He Won't Eat, or Refuses Meals

This is the situation most likely to have a fixable physical cause underneath it, and the most likely to go weeks before anyone checks. Start with the mouth.

Look for pain first. A cracked tooth, a tooth infection, a denture that no longer fits, thrush (white patches inside the cheeks that don't wipe off), or an ulcer under the tongue will end a meal reliably, and he may have no way to tell you which tooth. Look in good light, standing beside him rather than in front, and if he won't open his mouth, don't force it, since that is worth reporting on its own. Watch instead for chewing on one side, wincing, pulling away from cold drinks, or pushing a denture out with his tongue.

Constipation is common and badly underestimated, since someone who hasn't had a bowel movement in several days will not feel hungry, and coaxing doesn't change that. Ask the clinician or the pharmacist before starting a laxative, and if there is vomiting, a hard or swollen belly, or no wind passing, treat that as urgent rather than as constipation.

Then medications, especially anything started or increased in the last month. The main dementia drugs commonly cause nausea and appetite loss after a dose goes up: donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne). Opioids, antibiotics, metformin, digoxin, antidepressants and bladder medications can all do it too. Don't stop anything yourself, but bring the list to the prescriber and ask whether each one is still earning its place.

Then swallowing. Coughing during or after meals, a wet or gurgling voice after drinking, food sitting unswallowed in the cheek, or a drift toward softer foods all point toward dysphagia, which simply means trouble swallowing. When the swallow has become frightening, refusing to eat is a reasonable response rather than resistance. This one is a referral rather than a technique: ask the doctor's office for a swallow evaluation with speech therapy, since the referral has to come from the clinician, and ask on the day you notice the coughing, since scheduling takes weeks.

The senses change earlier than families expect. Smell dulls years before diagnosis, and since most of what we call flavor is smell, food that used to taste like something tastes like almost nothing. Sweetness holds up longest, which is why someone who pushes dinner away will finish a bowl of ice cream, and that isn't stubbornness. Vision matters too, since the eye loses the ability to separate close shades and mashed potato on a white plate can be genuinely hard to see.

Depression is common here and undertreated, and it shows up as lost appetite as often as sadness. So does the meal itself: a crowded plate, a patterned tablecloth, a television, or three people talking are each enough to stop a meal for someone whose attention is the resource in shortest supply. And if he has also become noticeably more confused in the last day or two, that points at infection, and the sudden-confusion guide is the one to read tonight.

There are two situations here and they are handled differently. Reduced intake in the final stage of dementia is part of the body's own process, managed with comfort as the goal rather than calories, and there is good reason to believe it is not experienced as hunger or thirst. Mouth care, small tastes of what he likes, and sips for pleasure are what help. Reduced intake at any earlier point is a problem with a cause, and the cause is usually findable. Late-stage decline comes on slowly, alongside losing speech, walking and recognition, while a fixable cause shows up over days or weeks in someone whose other abilities haven't changed. If you can't tell, ask the clinician exactly that.

If anyone raises a feeding tube, the evidence in advanced dementia is settled, and the American Geriatrics Society recommends against it. Tubes have not been shown to extend life, to prevent pneumonia from food going into the lungs, or to heal pressure sores, and they often lead to agitation and restraints. Careful hand feeding is what is recommended instead. You are allowed to ask to speak with palliative care before deciding anything, and this is far easier to settle before a hospital admission than during one.

Change the conditions before you change the menu.

1. Make the swallow safer first. Sit him fully upright, chin tucked slightly down rather than tipped back, and keep him upright for half an hour after. Never feed someone who is drowsy, and give one small bite at a time, checking the mouth is empty before the next. Brush his teeth, gums and tongue twice a day, since a mouth full of bacteria is one of the main reasons a small amount of food in the lungs turns into pneumonia. This does more for his safety than anything else on the page.
2. Change the plate before the food. A plain, strongly colored plate on a plain placemat helps when the eye can no longer separate close shades, though the evidence rests on one very small study, so try it for a week and drop it if it does nothing. Put one or two items out and bring the rest later, since a full plate can look like a task to complete.
3. Turn the television off, clear the table, keep the room to one conversation, and move the main meal to whenever he is most alert, usually breakfast or lunch. Stop treating dinner as the meal that has to work.
4. Switch to finger foods when utensils become the obstacle: sandwich quarters, meatballs, cheese cubes, chicken strips, potato wedges. They let people keep feeding themselves after cutlery stops working.
5. If, and only if, swallowing is not a concern, add calories rather than volume: whole milk, butter or oil stirred into food, full-fat yogurt, a blended drink. If you've seen coughing at meals or heard a wet voice afterward, stop here and get the swallow looked at first, and don't thicken drinks or change textures on your own, since the wrong texture makes things worse.

Weigh weekly, same scale, same time of day, and write it down. An unintentional loss of about five percent of body weight over six months or less is worth a call, which is roughly eight pounds in someone who weighs 160. Don't wait for a threshold, since a steady downward line, a belt hole, or a ring that has loosened is reason enough on its own. If there's no scale, or he can't stand on one safely, photograph his face every couple of weeks, since change shows up in photographs long before you see it in the room.

Feeding someone is one of the oldest ways there is to take care of them, and having it refused lands harder than anyone expects. That is not you being dramatic. That is what feeding someone means. You are not required to win every meal, refusing food is not the same as choosing to die, and letting a meal go is not the same as giving up. A day where he ate ice cream and drank a milkshake is a day he took in calories, and that counts.