April 10, 2017

Mealtime Rituals and Person-Centered Care for Adults with Alzheimer’s disease


by Justin Martin, OTS Doctorate Program, and M. Tracy Morrison OTD R/L, Chair, Occupational Therapy,  Arkansas State University (ASU)

Personhood is a term used to describe the actions taken by self or others for the purposes of promoting personal autonomy and quality of a life (Little, 2014). Societal conversations about personhood can be found alongside those about spirituality and human rights (Martin & Sabbagh, 2011). While US healthcare policies unanimously promote personhood concepts, the process of preserving personhood during times of personal health decline and increased dependency levels remains relatively unexplored among aging populations.

Mealtime choice is enjoyed as a ritual of personhood during the first year of postnatal development (Birch, Savage, & Ventura, 2007). Infant caregivers are encouraged to facilitate infant engagement levels in the feeding process through varied methods that include increased feeding times, environmental modifications and additional food choices. By mid-childhood, mealtime rituals become expressions of personhood and incorporated into interpersonal social dynamics. By adulthood, mealtime rituals are carried across generations between the parent and offspring. And upon late adulthood, the mealtime ritual may be one of the only remaining expressions of personhood that generalizes into institutionalized care settings (Kiser, Medoff, Black, Nurse, & Fiese, 2010).

There is a paucity of information about the influence of mealtime rituals on the quality of life and the well-being of individuals with Alzheimer’s disease (AD).
Individuals with AD commonly experience negative behaviors including feeding aversions, apathy, anxiety, disinhibition, fear and depression (Burns-Cox, 1980).

These behaviors dramatically increase the level of caregiver burden and increased risk of negative health incidences. Evidence suggests personhood rituals, for example meditation and religious ceremonies, facilitate positive behaviors and neuroprotective changes among individuals with AD (Chow, et al., 2009). Person-centered contexts remain the most appropriate therapeutic approaches for residents with AD because they stimulate positive emotional memories that facilitate cooperative actions that suggest positive developments despite the degenerative nature of AD (Chow, et al., 2009).

Occupational therapists prioritize “how” or “whether” the person served participates in meaningful activities (i.e. occupations). A fundamental principle within this profession is that the engagement in personhood activities promotes well-being and that well-being is an intrinsic state that promotes the quality of life regardless of health status (Gray, 1998). Occupational therapists (OTs) promote the person’s engagement levels through interventions that incorporate sensory, cognitive, physical and environmental factors. Most commonly, OTs focus interventional efforts around the rituals, habits and routines of the person with AD and they measure outcomes the promote well-being and ability levels pre- and post-intervention (Padilla, 2011).

Occupational therapists utilize numerous therapeutic methods theoretically supported in the cognitive neurosciences (Arbesman & Lieberman, 2011). The use of visual priming and reminiscence to promote engagement and well-being in adults with AD has been proven effective and worthwhile (Burns, Jacoby, & Levy, 1990).

The premise that negative behaviors result in feeding aversions during mealtime also suggests that increased engagement in mealtime activities may promote both feeding and well-being. The feasibility of a program developed to promote personhood during the mealtime ritual was recently explored among a cohort of individuals with AD living in memory care facilities. When residents were provided with contextual supports associated with mealtime options (versus only verbal instructions), their engagement levels in mealtime activities improved. Additionally, caregivers reported reduced burden levels associated with mealtime duties. These observations suggest that mealtime may be the ideal context for therapeutic activities and that well-being may be promoted through personalized mealtime rituals.

Institutional care does not replace the home environment, but personal rituals generalize beyond home environments because they are acts of personhood. And in likeness to the ritual of prayer, the ritual of mealtime activities may be valuable to the well-being of the individual with AD (Greenwood, et al., 2005). Therapeutic programs that reduce barriers to promote engagement in personhood rituals are important considerations during end of life care. The personalized mealtime rituals may be the last personhood ritual available in the adult with advanced AD and therefore may serve as an important therapeutic tool for healthcare professionals working in memory care facilities.


1. Martin, G.A., & Sabbagh, M.N., (2011). Palliative care for advanced Alzheimer’s and dementia: guidelines and standards for evidenced-based care. New York: Springer.
2. Little, M. (2014). Theorising personhood: for better or for worse. European Journal for Person Centered Healthcare, 2(1), 57.doi:10.5750/ejpch.v2il.696.
3. Padilla, R. (2011). Effectiveness of occupational therapy services for people with Alzheimer’s disease and related dementias. The American Journal of Occupational Therapy, 65(5), 487-489.
4. Stages of Alzheimer’s. (2017). Retrieved from alz.org: Alzheimer’s Association: http://www.alz.org/alzheimers_disease_stages_og_alzhemers.asp.