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T here are many nutritional i. ssues faced by people diagnosed with dementia and lor health care staff caritig for these [x-ople. lTiese issues can include trying to ensure an I iptimum diet containing the cortiect vitamins atid mitierals to iry to help . sk)w the progression of the disease. As Is more commonly the case, however, issues can I K as basic as liiiding pr;u tical ways to encourage someone with dementia to consume enough calorics to prevent weight loss. 1 he prevalence of malnutrition in the eklcrly in hospitals and care homes has featured ill the press on a regular hasis in recent years (IJBC News. 2007).

it has been re(X)rted that appaiximately 16% of people in care homes, and as tiiany as 40% of people admitted lo luvspital from home are malnourished. Malnutrition in those aged 65 years antl over |irobably costs ;t2—4 billicwi more than cahng for an equal numlx;r of well-nourished individuals. This was highlighted in the Mahmlrilio}! Universal Serening 7oo/ Rejx}rt (Ktia, 2(H(3). This is tioc lost on tiiany of those caring Ibr individuals with dcmc-ntia: these p;iiirtus often have low biKiy weight, refuse m cat or ttrink, or have iK’haviouml or [ihysical problems which may make mealtimes ilifTicult at iK’st.

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Tliis tan contribute to the helplessness that may Ix- felt by staff caring for these individuals. Tliis article will dist u. ss the problems assoi iatcti with liementia and nutrition, what can lie done to overcome these problems, and whether it is ;iossible for those with dementia to avoid tnalnutrition. Ensuring those with dementia meet their nutritional needs can be challenging and frustrating for staff. Tara Hargreaves presents practical advice for staff to help promote better nutrition in older adults with dementia. year>;, and one in five over 80 years.

It is predmotiinatley a disease of ageing, atid i. s on the rise. It is estimated that by 2021 there will be 940000 people with dementia in tbe UK, with predictions that it will iturcuse by iS% in the nexi 15 years. It is further estimated that those aged 65 years and over living in Ekierly Mentally Infirm (EMI) hotnes is 79. 95%, nursing homes 66,9% and t^sidential care homes 52. 2% (Alzheimer’s Society. 2007). It costs . il7. O3 billion to care for people with dementia. This includes formal care agencies and the fitiancijil vjilue of unpaid informal care provided by family and fiiends.

The cost of caring for one person with dementia in a care home is i31 296 [KT year (Alzheimer’s S(x:iety, 2007). While there Is research investigating the role thai vitarnins and minerals may have in preventing dementia, the most ctimtnon nutritional issues linked to dementia arc related to the difficulty that this clietit gn)up can have with eating and drinking, and the consequential malnutrition. There are reports in the UK and elsewhere suggesting a frequent failure to recognize tnalnutrition in a tiumher of care settings and it has |-)een suggested chat this may he up to 10096 in some nui-sing homes (Eliit, 2003).

It is well documented that those with dementia often have a low body weight (Benati et al, 199H). It is important to question if this L a process of the disease itself, S or as result of reiluced intake resulting frotn tiiany of the [>t-actical i. ssue-s surroutiiling the disease. Ilicre is some reseaix’h to show that weight loss may be part of the ageing [irocess (Morley and Thomas, 1999), or that it may be a physiological response to dementia (Barrett-Connor et al, 1996). Research al. so demonstrates, however, that patients wiih dementia can ^ n weight (Barratt, 2004).

In the author’s experience, ihc largest contributing factor lu tbe weight loss of people with dementia is a reduced calorie intake, and possibly increased enei’gy expenditure uwitig to the matiy symptoms of tietiieniia. Tablo 1 . METHODS OF OVERCOMING FEEDING PROBLEMS Background Ihea- aiL- currently around 690 000 people with dementia in the UK. This is approxitnately 1. 1% of the total UK population (Al/hfimer’s S(x:iety, 2(X)7). Dementia effects one in twenty people over the age of 65 Tara Hargreaves, Senior Dietitian Care of the Elderly Dietetics Service, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh, EHIO SHF

