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    Nutrition in early_ad_report1 Nutrition in early_ad_report1 Document Transcript

    • 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. The importance of nutrition in the management of early Alzheimer’s disease
    • 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. The importance of nutrition 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. 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. 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 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. Nutritional intervention in Alzheimer’s disease 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. 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 integrated approach to provision of services is fundamental to the delivery of high quality care to people with dementia’.11 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. 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. 1 2 CONTENTS Introduction 1 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 Recommendations 7 Conclusion 7 References 7 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. It increasingly appears that what is good for the heart is also good for the brain. The Patient Experience “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 Ann Johnson, who lives with Alzheimer’s disease 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.
    • 3 4 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 Nutritional risk factors Raised plasma cholesterol 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. Nutritional protection 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 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 Moderate consumption of wine has been associated with a lower risk of developing Alzheimer’s disease.17 64 per cent of elderly care specialists think that there is good evidence linking vitamin B12 with good cognitive function. 64% B12 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 The results showed that: 89% 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). 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. 83% Only one-third of elderly care specialists routinely assess diet/nutrition during the diagnostic process for suspected Alzheimer’s disease. 33% 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). 22% Less than a third of elderly care specialists have access to a dietitian for people with early Alzheimer’s disease (29 per cent). 29% 53% Nutrition in Alzheimer’s disease in practice Of those elderly care specialists who don’t routinely assess diet and nutrition, 1 in 5 (20 per cent) of them have never considered nutritional assessment, while others don’t think it is relevant. 20% 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.
    • 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 5 6 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. Tool Target group 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 Characteristics of selected screening tools32 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. Phosphocholine CDP-choline Phosphatidylcholine Phospholipids Choline Omega-3 fatty acids B-vitamins anti-oxidants Uridine Cofactors New neuronal membrane 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 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. Kennedy EP, Weiss SB. The function of cytidine coenzymes in the biosynthesis of phospholipides. Biol Chem 1956;222:193–214. 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 The biochemical pathway for synthesising new neuronal membranes23 Table 1 * BMI = body mass index The Kennedy Cycle
    • 7 References 1.     Department of Health. What does the Mandate mean for people with dementia? [Online] 2012. Available at: http://mandate.dh.gov.uk/dementia [Accessed November 2012]. 2.     Department 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]. 3.     Alzheimer’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.     Morris MC, Evans DA, Bienias JL et al. Dietary fats and the risk of incident Alzheimer disease. Arch. Neurol. 2003;60(2):194–200. 5.     Notkola 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.     Kivipelto 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.     Solfrizzi V, Frisardi V, Seripa D et al. Mediterranean diet in predementia and dementia syndromes. Curr Alzheimer Res. 2011;8(5):520–542. 8.     Vassallo N, Scerri C. Mediterranean Diet and Dementia of the Alzheimer Type. Curr Aging Sci. 2012. 9.     Gu Y, Nieves JW, Stern Y et al. Food combination and Alzheimer disease risk: a protective diet. Arch. Neurol. 2010;67(6):699–706. 10.   Zandi 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.   NICE. Dementia [Online]. Available at: http://publications.nice.org.uk/dementia- quality-standard-qs1 [Accessed December 2012]. 12.   RCN. 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.   100 specialists were surveyed online. Fieldwork was conducted by MedeConnect Healthcare Insight 2–16 November 2012. 14.   Jacobs DR Jr, Gross MD, Tapsell LC. Food synergy: an operational concept for understanding nutrition. Am. J. Clin. Nutr. 2009;89(5):1543S–8S. 15.   Quadri 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.   Sachdev PS. Homocysteine and brain atrophy. Prog. Neuropsychopharmacol. Biol. Psychiatry. 2005;29(7):1152–61. 17.   Letenneur 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.   Matsuzaki 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.   Fillit H, Nash DT, Rundek T et al. Cardiovascular risk factors and dementia. Am J Geriatr Pharmacother. 2008;6(2):100–18. 20.   Alzheimer’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.   Alzheimer’s Society. Eating and drinking [Online]. Available at: http://www. alzheimers.org.uk/site/scripts/documents_info.php?documentID=149 [Accessed November 2012]. 22.   NICE. 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.   Kennedy EP, Weiss SB. The Function of Cytidine Coenzymes in the Biosynthesis of Phospholipides. J. Biol. Chem. 1956;222(1):193–214. 24.   Scheff 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.   Scheff 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. 26.   Zeisel SH. Choline: Critical Role During Fetal Development and Dietary Requirements in Adults. Annu Rev Nutr. 2006;26:229–50. 27.   Jicha GA, Markesbery WR. Omega-3 fatty acids: potential role in the management of early Alzheimer’s disease. Clin Interv Aging. 2010;5:45–61. 28.   Smach 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.   Glasø 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.   Cohen 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.   McWilliam C, Smith N, Stead M. Nutrition: the importance in early Alzheimer’s disease. Innovation in Healthcare. 2012:44–5. 32.   Perry 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]. The Patient Experience “My hope would be for people to understand it more, to get rid of the stigma of dementia”.12 Ann Johnson who is living with Alzheimer’s disease. Recommendations 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: • 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. 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