Observing People Living with Dementia at Mealtimes

The Edith Ellen work in partnership supporting people with Dementia, one of our Partnerships is with The DMAT team

The DMAT Team have kindly agreed to us using their article Observing People Living with Dementia at Mealtimes which provides a useful download for Observing People with Dementia at Mealtimes.

When I was working as a dietitian in the NHS one of my roles was visiting people living with dementia in care homes. The hardest part of my job was getting them to eat! I tried many interventions over several months, talking to the staff and relatives as well as the dementia residents in the care homes. Despite putting dietetic care plans in place many of them continued to lose weight.

I therefore decided to try a new approach and over a few days I simply sat in the dining room and observed some mealtimes. I learnt more in these few hours than I had the last few months working in the care homes. I observed many dementia related eating difficulties and environmental problems that were contributing to the person finding it hard to feed themselves and preventing adequate nutritional intake. Since I did these observations I cannot recommend enough the benefits of taking a step back from your normal way of working to simply observe not only the person but the environment the person with dementia finds themselves in. It is a skill rarely used in very busy caring settings nowadays but it is a vital skill in dementia care. I think the article by Beth Britton called ‘Harnessing the power of observation‘ describes the importance of this skill brilliantly and is really worth a read.    

I realised that until these environmental and behavioural eating difficulties were resolved my dietetic advice would not be effective. This became my motivation for creating the first version of the DMAT in 2011. The DMAT works in 3 stages with the first stage being the observational stage. A carer would use the DMAT ‘Initial Measurement Form’ to observe a mealtime and record the eating difficulties observed.

The DMAT Initial Measurement Form is free to download Please take a look and share with those involved in the nutritional care of people living with dementia

Free Download

The DMAT Initial Measurement Form helps carers to identify which environmental issues and eating difficulties are preventing the individual from consuming their food. The DMAT has not undergone psychometric evaluation for validity or reliability but provides a much needed resource to quickly and easily capture the most common eating difficulties an individual with dementia may present with. Feedback from pilot projects of the DMAT suggest it takes 7 minutes to observe someone at a mealtime and record all the eating difficulties.

Once the carer has gathered this initial observational information they enter the results into the online DMAT system which will automatically provide a range of interventions to choose from.  The carer can simply tick the box of the interventions they wish to implement and the DMAT system will generate a care plan based on this. The care plan will show which mealtime eating difficulties have been identified and what interventions are to be implemented to overcome these difficulties. Everyone caring for the individual will then have a care plan sheet explaining how to help make that persons mealtime more dementia friendly.

The aim of the DMAT is to reduce the amount of mealtime eating difficulties and also improve the independence of the person at mealtimes. This can help the person feed themselves for longer and maintain their nutritional status therefore improving their quality of life.

IMPORTANT PLEASE NOTE – When using the ‘DMAT Initial Measurement Form’ if you observe any ‘Oral Difficulties and Behaviours’ that are thought to compromise the safety of an individual (i.e. you witness signs of aspiration) when eating or drinking, please liaise with a speech & language therapist (SLT) immediately. If you are unsure of the warning signs for swallowing difficulties please discuss with a SLT or refer to your local guidelines and policies before using the DMAT. When using the online DMAT system you will be reminded about the importance of not delaying referral to health professionals for further advice if certain eating difficulties are witnessed.

The DMAT does not try to replace the advice from a healthcare professional. Nothing can better the personal advice from an expert tailored to the individual. Instead the DMAT tries to provide common sense, practical and cost effective solutions to mealtime problems based on the available evidence.

*The DMAT is not a substitute for good clinical care*

Malnutrition in our Elderly

Undernutrition or malnutrition is a term which describes the various health conditions caused by the body not receiving enough energy (food) or nutrients. Undernutrition can affect people in a variety of ways; they can become too short for their age (stunted); dangerously thin (wasted); and deficient in vitamins and minerals (micronutrient deficient).

Our aim is to end hunger, achieve food security and improved nutrition in our elderly by recognising why this occurs and retraining staff to understand it better and deal with it far more appropriately than they currently do.

Despite being easily preventable, undernutrition claims the lives of millions each year, making it the single largest killer worldwide. This is a very concentrated problem, with only 24 countries accounting for 80% of all cases of undernutrition, and the largest killer of our elderly and vulnerable in Care.

Many older adults are at risk for developing malnutrition, the lack of adequate nutrition to maintain health. The main cause of malnutrition in older adult is inadequate food and nutrient intake. A poor appetite or problems with chewing and swallowing may lead to lower food intake.

