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Dementia Care & Meal times: Cues and Clues
I was delighted to read Care UK dementia specialist trainer Mark Harrison’s moving description of mealtimes for people with dementia in care homes in the latest edition of Care Home Catering.
Each person with dementia is unique, but all have some loss of brain function
Each person with dementia has a unique set of challenges, yet there is a commonality: some loss of brain function. When this happens there is an adaptation of behaviour. For example, if the service user cannot remember being admitted to the care home they may try and search for a parental figure or for the familiarity of their home – reflective of a search for love and a place where they matter and are important.
Care home staff cannot be parents but they can give comfort and support. Mealtimes – done well – provide an ideal opportunity for this, but provided badly can lead to weight loss and dehydration.
Choosing what to eat is a complex cognitive process
Care home staff should be aware that complex cognitive decisions taking part in multiple areas of the brain underlie the choice to eat. Aromas can increase our desire to eat, and the recollection of such foods triggers our salivary glands. Our emotional memory reminds us of the enjoyment associated with the food; our factual memory may remind us about its health attributes. We can calculate whether we can afford to purchase food we want to buy, and we use all these parts of our brain – a juggling of cognitive reasoning – within a few seconds.
But someone with dementia does not have a complete collection of cognitive tools at their disposal. The loss of short term memory and the failure of abstract thinking can mean trying to make a choice without being able to mentally visualise the food, or understand the consequences of decisions. Dinner ordered from the menu for the following evening may elicit a familiar phrase ‘I didn’t order that!’
Poor dementia care – as well as dementia itself – is a risk factor for malnutrition
Dementia is undoubtedly a risk factor for malnutrition, but so is poor dementia care. Harrison’s article highlighted the ‘usual suspects of poor care home practice’, e.g. not showing the food choices, users seated waiting on meals for long periods of time with nothing to eat or drink, lack of flexibility and adaptability meet a service users’ needs and blended foods presented unappetisingly on plates.
A combination of inadequate training and poor environment can lead to group rather than personalised care, where people with dementia are ‘fed’ in a rather mechanised way. Dementia gets all the blame but perhaps we should also be looking closely also at the other culprits like rigid routines, sensory disturbances (e.g. loud background noise) and lack of appealing aromas that might promote appetite.
Clues in the dining room
It is important to recognise that things can be done to improve the dining environment like giving diners a drink while they wait, using stronger flavours to compensate for taste changes and increasing snacks throughout the day. Keen observations are key e.g. recognising that someone scraping their soup bowl may want more.
Harrison described his observation of a malnourished service user that found it difficult to recognise that the food on offer was free, despite staff assurances. The solution - giving the service user a wallet with fake money – he started to eat better and staff even received tips!
Another fascinating observation described, centred on a change in dining arrangements from smaller dining tables to a long row of tables, temporarily dressed in white catering paper. A service user was observed repeatedly standing up, looking around nervously, saying a few words and leaving the table. On closer observation, Harrison heard him say ‘Thank you for coming.’ The service user had thought he was at his daughter’s wedding: long tables, white tablecloths and many unfamiliar people – he was getting up to give the speech! Feeling embarrassed that he couldn’t remember it, he left the table. Splitting the tables apart helped the man eat again.
People eat when they feel right. In dementia, eating decisions may be more emotionally determined than factually – those working with care home service users should bear this in mind.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor