OLDER PEOPLE AND NUTRITION
Nutrition and dementia: what can we do to help? Sarah Brook
T
he World Health Organization (WHO) (2012) and Alzheimer’s Disease International (ADI) (2013) report on a significant, growing number of cases of dementia each year, with 850 000 living with the condition in the UK (Alzheimer’s Society, 2013). Dementia is most common in older people, with Alzheimer’s disease and vascular dementia being the most common types. Dementia is an umbrella term used to describe deterioration in brain and physical function that affects individuals differently, yet often has similar effects on a person’s wellbeing and nutritional status (National Institute for Health and Care Excellence (NICE), 2010). It is also a changeable condition that may vary from dayto-day, meaning care plans have to be flexible. A third of dementia sufferers live on their own in the community (Alzheimer’s Society, 2013), and malnutrition is prevalent in this client group (Gillette-Guyonnet et al, 2000; Meijers et al, 2014). Therefore, health professionals should be aware of the implications of malnutrition in older people with dementia, and have an awareness of current strategies that are helpful in overcoming these, particularly in vulnerable people living alone. Malnutrition even occurs in long-term care settings (Cowan et al, 2004); therefore, it could be argued that, overall, most people with dementia are at risk of malnutrition, regardless of their social circumstances.
ABSTRACT
This review explores dementia progression and links to how the nutritional status of a person with dementia may be affected. It will also consider what health professionals based in community can do to maximise the nutritional status of the person with dementia. Practical, holistic suggestions—covering small appetite, communication difficulties, mood changes, swallowing problems and aversive mealtime behaviour—will be covered. Existing literature and current guidelines will be explored, common practice points around the nutritional care of people with dementia will be discussed, and local initiatives to help tackle malnutrition, particularly in those with dementia, will be highlighted.
KEY WORDS
Dementia w Nutrition w Community w Personal w Holistic
S24
Email: [email protected]
As Hippocrates anecdotally quoted:
‘Let food be thy medicine, and medicine be thy food’ There is much to be said for supporting an individual to achieve an adequate nutritional intake. Conversely, it is worth noting that some people with certain dementias may suffer from being overweight; however, this article will predominantly focus on malnutrition.
Stages of dementia and the related nutritional consequences There are three main stages that dementia typically progresses through: Early Middle Late (Prince et al, 2013). It is not until the later stages that malnutrition tends to be most obvious, so problems in the earlier stages may be missed and lead to increased morbidity, if not addressed soon enough. Furthermore, everyone with dementia is different and experiences varying types and degrees of symptoms. This article will discuss selected nutritionrelated issues individuals may experience; Mild cognitive dysfunction in the early stages of dementia may cause people to forget to shop, experience appetite or taste changes with sweet or savoury foods, and not realise refrigerated food is mouldy. They could also experience psychological changes, where their mood and appetite are linked. Someone in the middle stage of dementia will tend to display more pronounced changes, such as oral food hoarding, eat non-foods—termed ‘pica’—or have poor concentration and leave a meal part-way through. These issues can impact negatively on nutritional intake and result in slow weight loss. During the late stages of dementia, individuals may experience such severely impaired cognitive and physical functioning that they may not recognise or be able to ask for food or drink, or present with aversive feeding behaviours, such as refusing to eat, spitting out food or taking a long time to eat a meal. They may also experience tremors, which can reduce ability to use cutlery, thus requiring support at mealtimes, leading to an increased energy expenditure and resulting in weight loss.
© 2014 MA Healthcare Ltd
Specialist Dietitian, Salford Royal Foundation Trust
Nutrition, October 2014
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
OLDER PEOPLE AND NUTRITION It is important not to forget other factors which could be affecting an individual’s dietary intake too. Illfitting dentures and poor oral health are also implicated with poor dietary intake (Sahyoun and Krall, 2003). Dehydration is also common in dementia and has even been linked to morbidity in the terminal stages of the condition (Koopmans et al, 2007). It is therefore of utmost importance to not only consider encouraging nutrition, but also frequent fluid intake too to reduce complications associated with dehydration, including constipation, which could even affect appetite. Behavioural needs should be considered when determining the level of support an individual with dementia requires at mealtimes, They can be identified using simple observation or a validated tool, such as the Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q), which is ideal for those in the later stages, who demonstrate the aversive feeding behaviours mentioned above (Watson and Dreary, 1997).