Good nutrition is critical to overall health and well-being — yet many older adults are at risk of inadequate nutrition and it is preventable.

Problems caused by malnutrition

·         Malnutrition in older adults can lead to various health concerns, including:

·         A weak immune system, which increases the risk of infections

·         Poor wound healing

·         Muscle weakness, which can lead to falls and fractures

In addition, malnutrition can lead to further disinterest in eating or lack of appetite — which only makes the problem worse.

Causes of Malnutrition

The causes of malnutrition might seem straightforward — too little food or a diet lacking in nutrients. In reality, though, malnutrition is often caused by a combination of physical, social and psychological issues. For example:

Health concerns. Older adults often have health problems, such as dementia or dental issues, that can lead to decreased appetite or trouble eating. Other factors that might play a role include a chronic illness, use of certain medications, difficulty swallowing or absorbing nutrients, a recent hospitalization, or a diminished sense of taste or smell.

Restricted diets. Dietary restrictions — such as limits on salt, fat, protein or sugar — can help manage certain medical conditions, but might also contribute to inadequate eating.

Limited income. Some older adults might have trouble affording groceries, especially if they're taking expensive medications.

Reduced social contact. Older adults who eat alone might not enjoy meals as before, causing them to lose interest in cooking and eating.

Depression. Grief, loneliness, failing health, lack of mobility and other factors might contribute to depression — causing loss of appetite.

Alcoholism. Too much alcohol can interfere with the digestion and absorption of nutrients. Nutrients might also be lacking if alcohol is substituted for meals

The Signs of Malnutrition

The signs of malnutrition in older adults can be tough to spot, especially in people who don't seem at risk — but uncovering problems at the earliest stage can help prevent complications later.

Medications. Many drugs affect appetite, digestion and nutrient absorption.

Red flags. In addition to weight loss, malnutrition can cause poor wound healing, easy bruising and dental difficulties.

Weight loss. Help monitor his or her weight at home. You might also watch for other signs of weight loss, such as changes in how clothing fits.

Eating habits. Spend time during meals at home, not just on special occasions. If one lives alone, find out who buys his or her food. If they are in a hospital or long term care facility, visit during mealtimes.

Making a BIG Difference

Even small dietary changes can make a big difference in an older adult's health and well-being. For example:

Engage doctors. If the person is losing weight, work with his or her doctors to identify — and address — any contributing factors. This might include changing medications that affect appetite, suspending any diet restrictions until the person is eating more effectively, and working with a dentist to treat oral pain or chewing problems. Request screenings for nutrition problems during routine office visits, and ask about nutritional supplements. You might also ask for a referral to a registered dietitian.

Encourage the person to eat foods packed with nutrients. Spread peanut or other nut butters on toast and crackers, fresh fruits, and raw vegetables. Sprinkle finely chopped nuts or wheat germ on yogurt, fruit and cereal. Add extra egg whites to scrambled eggs and omelettes and encourage use of whole milk. Add cheese to sandwiches, vegetables, soups, rice and noodles

The one chefs forget - Restore life to bland food. Make a restricted diet more appealing by using lemon juice, herbs and spices. If loss of taste and smell is a problem, experiment with seasonings and recipes.

Plan between-meal snacks. A piece of fruit or cheese, a spoonful of peanut butter, or a fruit smoothie can provide nutrients and calories.

Make meals social events. Drop by during mealtime or invite your loved one to your home for occasional meals. Encourage your loved one to join programs where he or she can eat with others.

I know, in some people this next part can be difficult, especially when they have become restricted in movement. Encourage regular physical activity. Daily exercise — even if it's light — can stimulate appetite and strengthen bones and muscles.

Consider outside help. If necessary, hire a home health aide to shop for groceries or prepare meals. Also, consider Meals on Wheels and other community services, including home visits from nurses and registered dietitians. Your local Area Agency on Aging or a county social worker also might be helpful.

And remember the one things Care Providers don’t want to know - identifying and treating nutrition issues early can promote good health, independence and increased longevity.

Dehydration in Older Adults

What causes dehydration?

It’s not always as simple as not drinking enough water, although primarily this is the key reason.

As we age our ability to recognise thirst signals reduce which can often result in older adults becoming easily dehydrated.

Drinking 8 glasses of water a day, even if you don’t feel thirsty will ensure that you stay sufficiently hydrated if you are not unwell.

Should you be feeling unwell and have been sick or experienced a bout of diarrhoea then the body will require more water to replenish itself and the electrolytes lost.