Malnutrition in People Living with Dementia

July 2025 Issue

 
By Kelly Lambert, PhD, Dietitian, Associate Professor, School of Medical, Indigenous and Health Sciences, University of Wollongong.

One of the important concerns expressed by families who have a loved one with dementia is the effect it has on eating and drinking. This can lead to malnutrition and other negative consequences. Here, we will discuss the causes and consequences of malnutrition and explore some strategies to help manage it.

What is malnutrition?

Malnutrition is a general term for when people do not eat appropriate amounts of food for good health (National Cancer Institute, 2025). When discussing malnutrition in people with dementia, we generally refer to undernutrition: in other words, there is a deficiency of calories, as well as vitamins and minerals. How do you detect malnutrition? A nutrition assessment is needed to diagnose malnutrition. This includes consideration of a person’s medical history, a physical examination, assessing usual diet, measuring body weight and examining any history of unintentional loss of weight.

How common is malnutrition in people with dementia?

Unfortunately, malnutrition is very common. A recent study of more than 8700 people living with dementia estimated that one in four people with dementia in residential aged care are malnourished (27%), and more than half (57%) are at risk of becoming malnourished (Perry et al., 2023). However, this is probably an underestimate, as many people with severe dementia are excluded from research studies.

What are the consequences of malnutrition in people with dementia?

There are many serious consequences of malnutrition (Figure 2). These impact the person with dementia and place a burden on the health system (Norman et al., 2021).

Consequences of malnutrition include:

  1. Loss of muscle – which can lead to decline in strength, increased risk of falls and worsening frailty (Landi et al., 2019; Ligthart-Melis et al., 2020).
  2. Loss of bone strength – which can increase the risk of bone fractures (Kueper et al., 2015).
  3. Reduced immunity – which can increase the risk of infections and delay recovery from illness.
  4. Increased risk of pneumonia – due to reduced lung muscle strength, increased susceptibility to infection, and a reduced immune response (van der Maarel-Wierink et al., 2011).
  5. Reduced wound healing – malnutrition, especially long-term inadequate amounts of vitamins and minerals, affects the repair of muscle tissue and contributes to chronic wounds and delays recovery of existing wounds (Stechmiller, 2010).
  6. Worsened cognition and increased confusion – malnutrition leads to nerve cell damage and can worsen confusion (Feng et al., 2022).
  7. Increased risk of hospitalisation and death (Valmorbida et al., 2020).

What contributes to malnutrition in people with dementia?

Malnutrition which develops in people with dementia is due to a wide range of factors. These include barriers at the individual level and barriers to food intake from various systemic factors.

At the individual level:

  • Cognitive impairment: People may forget to eat or have difficulty recognising food. They may forget usual food combinations (e.g. meat and three vegetables, bread and butter). They may also have challenges using cutlery or recognising food on multipatterned plates. They may also fail to recognise hunger and thirst cues.
  • Behavioural and psychological symptoms: agitation, depression and changes in food preferences can lead to a decrease in overall food intake.
  • Swallowing and chewing difficulties: Dysphagia is common in those with malnutrition and may develop as a consequence of prolonged malnutrition. Other factors, such as a lack of regular oral hygiene, poor dentition or poorly fitting dentures, can make getting adequate food challenging.
  • Sensory changes: Food may taste less pleasant, or people living with dementia may enjoy unusual food or flavour combinations. They may also have challenges in judging the temperature of foods and can burn their mouth, making eating uncomfortable or unsafe.
  • Medication side effects: Medications used to help manage dementia can impact appetite or cause symptoms that can impact appetite. For example, cholinesterase inhibitors (Aricept, Exelon), antipsychotics (Risperidone), or sleep medications can all impact appetite and digestion.

Factors contributing to malnutrition at the system level include:

  • Social factors: Eating is a social experience (Björnwall et al., 2024). Despite confusion, people with dementia tend to eat less when they eat alone (Björnwall et al., 2021). Being placed in a room in isolation for a meal is likely to lead to reduced intake of food.
  • Environmental factors: Institutional settings, like residential aged care facilities, are barriers to optimal food intake. Residents report wanting increased autonomy over food choice to select foods they desire, with an increase in variety and choice, including meals to meet the needs of culturally diverse residents (Mellow et al., 2024).
  • Structural factors: Lack of assistance at meals due to reduced staffing is a major contributor to many people getting inadequate food and drink (Simmons et al., 2001). Time required for optimal feeding assistance has been estimated to be at least 38 minutes per resident per meal compared to the current average of nine minutes (Simmons et al., 2001).
  • Policy related factors: Lack of regular (ideally monthly) nutrition screening and irregular weighing of residents can contribute to missed opportunities to identify malnutrition early.

Strategies to help people living with dementia who have malnutrition

A multipronged approach is needed to help treat malnutrition:

Family members, for example, can:

  • Offer your loved one’s favourite foods regularly and eat with them in a relaxed environment. However, it is noted that reduced choice is key because decision- making at mealtimes can often cause confusion and agitation (Ball et al., 2015).
  • Help ensure the mouth is cleaned after a meal.
  • Watch out that food is being swallowed safely and not pooling in the cheeks. A gurgling voice after meals or coughing at mealtimes may indicate that food is not being swallowed safely.
  • Know your loved one’s weight and ask if they have been weighed.

Diets can be modified:

  • Ensure nutrient-dense meals are offered. Add condiments to meals such as sour cream, cream, gravy or sauce. Cream-based soups can be nourishing and high in nutrients for a small volume.
  • Offer nourishing fluids regularly, such as milkshakes with enriched milk, juice or cordial. Try offering these when taking tablets rather than water to maximise the calories consumed.
  • Offer regular mini meals or a grazing pattern of eating rather than three meals and a few snacks per day.
  • Offer finger foods if using cutlery is challenging.
  • Do not offer texture-modified diets unless there is a proven problem with difficulty swallowing. This can reduce the enjoyment of food and the nutrient density.
  • Ensure the dining environment is uncluttered and free from distracting items, including non-essential table items (e.g., flowers, condiments), cutlery and decorations. Use white or solid-coloured cutlery and plates, and avoid patterned tablecloths.

Residential Aged Care staff can also be a great help. For example:

  • Weigh all residents, especially those with dementia, every month. If unintentional weight loss is detected, increase weighing to weekly in conjunction with strategies to improve food intake.
  • Check that dentures are fitting well and are used with meals.
  • Treat constipation promptly, as this can contribute to a reluctance to eat meals.
  • Ensure regular oral hygiene, including teeth and mouth brushing after meals.
  • Play music at mealtimes as this has been shown to improve intake (Ho et al., 2011; Ragneskog et al., 1996).
  • Plan where residents will be seated at meals to create a homely environment, and opportunities for genuine social interaction can occur (Lea et al., 2017).
  • Offer hydration opportunities regularly. People with dementia will fail to recognise thirst cues. Dehydration contributes to worsened confusion, urinary tract infections, constipation and poor food intake.

Malnutrition in people with dementia is common. Weekly weighing, in conjunction with a family and team-based approach to care, can identify risk factors for malnutrition early and implement effective strategies.

References

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Björnwall, A., Colombo, P. E., Mattsson Sydner, Y., & Neuman, N. (2024). The impact of eating alone on food intake and everyday eating routines: A cross-sectional study of community-living 70- to 75-year- olds in Sweden. BMC Public Health, 24(1), 2214. doi.org/10.1186/s12889-024-19560-0

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