© 2014 MA Healthcare Ltd
Identifying a nutritional problem Regular screening for malnutrition using a validated tool like the Malnutrition Universal Screening Tool (MUST) (Todorovic et al, 2011) is good practice. This monitors anthropometry including weight, height and body mass index (BMI) in kilograms per square meter (Kg/m2), alongside percentage weight loss and presence of acute disease, as recommended by NICE (2006). MUST is strongly supported by NICE for use in the acute and community setting, because malnutrition is arguably a cause and consequence of ill health, as well as being estimated to cost £13 billion a year in public health expenditure. Therefore, malnutrition is an individual and public health interest to be aware of and attempt to combat. Given that almost all of the 3 million people living with malnutrition in the UK are based in community, primary care settings are particularly pertinent to implementing such a tool (Elia and Russell, 2009). It is also worth noting that midupper arm circumference can be used as an alternative anthropometrical measure of nutritional status if height or weight is unavailable (Todorovic et al, 2011). Some argue that as BMI cut off points are based on young, healthy individuals, and are less accurate for older individuals with reduced height and higher fat mass. Cook et al (2005) suggested clinical judgement should be considered and include practical issues around food provision and level of assistance required in order to provide a personalised treatment plan. Therefore, objective and subjective information could be supportive of a referral to a dietitian for a personalised care plan to help treat malnutrition. ‘We all have likes and dislikes and eating habits that are particular to us as individuals’ (Social Care Institute for Excellence (SCIE) (2004). Monitoring and treating malnutrition is important as it can reduce the ability to fight infection and muscular strength, which may lead to falls and ultimately dysphagiarelated aspiration pneumonia (Parker and Power, 2013).
Nutrition, October 2014
It is good practice to refer anyone with symptoms of dysphagia to a speech and language therapist for a swallow assessment and advice on an appropriately textured diet and consistency fluids. Further information on texturemodified diets is available from the National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group (2011). Nutrition support, particularly in the later stages of dementia, can raise moral and ethical issues which are outside the scope for this article; however, it is helpful to be aware that a supportive multidisciplinary team (MDT) can help action in an individual’s best interests.
Prescriptive measures or food first? Oral nutritional supplements (ONS) have shown reduced incidence of malnutrition-associated comorbidities and there is consistent evidence that they maintain and improve weight when used appropriately (Prince et al, 2014), suggesting that they would be of priority when initiating oral nutrition support. However, the fact that they can lead to reduced appetite and gastrointestinal upset, and can be poorly tolerated as an unfamiliar product, should be taken into account when prescribing these products, alongside the cost implications they hold. However, most localities now follow an ‘appropriate prescribing’ pathway, making these issues less problematic and prescribing more appropriate (Stratton and Elia, 2010). Conversely, in a climate where cost-effectiveness is paramount, food fortification approaches may also be as beneficial and are often promoted initially by a dietitian, but more research is required to support such strategies as an initial or sole approach for oral nutrition support. Neither micronutrient or macronutrient supplementation in dementia has any definitive beneficial supporting evidence at present. However, there is a growing evidence base for the potential benefits of vitamin E supplementation in slowing the progression of mild-to-moderate dementia and medicinal drinks, which have shown some, albeit clinically insignificant, benefits at present (Prince et al. 2014). Overall, more evidence is required into nutritional supplement therapy in dementia for which trials are ongoing.
What can community nurses do? The Care Quality Commission (CQC) (2010) report in ‘Outcome 5’ that a ‘registered person must ensure that service users are protected from the risks of inadequate nutrition and hydration.’ Furthermore, staff should ensure nutritional screening using a validated tool, such as MUST, is carried out regularly by trained staff and referrals made to allied health professionals if required for a full nutritional assessment. For details on what to do following MUST completion, Todorovic et al (2011) provide detailed information. However, as a rule of thumb, if a person scores two or more on the MUST tool, they are likely to require referral to a dietitian. It is also worth consulting local malnutrition screening policies as some adapt the MUST to suit local needs.
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Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
OLDER PEOPLE AND NUTRITION Table 1. Food fortification strategies Strategy
Food for thought
Food fortification Adding extra calories to food
Add butter, double cream, cheese or oil to soup, mashed potato, cooked meals Add 2–4 tablespoons of skimmed milk powder to whole milk to make ‘fortified milk’ and use in place of normal milk
Using full-fat dairy products
Dairy products are a great source of calcium and protein. Full-fat versions add extra calories for undernourished people
Homemade nourishing drinks
Ice cream, honey, sugar, cream and topping with whipped cream adds extra calories to drinks and smoothies
Aiding recognition of food, hunger and thirst Coloured crockery
Contrasting coloured plates and bowls or assistive tableware helps identify food from the vessel
Frequent offers of food and drink
Cognitive decline may mean eating and drinking is forgotten. Frequent prompting can help as part of a ‘little and often’ approach
Appropriate eating environment
A calm atmosphere can reduce meal interruption and calming music may relax a confused person with dementia and increase concentration
Assistance Assistance at mealtimes
Calmly assisting a person who is sat upright, alert and comfortable means they are at reduced risk of aspirating
Make food easy to eat
Cut food into small pieces or provide soft options for those with loose dentures or sore mouths and maintain independence
suffice to maintain nutrition and hydration requirements, but are worth trialling. With regard to the care home environment, some small studies have suggested familiar background noise and diffusion of food-preparation smells could stimulate the appetite of someone with dementia (Prince et al, 2014). Experience from practice has demonstrated that staff sitting with residents in the dining area can act as prompts to continue their meal. Liaising with catering staff to implement food fortification strategies has been well received locally, meaning the needs of residents with increased nutritional requirements were met. However this requires organisational flexibility and the added expense that milk powder and double cream carry, although this could be beneficial in specific cases and is ultimately in the best interests of the individual.