Try to have stnall frequent calorie^lense meals and between-meal snacks Carry out a detailed assessment of individuals’ preferences and needs Try to create a caltn atmosphere in dining room or area Try to allow plenty of time with patients at mealtimes Learn to understand individuals” verbal and non-verbal cues Nursing & Residential Care, March 2008, Vol 10, No 3 118 Dementia and weight loss Ttie issues thai cause those with dementia to lose weight are discussed in turn tielow: Reduced food intake Many okier peo[ilc with or without dementia

report a reduced appetite (Marcus and Berry, 199H), Studies have shown that there may he a number of physiological reasons for this. It is known that there is a decline in gastric emptying as we age. ‘I’his has been ass(Kuated with increased satiation owing to the slower Table 2. HNGER FOOD EXAMPLES Breads and cereals Buttered toast fingers Rolls with butter Sandwiches Buttered muffins, crumpets Crackers with butter French toast Fruit load, fruit cake, teabread Gingerbread, scones, wafffes Cereal bars Chapattis.

small pitta, won tons movement of food thi’ough the gastrointestinal tract. There has also Ijeen research to show thai a number of hormones are altered with the ageing process, iind these can contribute to feelings of flillness or have anorectic effects (Morley and Thomas, 1999). It is important Ut consider this alongside the knowledge that there is a demcmstmted decline in the ability to taste and smell as we age, which also contributes to a retiuced intake of food, (Schiffinan and Warwick, 1992).

it is therefore difficult to asscertain whether reduced int;ike in those with dementia is a result of the prcKesses asstKiated with ageing, linked to ftXKi refusal as part of the dementia pr(x:ess, or linked to another psychiatric or psychological problem such as depression or paranoia, Reaiisltically, it is likely to be a combination of these factors. Vegetables Carrot sticks/coins, raw or cooked Broccoli spears Brussels sprouts Green beans, mangetout Chips, potato waffles New potato, sweet potato slices Fried onion rings, mushrooms Sliced cucumber, tomato, celery

Feeding difficulties The process of dementia creates some physical difficulties at mealtimes. The very nature of dementia means that intlividuals may lose the skills to eat. There may be a gradual loss ofmotorskills, for example, an individual may no longer know bow to use a knife and tork, A[iraxia (,)f eating is also common in thcxse with advancing dementia. An indiviilual with this condition may intend to open his,’1ier mouth to eat but is unable to do so. As a consequence it may appear to he refusing f(H)d.

Agitation or restlessness is also i^|K)rted as a reason why those with dementia may lase weight,as they are unable to sit forpn)longc cubes, fried bean curd cubes Jamaican patties, kebabs Fruit Banana Melon Sliced apple or pear Strawberries, raspberries, blueberries Grapes Pear halves Mandarin orange segments Quartered kiwi fruit, pineapple rings Finger Food SnacifS Dried apricots, prunes (no stones), pineapple, mango and other dried fruit Ice cream or sorbet in cones Peanut butter sandwiches, pate on toast, marmite fingers Savoury snacks Fortified biscuits or cereal bars Chocolate Feeding skllis of nursing staff

Nursing staff tiften report feelings of hcl|ilessness when tr>’ing to help patients with dementia to eat (Mantborpe and VC^Lson, 2003), Dewing (2003) reported many nurses to cite feeding patienLs as their least favourite job. There is often little training available on the feeding of patients other than for the use of nutritional supplements or nas(jgastric and percutaneous endoscopic gastrostomy 119 Nursing & Residential Care, March 2008. Vol 10, No 3 tubt’S. Time constraints, particularly at mealtimes, can mean that stafF may be unable or unwilling to allow individuals the necessary independence with eating.

How are these problems overcome? Assessment . ‘ltierc L much that can be done to prevent s weight Icjss in those with dementia. As a first step it is important that staff have the time to find out more about the individuals they are caring for, including their fcxxj likes and dislikes. Having a gfXKl assessment ptxx’ess rationalizes staff input to those with the greatest needs. Assessments should allow staif to find out atiout the person, and, suteequently, be lietter equipped in meet his/her needs.

There are many different assessment tools available that may document whether or not an inciividual needs help at mealtimes, what their food preferences are, oi” whether someone has a swallowing difficulty or dysphagia (Archibald, 2()06). While these assessments can . seem time consuming at first, they allow staff to tailor care to the needs of the intlividual. Fortified diets As older people in general tend to have smaller appetites (Morley and Tht^mas, 1999) it is useful to try to work with the catering department to provide smaller portions (jf f(KKi that are of high nutritional value.

