For dementia awareness week what can be more fitting from a nutrition scientist than an article that highlights new research looking at nutritional care for dementia, published in BMC Geriatrics from the Ageing and Dementia research team at Bournemouth University.
We know that eating and drinking difficulties are common in dementia. This can be because of cognitive impairments, physical disabilities and psychological factors like depression and agitation. Behavioural challenges impacting on intake include mealtime wandering, pacing, refusal and indifference. Support may become necessary to help maintain nutritional intake.
But what interventions can best support nutrition in people living with dementia?
Weight loss and malnutrition are detrimental to health and quality of life. Current research suggests that interventions to help increase food/fluid intake like assistance with eating, nutritional supplements, managing swallowing problems, as well as looking at how food is presented and the environment in which it is served may be helpful. However, there is no definitive evidence with regards to which measures are most effective to prevent a long-term decline in nutrition status. There is a particular lack of evidence for the most effective interventions implemented by those responsible for the delivery of care – frontline care home staff – over significant periods of time i.e. in real-life situations. Jane Murphy and colleagues at Bournemouth University have started to explore this and looked to develop an evidence-based model for day to day nutritional care to inform and upskill those responsible for delivering food and nutrition to people living with dementia in care homes.
Their research was undertaken using a number of interviews and focus groups with 50 participants including care workers, catering assistants, nurses, dietitians, speech and language therapists and family carers. From the participants’ contribution, several themes emerged:
- Person-centred nutritional care
- Ready availability of food and drinks
- Tools, resources and environment
- Resident’s relationship with others
- Participation in activities
- Consistency of care
- Provision of information
The themes can be used as a framework to guide improvements in nutritional care, and are described in more detail below, and illustrated with some of the participants’ words collected within the research.
Person-centred nutritional care
The overarching theme that emerged from the interviews and focus groups was person-centred nutritional care. This includes understanding the importance of dementia stage in providing individualised nutrition care. As dementia progresses, there can be a reduced comprehension of mealtimes whether that’s with the crockery used, or the environment in which meals are eaten. Furthermore swallowing ability can deteriorate as disease progresses.
Participants in this study reported that residents with dementia were more frequently entering care homes at later stages, where their nutritional needs required a greater level of support. This increased pressure on staff, particularly in relation to the time required to develop insight into specific and changing nutritional needs, as well as into individual day to day variability of factors, for example, mood, which can have a significant impact on dietary intake. Understanding how to settle a resident, providing reassurance or changing the environment could improve intake on more anxious days. Clearly, then the relationship developed between the resident and care staff is an important factor. Staff eating with residents may help to afford trust especially when fears have been built up around eating and/or drinking. Close monitoring and observation of people living with dementia is also important because as the disease progresses, there may be a lack of ability to communicate pain or discomfort when eating (like a sore throat or ill-fitting dentures).
Life histories can be important in understanding food behaviour
The participants also reported how developing a good insight into residents’ life histories could be key to understanding mealtime behaviour as illustrated below:
“Her main meal would be put in front of her and the first thing she would do is actually tip one of the drinks… on to her meal… but we chatted to the family… we discovered this lady had been a horticulturist… the plates we used at that time had a rim of flowers… and she was watering the flowers. And the minute we changed our crockery… on to a plain white plate, it stopped.”
For individualised nutrition care, the ready availability of food and drinks was identified, so that alongside set menus there should be a flexibility to adapt to individual needs e.g. adapting to times where appetite is best, or when the person is the most alert.
Finger foods were commended by participants as a way of increasing intake.
“They tend to prefer food they can access easily so soups they suddenly stop eating, but yeah if you pop like a really nice display of finger food in front they’ll all quite happily sit there and eat those.”
Responding to taste changes, common in people with dementia, is also key. For example, changes in spice levels may encourage intake if a taste for stronger flavours develops. Variety was also mentioned as being important. Participants reported some simple successes, for example increasing residents fluid intake through providing a wider variety of options, such as ice lollies, jellies, cool drink and water machines, smoothies, mini cartons, high water containing fruit and veg like melons, oranges, cucumbers, and fruit bowls.
Stimulating the senses may help to increase appetite
Participants also stressed paying attention to stimulating the senses using colours and smells, by, for example, baking and providing cooked breakfasts and Sunday roasts. These aromas were identified to evoke past memories
“Just the smell of a cooked breakfast will start people talking about the cooked breakfast they remember they had after D-Day and you’ll get these amazing conversations… that come from just the aromas.’’
Another emerging theme for improved intake was availability and use of a range of appropriate tools and resources. This could include specialised equipment (e.g. adaptive crockery and utensils) but could also be simpler items.
“We’ve bought camping mugs because they’re lighter but still resemble a mug. It’s about normalising everyday utensils.”
A range of environmental factors which could be used to engage the person during mealtimes were described. These included setting tables and the dining room in different ways for different meals. Other environmental aspects included the creation of a relaxed atmosphere:
“It’s far more about creating the right atmosphere y’know, all the basics, the lighting, the way the table is set up, background music, having the right implements, the food itself, I think all of these things are what’s creating a relaxed atmosphere”.
Another finding was the problem of using menus for selection of meal choices in residents with dementia. Visual menu aids were generally considered unhelpful, but presenting residents with ready plated meals on a tray at mealtimes and patiently offering alternatives if appropriate, was useful.
“I think choice has got to be on the plate, in front of you, see it and smell it… but not pictures. Definitely not”.
A further theme captured were the ways in which activities could be used to stimulate appetite. Activities that involved food (gardening, baking, going shopping, preparing meals, cake decorating) could be tailored to the person’s stage of dementia, life history and past occupation.
“It’s about stimulation, engagement, occupation… involvement, inclusion… and doing something so they might be icing cakes… We look at our residents and we see what makes them tick and what they like to do.”
Themed days such as cultural awareness days, ‘taster days’, cinema events with snacks, afternoon teas, or ice cream days offered important opportunities to promote eating and drinking.
Consistency of care and communication within and across health and social care is important
The need for prioritisation and consistency in the provision of nutritional care was highlighted, not only in the care homes but also across health and social care environments. Better means of communication across the ‘circle of support’ (healthcare professionals, -speech and language therapists, registered dietitians, GPs, nurses, care home staff, family carers, formal carers and people living with dementia) was emphasised, as was the need for better information, education, training and support to guide nutritional care.
“‘It needs to be spread over everything and not just from when [people] come to a care home. It needs to be in the day centres and in the homes, that’s the major problem.”
Further research is needed to evaluate the effectiveness of such evidence-based interventions and their impact on practice to directly support eating and drinking in people with dementia. In the meantime, though they provide food for thought!