A holistic approach to managing malnutrition An MDT approach to nutritional care in dementia is best practice (Parker and Power, 2013) and communication with family and friends is vital to meet the needs of the individual with dementia (WHO, 2012). Furthermore, adaptations to an individual’s living environment could help support independent living (NICE, 2013), such as glass cupboard doors to increase visibility and help to trigger memory, contrasting coloured crockery to distinguish foods, and modified cutlery for people with dexterity problems, for example, which can be discussed with an occupational therapist. Charities, such as AgeUK and Alzheimer’s Society, may also run services locally, holding events to encourage socialisation in this client group. It is worth seeing what is available in each area of the UK.
Own home People living alone in their own home may be in the early stages of dementia and could be vulnerable to malnutrition, particularly where screening is not routinely carried out. Nurses and carers should be vigilant in spotting the signs of malnutrition; consider whether a person’s clothes and jewellery are loose, or if they leave their meals. Speaking with family members can assist subjective identification of malnutrition and MUST acts as an objective assessment, which may be reported to the service user’s GP for referral to a dietitian. Additionally, food fortification strategies to increase protein and energy intake can be triaged to family members and carers before referring to a dietitian for a full nutritional assessment.
Care homes Weekly nutritional screening and food charts are essential when monitoring malnourished residents. These residents are likely to be in the later stages of dementia and require mealtime interventions, which will require valuable staff time as people with dementia can take longer to eat due to confusion and poor attention. Here, simple food fortification and behavioural strategies (Table 1) may not
S26
The NICE (2010) Quality Statement (QS) recommends that dementia services provide assessments and personalised care plans alongside appropriately trained staff. Family caregivers or carers in care homes may not already have the knowledge and skills to assess and manage the often complex nutritional needs of a person with dementia. This therefore requires ‘education and training, relevant to their post’ for people working closely with dementia (NICE, 2006). It is reasonable that it should be the responsibility of key staff members and their team leaders to ensure that their training needs are up-to-date. Effective communication between all care providers and family members involved will support an effective and personalised nutritional care plan and continuation of care. Salford has been chosen as a pilot site for the ‘Age UK Malnutrition Pathway’, and is involved in the creation and implementation of an accessible, multiprofessional e-learning package combining malnutrition and dysphagia. This innovative strategy—in relation to the NICE (2006) and CQC (2010) recommendations on the importance of malnutrition training—will reduce poorly attended classroom sessions and hopefully reach a wider audience to raise awareness of the growing problem of malnutrition, particularly in people with swallowing problems, such as those with dementia.
© 2014 MA Healthcare Ltd
Training and local initiatives
Nutrition, October 2014
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
OLDER PEOPLE AND NUTRITION
Conclusion Dementia is a common occurrence in the ageing community and is strongly linked to malnutrition. These problems become more pertinent as the disease progresses, but early identification and monitoring of malnutrition and appropriate intervention is important to avoid often preventable comorbidities. There are many ways in which we can all contribute to the effective holistic care of nutrition in dementia of which MDT working and a knowledge of the condition and individual with dementia is key. BJCN Alzheimer’s Disease International (2013) World Alzheimer Report 2013: An analysis of long-term care for dementia. http://tinyurl.com/ksqrwd6 (accessed 29 September 2014) Alzheimer’s Society (2013) Dementia 2013 infographic. http://tinyurl.com/ qgunhdt (accessed 29 September 2014) Care Quality Commission (2010) Essential Standards of Quality and Safety. Care Quality Commission, London Cook Z, Kirk S, Lawrenson S, Sandford S (2005) Use of BMI in the assessment of undernutrition in older subjects: reflecting on practice. Proc Nutr Soc 64(3): 313–7 Cowan DT, Roberts JD, Fitzpatrick JM, While AE (2004) Nutritional status of older people in long term care settings: current status and future directions. Int J Nurs Stud 41(3): 225–37 Elia, M., Russell, C (2009) Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition. BAPEN, London. http://tinyurl.com/btqysd (accessed 29 September 2014) Gillette-Guyonnet S, Nourhashemi F, Andrieu S et al (2000) Weight loss in Alzheimer disease. Am J Clin Nutr 71(2): 637S–642S Koopmans RT, van der Sterren KJ, van der Steen JT (2007) The ‘natural’ endpoint of dementia: death from cachexia or dehydration following palliative care? Int J Geriatr Psychiatry 22(4): 350–5 Meijers J, Schols J, Halfens R (2014) Malnutrition in care home residents with dementia. J Nutr Health Aging 18(6): 595–600 National Institute for Health and Care Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. http://tinyurl.com/kz8nu6h (accessed 29 September 2014) National Institute for Health and Care Excellence (2010) Dementia Quality Standard. QS1. http://tinyurl.com/kpodkkw (accessed 29 September 2014)
