Exploring some simple solutions to overcome mealtime difficulties and improve nutrition in people with dementia by increasing their interest in food
Les Clarke, MA, DipSM, RGN, is director of older people’s services, Housing 21.
Clarke, L. (2009) Improving nutrition in dementia by using menu picture cards and cooking activities. Nursing Times; 105: 30, early online publication.
This article outlines an initiative to help service users at a day centre for people with dementia develop a keener interest in food and mealtimes. The simple changes have had a profound effect, not only on clients’ interest in eating but also on their food and fluid intake.
Keywords: Dementia, Nutrition, Older people
- This article has been double-blind peer-reviewed
The National Dementia Strategy sets out the Department of Health’s goal for people to be helped to live well with dementia, regardless of their stage of illness or where they are cared for.
The strategy also points out the huge challenge facing society posed by the forthcoming rise in the number of people with dementia. In the next 30 years, this figure is likely to double to 1.4 million, with costs trebling to over £50bn a year (DH, 2009).
It is thought that around 25% of the costs of caring for this group may be attributable to the time carers spend helping with eating and drinking (Barratt, 2004).
Older people are at increased risk of malnutrition for a number of social, economic and clinical reasons (European Nutrition for Health Alliance, 2005). Age Concern (2006) reported that 60% of older inpatients are at risk of becoming malnourished or deteriorating nutritionally while in hospital.
Over half the cost of malnutrition comes from spending on people over the age of 65 (European Nutrition for Health Alliance et al, 2006). The benefits of improving nutritional intake are clear.
Studies often focus on the problems of providing food instead of the experience of those receiving food (Manthorpe, 2003).
Malnutrition is a common feature in people with dementia (Watts et al, 2007). They may find eating difficult and common observations are a refusal to eat, an apparent loss of appetite, forgetting to chew or swallow, overeating or being easily distracted by their environment.
Meeting government guidelines for eating healthily clearly poses a problem for those looking after people with dementia.
A lack of essential nutrients, weight loss and dehydration can compound dementia symptoms, with patients becoming more confused and agitated. Encouraging them to eat a healthy, balanced diet is extremely important, but not always so easily achieved.
Staff working in dementia care are familiar with the warning signs, such as patients leaving food uneaten or leaving the table simply because someone else, who has eaten their meal more quickly, has done so. Overcoming these problems is challenging.
Wilshaw House in Ashton under Lyne is a specialist day centre providing support for people with dementia seven days a week. A team of 10 staff provide care to more than 100 service users per week and around 20 each day. Some visit more than once a week.
The focus is on encouraging social interaction, independence, regaining basic life skills and restoring self-esteem. Activities are many and varied and include arts and crafts, reminiscence groups, exercise, life skills, music appreciation and quizzes.
When Housing 21 (a national provider of services for older people) took over the care contract in 2007, care staff noted that service users were uninterested in food or eating. They would leave the table without finishing their lunch and would spend much of the afternoon sleeping. Getting them to engage in stimulating activities after lunch was an uphill struggle.
The challenge to staff was to find a solution that would:
- Restore service users’ interest in food;
- Provide them with a choice;
- Stimulate the desire to eat;
- Ensure a healthy and balanced diet;
- Encourage participation in the social and practical activities surrounding preparing and serving meals.
The day’s menu choices had always been written up on a board, with staff also asking service users at the beginning of the day what they would like for lunch.
The problem with this method is that people with dementia can lose the ability to think for themselves and will often say the same thing as the person sitting next to them, believing this is the correct answer to the question asked.
A fairly simple solution was to create picture menu cards showing the day’s meal choices, as it is helpful to see what food looks like. People will choose what they think looks good. The words ‘shepherd’s pie’ may not mean anything to a person with dementia, until they see and recognise exactly how this appears.
The menu cards were produced by sticking pictures of food onto card. It did not involve any costly design or printing because pictures of food are fairly easy to find. Old cookery books, magazines, websites and digital photographs provide excellent sources of culinary images.
A typical day’s lunch menu consists of a choice of main meal, for example roast chicken or lamb stew and vegetables, and a lighter option such as sandwiches or jacket potatoes.
