ICE. Dementia [Online]. Available at: http://publications.nice.org.uk/dementiaquality-standard-qs1 [Accessed December 2012].
12. R
CN. Dementia. Commitment to the care of people with dementia in hospital
settings [Online] 2012. Available at: http://www.rcn.org.uk/__data/assets/pdf_
file/0011/480269/004235.pdf [Accessed November 2012].
13. 1
00 specialists were surveyed online. Fieldwork was conducted by MedeConnect
Healthcare Insight 2–16 November 2012.
14. J acobs DR Jr, Gross MD, Tapsell LC. Food synergy: an operational concept for
understanding nutrition. Am. J. Clin. Nutr. 2009;89(5):1543S–8S.
15. Q
uadri P, Fragiacomo C, Pezzati R et al. Homocysteine, folate, and vitamin B-12 in
mild cognitive impairment, Alzheimer disease, and vascular dementia. Am. J. Clin.
Nutr. 2004;80(1):114–122.
16. S
achdev PS. Homocysteine and brain atrophy. Prog. Neuropsychopharmacol. Biol.
Psychiatry. 2005;29(7):1152–61.
17. L etenneur L, Larrieu S, Barberger-Gateau P. Alcohol and tobacco consumption as
risk factors of dementia: a review of epidemiological studies. Biomed. Pharmacother.
2004;58(2):95–9.
18. M
atsuzaki T, Sasaki K, Hata J et al. Association of Alzheimer disease pathology with
abnormal lipid metabolism The Hisayama Study. Neurology. 2011;77(11):1068–75.
19. F
illit H, Nash DT, Rundek T et al. Cardiovascular risk factors and dementia. Am J
Geriatr Pharmacother. 2008;6(2):100–18.
20. A
lzheimer’s Association. Adopt a Brain-Healthy Diet | Alzheimer’s Association
[Online]. Available at: http://www.alz.org/we_can_help_adopt_a_brain_healthy_diet.
asp [Accessed November 2012].
21. A
lzheimer’s Society. Eating and drinking [Online]. Available at: http://www.
alzheimers.org.uk/site/scripts/documents_info.php?documentID=149 [Accessed
November 2012].
22. N
ICE. Dementia. Supporting people with dementia and their carers in health
and social care [Online] 2006. Available at: http://www.nice.org.uk/nicemedia/
live/10998/30318/30318.pdf [Accessed November 2012].
23. K
ennedy EP, Weiss SB. The Function of Cytidine Coenzymes in the Biosynthesis of
Phospholipides. J. Biol. Chem. 1956;222(1):193–214.
24. S
cheff SW, Price DA, Schmitt FA et al. Synaptic alterations in CA1 in mild Alzheimer
disease and mild cognitive impairment. Neurology. 2007;68(18):1501–8.
25. S
cheff SW, Price DA, Schmitt FA et al. Hippocampal synaptic loss in early
Alzheimer’s disease and mild cognitive impairment. Neurobiol. Aging.
2006;27(10):1372–84.
The Patient Experience
26. Z
eisel SH. Choline: Critical Role During Fetal Development and Dietary
Requirements in Adults. Annu Rev Nutr. 2006;26:229–50.
“My hope would be for people to understand it more,
to get rid of the stigma of dementia”.12
27. J icha GA, Markesbery WR. Omega-3 fatty acids: potential role in the management
of early Alzheimer’s disease. Clin Interv Aging. 2010;5:45–61.
Ann Johnson who is living with Alzheimer’s disease.
Editorial support provided by Mark Hunter.
This report has been produced in conjunction with independent authors. It has
been supported by Nutricia Advanced Medical Nutrition which has provided
editorial and financial support.
©January 2013
7
2. D
epartment of Health. Prime Minister’s challenge on dementia [Online] 2012.
Available at: http://www.dh.gov.uk/health/2012/03/pm-dementia-challenge/
[Accessed November 2012].
28. S
mach MA, Jacob N, Golmard J-L et al. Folate and homocysteine in the
cerebrospinal fluid of patients with Alzheimer’s disease or dementia: a case control
study. Eur. Neurol. 2011;65(5):270–8.
29. G
lasø M, Nordbø G, Diep L et al. Reduced concentrations of several vitamins
in normal weight patients with late-onset dementia of the Alzheimer type without
vascular disease. J Nutr Health Aging. 2004;8(5):407–13.
30. C
ohen BM, Renshaw PF, Stoll AL, et al. Decreased brain choline uptake in
older adults. An in vivo proton magnetic resonance spectroscopy study. JAMA.
1995;274(11):
902–7.
31. M
cWilliam C, Smith N, Stead M. Nutrition: the importance in early Alzheimer’s
disease. Innovation in Healthcare. 2012:44–5.
32. P
erry L. Using nutritional screening tools to identify malnourished patients [Online].
Available at: http://www.nursingtimes.net/nursing-practice/clinical-zones/nutrition/
using-nutritional-screening-tools-to-identify-malnourished-patients/1958881.article
[Accessed November 2012].