KEY POINTS
w Each person with dementia has different needs. Identifying these using weekly screenings and communication will highlight these w Malnutrition is common in dementia and food fortification strategies can help to achieve a nourishing diet w A conducive eating environment can help to promote nutritional intake w Multidisciplinary teamwork is key to supporting the nutritional needs of people with dementia
National Institute for Health and Care Excellence (2013) Quality Standard for Supporting People to Live Well with Dementia. QS30. http://tinyurl.com/l6vyyty (accessed 29 September 2014) National Patient Safety Agency Dysphagia Expert Reference Group (2011) Dysphagia diet food texture descriptors. http://tinyurl.com/l4o2say (accessed 29 September 2014) Parker M, Power D (2013) Management of swallowing difficulties in people with advanced dementia. Nurs Older People 25(2): 26–31 Prince, M., Albanese, E., Guerchet, M., Prina, M (2014) Nutrition and Dementia: A Review of Available Research. Alzheimer’s Disease International, London Prince M, Prina M, Guerchet M (2013) World Alzheimer Report. Alzheimer’s Disease International, London Sahyoun N, Krall E (2003) Low dietary quality among older adults with selfperceived ill-fitting dentures. J Am Diet Assoc 103(11): 1494–9 Social Care Institute for Excellence (2014) Dementia Gateway: living with dementia, eating well with dementia. http://tinyurl.com/laavre9 (accessed 29 September 2014) Stratton R, Elia M (2010) Encouraging appropriate, evidence based use of oral nutritional supplements. Proc Nut Soc 69(4): 477–87 Todorovic V, Russell C, Elia M (2011) The ‘MUST’ Explanatory Booklet: A Guide to the Malnutrition Universal Screening Tool, Redditch: BAPEN. http://tinyurl.com/7vrjsyb (accessed 29 September 2014) Watson R, Dreary I (1997) A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. J Adv Nurs 26(1): 25–32 World Health Organization (2012) Dementia: A public health priority. WHO: Geneva. http://tinyurl.com/btsrhoz (accessed 29 September 2014)
About the book
Kirsty Beart
This book begins by asking you to try to imagine the life you have now changing beyond all recognition. One day you wake up and don’t know where you are. You ask someone near you where you are but they seem unable to understand your question. Why do they not understand, what is wrong with them? It is hard to contemplate this and to fully comprehend the emotional turmoil caused by the symptoms of a dementia type illness. This book has been written with the intention of helping its readers to understand the perspective of the person who has been labelled as suffering with dementia, as well as that of the carers and the professionals. It is split into two sections to help the reader identify the parts they need to read at different times or for varying purposes. Section 1 offers information and debate about the theoretical issues and explanations of dementia and memory loss. This includes explanations of what dementia actually is and where it comes from in the first place. Section 2 moves into the more practical side of this text. Many areas of concern for carers and professionals alike are similar and this section brings their ideas and perspectives together so that they might be able to benefit from each other.
This book is written with the intention of helping readers understand the perspective of the person with dementia, as well as that of carers and professionals. It covers:
§
Information and debate on theoretical issues and explanations of dementia and About the author memory loss Kirsty Beart is a Lecturer in Mental Health Nursing at De Montfort University, Leicester, UK.
§ §
Other titles in the Fundamental Aspects of Nursing series include:
Explanations of what dementia is and where it comes from
Fundamental Aspects of Caring for the Person with Dementia
Caring for the Person with Dementia
Fundamental Aspects of
Caring for the Person with Dementia Kirsty Beart
Adult Nursing Procedures Caring for the Acutely Ill Adult Community Nursing Complementary Therapies for Health Care Professionals Gynaecology Nursing Legal, Ethical and Professional Issues in Nursing Men’s Health Tissue Viability Nursing Palliative Care Nursing Women’s Heath Series Editor: John Fowler
The ideas and perspectives of carers and professionals alike
ISBN-13: 978-1-85642-308-8; 234 x 156 mm; paperback; 160 pages; publication 2006; £19.99
Order your copies by visiting
www.quaybooks.co.uk
or call our Hotline
Kirsty Beart
© 2014 MA Healthcare Ltd
This book will be suitable for nurses, student nurses and carers alike.