Building up a bank of picture card images has been a gradual process and is continually evolving as new choices are added to the menu.
Many pictures show complete meals but it is known this is of little help to those with tunnel vision resulting from glaucoma, so many cards now break the meals down into individual items.
It is important to recognise that people with dementia also have other conditions that commonly affect older people and these can contribute to confusion and other effects of dementia if not taken into account.
Particular attention is paid to the following:
- Menus offer food rich in the essential vitamins that are recommended for people with dementia;
- A bowl of fresh fruit and selection of yoghurt is always available;
- A light option is always available (as some service users have an evening meal at home);
- There is a variety of selections from day to day.
While the menu cards had clearly stimulated service users’ interest in food – it was immediately obvious that people had started to choose for themselves – it was also apparent to staff that even more could be done. This included supporting people in shopping for ingredients and helping to prepare and cook food.
Stimulating interest in food
Integral to the project’s success was to maintain this interest in food.
The team was already familiar with devising activity programmes designed to encourage social interaction and mental stimulation. The solution was to take this a step further and engage service users in other aspects of eating – such as shopping, preparation and cooking – by incorporating these as activities in the ‘daily living’ group.
Taking small groups out at a time, staff found that a daily trip to the supermarket soon became a welcome addition to the day’s structure. The simple act of selecting fruit and vegetables was an enjoyable task with double benefits – not only rekindling an interest in food but also helping to improve self-esteem.
Wilshaw House has a second kitchen, much smaller than the large catering kitchen which is used for main menu preparation. Clients use this second kitchen to prepare and cook food they have bought.
The activities here range from the simple act of making a cup of tea or a slice of toast through to cooking breakfast or baking a cake, which might be something some service users have not done for several years. They are encouraged to make tea or coffee for each other.
Stimulating this interest in food has extended outside, where a small area has been turned into a sensory garden with herbs such as mint and another area designated for growing vegetables. Links have also been made with a local allotment so service users can grow even more fruit and vegetables.
Experiencing different places to eat, through, for example, an outing to the local pub for Sunday lunch, a curry evening or visit to the local fish and chip shop, have also proved popular. One successful outing to a Chinese quarter allowed a few clients to experience the flavours of this cuisine for the first time.
The dining room
Fundamental to this project are the objectives of giving people choice, control and independence.
Service users are therefore enabled and supported to help themselves to vegetables rather than having these put on the plate for them. In doing this, they are choosing the size of the portions as well.
Staff guide and encourage them to choose a balanced diet but are careful not to institutionalise mealtimes or introduce stressors to the event.
A programme of staff training was introduced to ensure that staff were aware of the social, cognitive and dexterity requirements involved in maintaining and enjoying a healthy diet, as well as the basic nutritional needs of older people with dementia. The simple acts of peeling a banana or taking the lid off a yoghurt pot are frequently forgotten by this group of clients.
To help address this problem, staff (who used to eat separately) now join service users at the table. This has the benefit of encouraging them to copy or follow their example. By observing staff, they are able to do tasks that many of us take for granted.
It also appeared that service users were taking their cue from people around them. Therefore, if one person finished their meal and left the table, it was not unusual for others seated with them to follow suit. The provision of a ‘slow-eaters’ table has overcome this problem and encourages those who need a bit more time to finish their meal at their own pace.
The system of ‘protected mealtimes’ has also been put in place, allowing service users to eat without interruptions as environmental noise and distractions are reduced to a minimum.
Liaison with colleagues in other services and family carers is important to ensure that information is shared and effective practice is adopted by all. To promote consistency of approach, outreach domiciliary care from the centre is being developed to provide service users with continuity of care at home. This also means that care at the centre can reflect their lifestyle and choices in the home environment.
Monitoring and evaluation
Regular meetings are held with service users to obtain their feedback on the mealtime menu.
Key workers review individual objectives and outcomes with them. This includes assessment of behaviour, mood and general health as well as service users’ satisfaction with the service. Approaches to care are adjusted accordingly.
Staff meetings are held to discuss concerns about individual clients and to identify strengths and weaknesses in service delivery. The feedback clearly supports the impression that service users and staff are now thinking more about food and making more suggestions for menus.