This lan be achieved with the addition of, for example, cream, milk [Mwder, butter, or sugar to TrxKis to increase the calorie and protein content while allowing for a small portion size, as well a. s lieing able to supply calorie dense snacks in between meals. Mealtime environment The cnvirt)nmcnt ihat fo(H. I is . served in can have an impact on how well individuals eai. li is important to consider the following questions regarding environment: • What is the atmosphere in the dining rcxim like? • Are mealtimes interrupted by clinical procedures? • Is the dining room atmosphere cxjnducive to scxial interaction?

• What are ihc important ihings that may need to be known atx)ut an individual’s tiaily routine? • Are fcxxi preferences and preferred portion sizes known and utilized? • Is the mealtime rushed or chaotic? Crc-ating a calming atmosphere at mealtimes can encourage better intake even in indivkiu als who normally will not settle :i( mealtimes. Edwards and Beck (2(XU) found that an aquarium placed in the dining room improved food inmke in 15% of patients. It may be that tho. se residents who woiiki normally wander Table 3. CONSISTENCY MODIRED DIETS-CLASSIFICATION OF SOLIDS National descriptor A Classification

Description of texture • A food that has been liquidized and sieved if required • A smooth uniforn consitency • Too thin to be eaten with a fork Food Examples • Tinned tomato soup • Pouring custard • Puree macaroni cheese • Mousse/ smooth fromage frais • Soft whipped cream Liquidized Thick puree • A food that has been pureed and sieved if required • A thick, smooth, uniform consistency • A thickener may be required • Must not separate into liquid and solid components during swallowing • It should be moist, and slip rather than stick, during swallow • Will hold its own shape on a plate and can be moulded, layered and piped

D Minced mashed • Food that is moist with texture • Consists of food pieces which are easily mashed with a fork • These foods should be served or coated with a thick gravy or sauce • Soup made up of solids and liquid together required to be pureed Flaked fish in sauce Rice pudding Soft/easily chewed • Dishes consiting of soft, moist, bite sized pieces • Suitable foods can be broken in to pieces with a fork • Dishes made up of solids and liquids together are allowed • Avoid foods which provide a choking hazard Tender meat casseroles Apple crumble with custard

Adapted ffom National Descriptors for Texture Modification in Adults Produced by British Dietetic Association and Royal College of Speech and Language Tnerapists (2002) 121 Nursing & Residential Care, March 2008, Vol 10, No 3 Nutrition and dementia were able to sit for longer periods observing [he ;uiuariuni, antl so ate letter To tackle Iifhavioiira! problems it is important to asccruin the reason behind tbe beb;mour. Often lx;havi(Hir. il jirnblcms can arise :LS a result oC the iiiiliviclual being unable to express a [X)int of view or preference, ‘laking some lime to get to know indivicluals is important.

Individuals of mixed abilities sitting at shared tables may allow for subtle pn)mpting and promote a better intake, tb(Ki, or dribbling may be a result of factors other than Ix-ing difficult or messy, and that patients should not be treated as in;nts in this situation. It is also worth noting that staff may [;rovidc more help thaJi is necessary owing to time constraints or with the best of intentions. This, however, can contribute to low self-esteem and perceived loss of indejiendence (Archiliald, 2006).

Independence should be encouraged by trying techniques such as prompting patients, or trying to place utensils in the hantis of individuals. Other helpful feeding tips include: easuring that the feeder is k;wer down and has eye contact with the persfin being feti. Staff should take their time and get into a rhythm when feeding someone, It is important to listen to the patient’s cues for when to feed the next mouthful. It can take up to 45 minutes to feed someone a meal. Staff should talk to the individual being fed, being careful to explain each step in the process.