Fundamental Aspects of Nursing series
www.quaybooks.co.uk
+44(0)1722 716 935 FA Dementia cover.indd 1
7/8/06 11:51:00
Nutrition, October 2014
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Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
Nutrition and dementia: what can we do to help? Sarah Brook
T
he World Health Organization (WHO) (2012) and Alzheimer’s Disease International (ADI) (2013) report on a significant, growing number of cases of dementia each year, with 850 000 living with the condition in the UK (Alzheimer’s Society, 2013). Dementia is most common in older people, with Alzheimer’s disease and vascular dementia being the most common types. Dementia is an umbrella term used to describe deterioration in brain and physical function that affects individuals differently, yet often has similar effects on a person’s wellbeing and nutritional status (National Institute for Health and Care Excellence (NICE), 2010). It is also a changeable condition that may vary from dayto-day, meaning care plans have to be flexible. A third of dementia sufferers live on their own in the community (Alzheimer’s Society, 2013), and malnutrition is prevalent in this client group (Gillette-Guyonnet et al, 2000; Meijers et al, 2014). Therefore, health professionals should be aware of the implications of malnutrition in older people with dementia, and have an awareness of current strategies that are helpful in overcoming these, particularly in vulnerable people living alone. Malnutrition even occurs in long-term care settings (Cowan et al, 2004); therefore, it could be argued that, overall, most people with dementia are at risk of malnutrition, regardless of their social circumstances.
ABSTRACT
This review explores dementia progression and links to how the nutritional status of a person with dementia may be affected. It will also consider what health professionals based in community can do to maximise the nutritional status of the person with dementia. Practical, holistic suggestions—covering small appetite, communication difficulties, mood changes, swallowing problems and aversive mealtime behaviour—will be covered. Existing literature and current guidelines will be explored, common practice points around the nutritional care of people with dementia will be discussed, and local initiatives to help tackle malnutrition, particularly in those with dementia, will be highlighted.
KEY WORDS
Dementia w Nutrition w Community w Personal w Holistic
S24
Email: [email protected]
As Hippocrates anecdotally quoted:
‘Let food be thy medicine, and medicine be thy food’ There is much to be said for supporting an individual to achieve an adequate nutritional intake. Conversely, it is worth noting that some people with certain dementias may suffer from being overweight; however, this article will predominantly focus on malnutrition.
Stages of dementia and the related nutritional consequences There are three main stages that dementia typically progresses through: Early Middle Late (Prince et al, 2013). It is not until the later stages that malnutrition tends to be most obvious, so problems in the earlier stages may be missed and lead to increased morbidity, if not addressed soon enough. Furthermore, everyone with dementia is different and experiences varying types and degrees of symptoms. This article will discuss selected nutritionrelated issues individuals may experience; Mild cognitive dysfunction in the early stages of dementia may cause people to forget to shop, experience appetite or taste changes with sweet or savoury foods, and not realise refrigerated food is mouldy. They could also experience psychological changes, where their mood and appetite are linked. Someone in the middle stage of dementia will tend to display more pronounced changes, such as oral food hoarding, eat non-foods—termed ‘pica’—or have poor concentration and leave a meal part-way through. These issues can impact negatively on nutritional intake and result in slow weight loss. During the late stages of dementia, individuals may experience such severely impaired cognitive and physical functioning that they may not recognise or be able to ask for food or drink, or present with aversive feeding behaviours, such as refusing to eat, spitting out food or taking a long time to eat a meal. They may also experience tremors, which can reduce ability to use cutlery, thus requiring support at mealtimes, leading to an increased energy expenditure and resulting in weight loss.
© 2014 MA Healthcare Ltd
Specialist Dietitian, Salford Royal Foundation Trust
Nutrition, October 2014
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
OLDER PEOPLE AND NUTRITION It is important not to forget other factors which could be affecting an individual’s dietary intake too. Illfitting dentures and poor oral health are also implicated with poor dietary intake (Sahyoun and Krall, 2003). Dehydration is also common in dementia and has even been linked to morbidity in the terminal stages of the condition (Koopmans et al, 2007). It is therefore of utmost importance to not only consider encouraging nutrition, but also frequent fluid intake too to reduce complications associated with dehydration, including constipation, which could even affect appetite. Behavioural needs should be considered when determining the level of support an individual with dementia requires at mealtimes, They can be identified using simple observation or a validated tool, such as the Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q), which is ideal for those in the later stages, who demonstrate the aversive feeding behaviours mentioned above (Watson and Dreary, 1997).