Both clients and staff are encouraged to make suggestions and express preferences. Some comments are extremely helpful, for example requests for vegetarian options. Some suggestions are not necessarily the healthiest option, for example, a request for deep fried chips rather than oven chips. What is most important, though, is the interest in food and in eating; the occasional deep fried chip is unlikely to do much harm.
Records showing the menu choices for each day are kept for a period of 12 months. These identify the most and least popular options and help inform future menus.
Small groups of service users also help to plan menus for the following week, coming up with new ideas, such as dishes from other countries. This is particularly important when working with an ethnically diverse group.
It is noticeable that service users are more settled. They take their time to eat and enjoy meals. It no longer appears that they regard lunch as a chore or something to fear or dread.
They stay seated for longer at the table and the tea or coffee that follows lunch is taken in the dining room, which also makes them inclined to take more time. Whereas most would wander away from the table before finishing their meal, almost all now stay seated.
One of the most noticeable benefits is the improvement in attention span following lunch. Clients want to take part in activities and have more energy to do so. None now take afternoon naps. This indicates that energy levels are being sustained; the increased alertness means they can participate in activities that provide mental and physical stimulation and maintain fitness and well-being.
The amount of wasted food has been dramatically reduced. Approximately 2.5L of uneaten or leftover food used to be discarded on a daily basis. This has reduced to around half a litre. This is a clear indication of satisfaction with the food provided and evidence of increased consumption.
While food wastage has reduced, fluid intake has increased. Clients always receive a drink on arrival, at mid morning, with their lunch, and at afternoon tea. Jugs of juice and water are available all day and service users are encouraged to regularly make a cup of tea or coffee, sometimes doing this for each other.
A key action priority from the DH’s (2007) nutrition action plan is nutritional screening for all people using health and social care services. In line with this recommendation, Housing 21 will be rolling out this approach at its other day centres. It will also develop a fuller set of evaluation criteria including: impact on behaviours; the extent to which the programme is followed in the home and the impact in the home setting; and the effect on clients’ weight and general health.
The approach will also be tested in other care settings including extra-care housing schemes and residential care homes.
One of the key objectives of the National Dementia Strategy is to improve care in care homes. Preventing malnutrition and its consequences would make a major contribution to improving care and residents’ quality of life.
The introduction of simple picture menu cards has given people with dementia the opportunity to make a choice. This, together with a few other minor changes, means service users at Wilshaw House are getting a healthy and balanced diet as well as enjoying a wide range of structured activities.
The success of this project is testament to the dedication and enthusiasm of staff. Their commitment was key to bringing about this change. Their reward is seeing service users involved, interested and eating well.
- Menu cards are easy and simple to produce.
- The menu choice should follow the five-a-day principle on fruit and vegetables.
- Menus should offer variety and include a light option for those not needing a main meal.
- Providing links with shopping, preparation and cooking further stimulates interest in food and eating.
- There are 700,000 people with dementia in the UK. This figure is set to rise to 1.4 million in the next 30 years (DH, 2009).
- People with dementia often have problems with eating.
- Poor nutrition can aggravate the symptoms of dementia.
- Studies often focus on the problems of providing food instead of the experience of those receiving food.
Age Concern (2006) Hungry to be Heard. The Scandal of Malnourished Older People in Hospital. London: Age Concern.
Barratt, J. (2004) Ensuring good nutrition in dementia care. Reviews in Clinical Gerontology; 14: 3: 247–251.
Department of Health (2009) Living Well with Dementia: A National Dementia Strategy. London: DH.
Department of Health (2007) Improving Nutritional Care. A joint Action Plan from the Department of Health and Nutrition Summit Stakeholders.London: DH.
European Nutrition for Health Alliance et al (2006) Malnutrition Among Older People in the Community. Policy Recommendations for ChangeLondon: European Nutrition for Health Alliance.
European Nutrition for Health Alliance (2005) Malnutrition Within an Ageing Population: a Call to Action. London: European Nutrition for Health Alliance.
Manthorpe, J. (2003) Poorly served? Eating and dementia. Journal of Advanced Nursing; 41: 2; 162–169.
Watts, V. et al (2007) Feeding problems in dementia. Geriatric Medicine; 37: 8, 15–19.