Alzheimer’s Society (2007) Detnentm UK . A nonary of key findings. Alzheimer’s Society, L Hit Ion Aahibaltl C (2()O6) Akvtirifi the nulriiinmit neeiis of iMtmils u ith dementia in fjosfUlai. Nurs . Vww/20(45): 4]-‘i Barratt J (2(K;i) Practiail nuiritional ciK of dticrly (leniemeci patieiit. s. C’u>r Opin Clin Nutr Metcth B:irn. ‘tt-C;)nnt)r F, Fticlstcin SI. , Corey-BUxim J, Wictierholi WC (1996) Weight lt)s. s [M-ccaiL-. s demt’iiiia in community – dwelling older adults, JAm GerSoc 44:1 Ui7-52 lmp:. //Ilcws. hbc. ct). llk/I^i/health/6’;682Kl.

stn1 Benati G, Cilia D, Cirillo c;, ami R’tiiinc V (1998) Rdaiioas Ix^twctn proicin Cabric MalniitritlDn aiui cognitive impairment. Arch Gerontol Geriatr 6-i9~A [Jewing J (2003) The respoasibilities of regLstereti niirsfs ttjwards people wiih tlt-mentia. In: MarsliailM (mf) lr>od(jlorious Rxxi: t’eisfxttiix’s on Fcxxi ami Dementia. Hawker Publications, Lonon Ktiwaal-s N, Btx:k A (2002) Animal assisted therapy and nutrition in Alzheimer’s disease. West / Nursing Res 24: 697-712 Elia M (2(K)^) Ihe “MUST /fe/Htri: Nuiriiiotial Screening of aiiiUls: tt mttltidisciplinaty resfyonsibility.

Malnutrition Advisory Group tiAPRN, Wrtaestcrshirc ManthorpeJ, Wiitson R (2003) Pcxirly served? Eatiny ): 162-9 Marcus E-U Berry E (1998) Refusal to eat in tlic elderiy. M//r/&7’56(6): 163-71 Morley J, ITitima. s D (1999) Anorexia and agin^: paihtiphysitilogy. Nutrition 15(6): 499-503 Schiffiiian S, Warwick Z (1993) Effect of flavor enhancement of foods for the dderly on nuiritionai status: ftxxl intake, buK^hemical indices, and anthmpometric measures. Physioi Befjav 53: 395-40 indepcnticnce

With feeding problems i[ Is important to encourage the individual to maintain a sense < )f inde[K-ndence, Techniques such as prompting, placing cutlery into an individual’s hands, offering some assistance, such :ts cutting up of ftxxl, or the use of finger ftxxis (Table 2), av help an individual remain independent, and may encourage int:ikc. Tluise with swallowing problems are at increased risk of ptK)r nutrition, however, it is possible to encourage gtxKl intake with the use of modifietl consistency meals (Table J), ihickening fluiiis and g{xxJ nursing caie.

To puree a meal, significant amounts of liquid need no be added to obtain the correct lexture. If litjuids tif low nutritional value are used, such as water or stock, pureed meals will be high in voiume but low in nutrients. lnstL-ad, where possible, catering staff should be encouraged to use milk, cheese sauce or ri( h gravies as liquids added to meals that need to be pureed, this will add more calories and protein, and may also add to the flavour.

It is recognized, however, that the use of well lortilied texture modifieii meals may not be enough for all dysphagic patients, and other means of feeding may need to be explored. Conclusion While many individuals with dementia have problems that put them at risk of pcxir nutritional intake, whether tbis Is a result of the nature of the disease or not. there are a number of practical dps that can be implemented in the kitchen and at ward level to prevent weight loss and encourage intake.

However, there is a need for more practical training and suppon for all staff caring for this client group. With the right support and training care home staff arc able to contribute to a reduction of malnutriiion in the care home and among those suffering dementia, NRC KEY POINTS WMIe there Is some evidence to show that weight loss In those with dementia may be a result of a metabolic process of the disease, in many individuals, the main cause for weight loss is a reduced intake In calories and/or increased energy expenditure Comprehensive assessments are required.

This includes getting to know patients’ likes and dislikes as well as the best way to Intake Addressing problems with feeding such as small frequent meals, fortified options, prompting, use of finger foods, use of pureed meals and creating a calm environment for eating, all heip encourage intake It is important to ensure that practicai training is avaiiabie to all staff to allow them to effectively promote good nutrition Feeding tecijniques Fhysital or lx.

‘havioural difficulties, or ftxid refusal ex[)erienced by staff when feeding patients with dementia are more difficult to oveaome. Tliei^- is a great scxrial, psychological and emotional element attached to ftxxl. As a result feeding someone can be an emotional and emotive ex|x? rience for both the person being led anil the individual providing the food. It is imponant for nursing staff to be aware of tlie patient with dementia’s reactions when feeding him/her, to realize that spitting out Nursing & Residential Care, March 2008. Vol 10. No 3

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