© 2014 MA Healthcare Ltd
Identifying a nutritional problem Regular screening for malnutrition using a validated tool like the Malnutrition Universal Screening Tool (MUST) (Todorovic et al, 2011) is good practice. This monitors anthropometry including weight, height and body mass index (BMI) in kilograms per square meter (Kg/m2), alongside percentage weight loss and presence of acute disease, as recommended by NICE (2006). MUST is strongly supported by NICE for use in the acute and community setting, because malnutrition is arguably a cause and consequence of ill health, as well as being estimated to cost £13 billion a year in public health expenditure. Therefore, malnutrition is an individual and public health interest to be aware of and attempt to combat. Given that almost all of the 3 million people living with malnutrition in the UK are based in community, primary care settings are particularly pertinent to implementing such a tool (Elia and Russell, 2009). It is also worth noting that midupper arm circumference can be used as an alternative anthropometrical measure of nutritional status if height or weight is unavailable (Todorovic et al, 2011). Some argue that as BMI cut off points are based on young, healthy individuals, and are less accurate for older individuals with reduced height and higher fat mass. Cook et al (2005) suggested clinical judgement should be considered and include practical issues around food provision and level of assistance required in order to provide a personalised treatment plan. Therefore, objective and subjective information could be supportive of a referral to a dietitian for a personalised care plan to help treat malnutrition. ‘We all have likes and dislikes and eating habits that are particular to us as individuals’ (Social Care Institute for Excellence (SCIE) (2004). Monitoring and treating malnutrition is important as it can reduce the ability to fight infection and muscular strength, which may lead to falls and ultimately dysphagiarelated aspiration pneumonia (Parker and Power, 2013).
Nutrition, October 2014
It is good practice to refer anyone with symptoms of dysphagia to a speech and language therapist for a swallow assessment and advice on an appropriately textured diet and consistency fluids. Further information on texturemodified diets is available from the National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group (2011). Nutrition support, particularly in the later stages of dementia, can raise moral and ethical issues which are outside the scope for this article; however, it is helpful to be aware that a supportive multidisciplinary team (MDT) can help action in an individual’s best interests.
Prescriptive measures or food first? Oral nutritional supplements (ONS) have shown reduced incidence of malnutrition-associated comorbidities and there is consistent evidence that they maintain and improve weight when used appropriately (Prince et al, 2014), suggesting that they would be of priority when initiating oral nutrition support. However, the fact that they can lead to reduced appetite and gastrointestinal upset, and can be poorly tolerated as an unfamiliar product, should be taken into account when prescribing these products, alongside the cost implications they hold. However, most localities now follow an ‘appropriate prescribing’ pathway, making these issues less problematic and prescribing more appropriate (Stratton and Elia, 2010). Conversely, in a climate where cost-effectiveness is paramount, food fortification approaches may also be as beneficial and are often promoted initially by a dietitian, but more research is required to support such strategies as an initial or sole approach for oral nutrition support. Neither micronutrient or macronutrient supplementation in dementia has any definitive beneficial supporting evidence at present. However, there is a growing evidence base for the potential benefits of vitamin E supplementation in slowing the progression of mild-to-moderate dementia and medicinal drinks, which have shown some, albeit clinically insignificant, benefits at present (Prince et al. 2014). Overall, more evidence is required into nutritional supplement therapy in dementia for which trials are ongoing.
What can community nurses do? The Care Quality Commission (CQC) (2010) report in ‘Outcome 5’ that a ‘registered person must ensure that service users are protected from the risks of inadequate nutrition and hydration.’ Furthermore, staff should ensure nutritional screening using a validated tool, such as MUST, is carried out regularly by trained staff and referrals made to allied health professionals if required for a full nutritional assessment. For details on what to do following MUST completion, Todorovic et al (2011) provide detailed information. However, as a rule of thumb, if a person scores two or more on the MUST tool, they are likely to require referral to a dietitian. It is also worth consulting local malnutrition screening policies as some adapt the MUST to suit local needs.
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Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on September 10, 2015. For personal use only. No other uses without permission. . All rights re
OLDER PEOPLE AND NUTRITION Table 1. Food fortification strategies Strategy
Food for thought
Food fortification Adding extra calories to food
Add butter, double cream, cheese or oil to soup, mashed potato, cooked meals Add 2–4 tablespoons of skimmed milk powder to whole milk to make ‘fortified milk’ and use in place of normal milk
Using full-fat dairy products
Dairy products are a great source of calcium and protein. Full-fat versions add extra calories for undernourished people
Homemade nourishing drinks
Ice cream, honey, sugar, cream and topping with whipped cream adds extra calories to drinks and smoothies
Aiding recognition of food, hunger and thirst Coloured crockery
Contrasting coloured plates and bowls or assistive tableware helps identify food from the vessel
Frequent offers of food and drink
Cognitive decline may mean eating and drinking is forgotten. Frequent prompting can help as part of a ‘little and often’ approach
Appropriate eating environment
A calm atmosphere can reduce meal interruption and calming music may relax a confused person with dementia and increase concentration
Assistance Assistance at mealtimes
Calmly assisting a person who is sat upright, alert and comfortable means they are at reduced risk of aspirating
Make food easy to eat
Cut food into small pieces or provide soft options for those with loose dentures or sore mouths and maintain independence
suffice to maintain nutrition and hydration requirements, but are worth trialling. With regard to the care home environment, some small studies have suggested familiar background noise and diffusion of food-preparation smells could stimulate the appetite of someone with dementia (Prince et al, 2014). Experience from practice has demonstrated that staff sitting with residents in the dining area can act as prompts to continue their meal. Liaising with catering staff to implement food fortification strategies has been well received locally, meaning the needs of residents with increased nutritional requirements were met. However this requires organisational flexibility and the added expense that milk powder and double cream carry, although this could be beneficial in specific cases and is ultimately in the best interests of the individual.
A holistic approach to managing malnutrition An MDT approach to nutritional care in dementia is best practice (Parker and Power, 2013) and communication with family and friends is vital to meet the needs of the individual with dementia (WHO, 2012). Furthermore, adaptations to an individual’s living environment could help support independent living (NICE, 2013), such as glass cupboard doors to increase visibility and help to trigger memory, contrasting coloured crockery to distinguish foods, and modified cutlery for people with dexterity problems, for example, which can be discussed with an occupational therapist. Charities, such as AgeUK and Alzheimer’s Society, may also run services locally, holding events to encourage socialisation in this client group. It is worth seeing what is available in each area of the UK.
Own home People living alone in their own home may be in the early stages of dementia and could be vulnerable to malnutrition, particularly where screening is not routinely carried out. Nurses and carers should be vigilant in spotting the signs of malnutrition; consider whether a person’s clothes and jewellery are loose, or if they leave their meals. Speaking with family members can assist subjective identification of malnutrition and MUST acts as an objective assessment, which may be reported to the service user’s GP for referral to a dietitian. Additionally, food fortification strategies to increase protein and energy intake can be triaged to family members and carers before referring to a dietitian for a full nutritional assessment.
Care homes Weekly nutritional screening and food charts are essential when monitoring malnourished residents. These residents are likely to be in the later stages of dementia and require mealtime interventions, which will require valuable staff time as people with dementia can take longer to eat due to confusion and poor attention. Here, simple food fortification and behavioural strategies (Table 1) may not
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The NICE (2010) Quality Statement (QS) recommends that dementia services provide assessments and personalised care plans alongside appropriately trained staff. Family caregivers or carers in care homes may not already have the knowledge and skills to assess and manage the often complex nutritional needs of a person with dementia. This therefore requires ‘education and training, relevant to their post’ for people working closely with dementia (NICE, 2006). It is reasonable that it should be the responsibility of key staff members and their team leaders to ensure that their training needs are up-to-date. Effective communication between all care providers and family members involved will support an effective and personalised nutritional care plan and continuation of care. Salford has been chosen as a pilot site for the ‘Age UK Malnutrition Pathway’, and is involved in the creation and implementation of an accessible, multiprofessional e-learning package combining malnutrition and dysphagia. This innovative strategy—in relation to the NICE (2006) and CQC (2010) recommendations on the importance of malnutrition training—will reduce poorly attended classroom sessions and hopefully reach a wider audience to raise awareness of the growing problem of malnutrition, particularly in people with swallowing problems, such as those with dementia.
© 2014 MA Healthcare Ltd
Training and local initiatives
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OLDER PEOPLE AND NUTRITION
Conclusion Dementia is a common occurrence in the ageing community and is strongly linked to malnutrition. These problems become more pertinent as the disease progresses, but early identification and monitoring of malnutrition and appropriate intervention is important to avoid often preventable comorbidities. There are many ways in which we can all contribute to the effective holistic care of nutrition in dementia of which MDT working and a knowledge of the condition and individual with dementia is key. BJCN Alzheimer’s Disease International (2013) World Alzheimer Report 2013: An analysis of long-term care for dementia. http://tinyurl.com/ksqrwd6 (accessed 29 September 2014) Alzheimer’s Society (2013) Dementia 2013 infographic. http://tinyurl.com/ qgunhdt (accessed 29 September 2014) Care Quality Commission (2010) Essential Standards of Quality and Safety. Care Quality Commission, London Cook Z, Kirk S, Lawrenson S, Sandford S (2005) Use of BMI in the assessment of undernutrition in older subjects: reflecting on practice. Proc Nutr Soc 64(3): 313–7 Cowan DT, Roberts JD, Fitzpatrick JM, While AE (2004) Nutritional status of older people in long term care settings: current status and future directions. Int J Nurs Stud 41(3): 225–37 Elia, M., Russell, C (2009) Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition. BAPEN, London. http://tinyurl.com/btqysd (accessed 29 September 2014) Gillette-Guyonnet S, Nourhashemi F, Andrieu S et al (2000) Weight loss in Alzheimer disease. Am J Clin Nutr 71(2): 637S–642S Koopmans RT, van der Sterren KJ, van der Steen JT (2007) The ‘natural’ endpoint of dementia: death from cachexia or dehydration following palliative care? Int J Geriatr Psychiatry 22(4): 350–5 Meijers J, Schols J, Halfens R (2014) Malnutrition in care home residents with dementia. J Nutr Health Aging 18(6): 595–600 National Institute for Health and Care Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. http://tinyurl.com/kz8nu6h (accessed 29 September 2014) National Institute for Health and Care Excellence (2010) Dementia Quality Standard. QS1. http://tinyurl.com/kpodkkw (accessed 29 September 2014)
KEY POINTS
w Each person with dementia has different needs. Identifying these using weekly screenings and communication will highlight these w Malnutrition is common in dementia and food fortification strategies can help to achieve a nourishing diet w A conducive eating environment can help to promote nutritional intake w Multidisciplinary teamwork is key to supporting the nutritional needs of people with dementia
National Institute for Health and Care Excellence (2013) Quality Standard for Supporting People to Live Well with Dementia. QS30. http://tinyurl.com/l6vyyty (accessed 29 September 2014) National Patient Safety Agency Dysphagia Expert Reference Group (2011) Dysphagia diet food texture descriptors. http://tinyurl.com/l4o2say (accessed 29 September 2014) Parker M, Power D (2013) Management of swallowing difficulties in people with advanced dementia. Nurs Older People 25(2): 26–31 Prince, M., Albanese, E., Guerchet, M., Prina, M (2014) Nutrition and Dementia: A Review of Available Research. Alzheimer’s Disease International, London Prince M, Prina M, Guerchet M (2013) World Alzheimer Report. Alzheimer’s Disease International, London Sahyoun N, Krall E (2003) Low dietary quality among older adults with selfperceived ill-fitting dentures. J Am Diet Assoc 103(11): 1494–9 Social Care Institute for Excellence (2014) Dementia Gateway: living with dementia, eating well with dementia. http://tinyurl.com/laavre9 (accessed 29 September 2014) Stratton R, Elia M (2010) Encouraging appropriate, evidence based use of oral nutritional supplements. Proc Nut Soc 69(4): 477–87 Todorovic V, Russell C, Elia M (2011) The ‘MUST’ Explanatory Booklet: A Guide to the Malnutrition Universal Screening Tool, Redditch: BAPEN. http://tinyurl.com/7vrjsyb (accessed 29 September 2014) Watson R, Dreary I (1997) A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. J Adv Nurs 26(1): 25–32 World Health Organization (2012) Dementia: A public health priority. WHO: Geneva. http://tinyurl.com/btsrhoz (accessed 29 September 2014)
About the book
Kirsty Beart
This book begins by asking you to try to imagine the life you have now changing beyond all recognition. One day you wake up and don’t know where you are. You ask someone near you where you are but they seem unable to understand your question. Why do they not understand, what is wrong with them? It is hard to contemplate this and to fully comprehend the emotional turmoil caused by the symptoms of a dementia type illness. This book has been written with the intention of helping its readers to understand the perspective of the person who has been labelled as suffering with dementia, as well as that of the carers and the professionals. It is split into two sections to help the reader identify the parts they need to read at different times or for varying purposes. Section 1 offers information and debate about the theoretical issues and explanations of dementia and memory loss. This includes explanations of what dementia actually is and where it comes from in the first place. Section 2 moves into the more practical side of this text. Many areas of concern for carers and professionals alike are similar and this section brings their ideas and perspectives together so that they might be able to benefit from each other.
This book is written with the intention of helping readers understand the perspective of the person with dementia, as well as that of carers and professionals. It covers:
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Information and debate on theoretical issues and explanations of dementia and About the author memory loss Kirsty Beart is a Lecturer in Mental Health Nursing at De Montfort University, Leicester, UK.
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Other titles in the Fundamental Aspects of Nursing series include:
Explanations of what dementia is and where it comes from
Fundamental Aspects of Caring for the Person with Dementia
Caring for the Person with Dementia
Fundamental Aspects of
Caring for the Person with Dementia Kirsty Beart
Adult Nursing Procedures Caring for the Acutely Ill Adult Community Nursing Complementary Therapies for Health Care Professionals Gynaecology Nursing Legal, Ethical and Professional Issues in Nursing Men’s Health Tissue Viability Nursing Palliative Care Nursing Women’s Heath Series Editor: John Fowler
The ideas and perspectives of carers and professionals alike
ISBN-13: 978-1-85642-308-8; 234 x 156 mm; paperback; 160 pages; publication 2006; £19.99
Order your copies by visiting
www.quaybooks.co.uk
or call our Hotline
Kirsty Beart
© 2014 MA Healthcare Ltd
This book will be suitable for nurses, student nurses and carers alike.
Fundamental Aspects of Nursing series
www.quaybooks.co.uk
+44(0)1722 716 935 FA Dementia cover.indd 1
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