Christine Eberhardie, MSc, RN, RNT, ILTM, MIHM.
Senior Lecturer, Faculty of Health and Social Care Sciences, Kingston University and St George’s Hospital Medical School, Kingston upon Thames, Surrey
A recent European report showed that 47% of the elderly population has an inadequate intake of one or more nutrients (de Groot et al, 1999). This is supported in the UK by studies in hospital and the community (McWhirter and Pennington, 1994; Edington et al, 1996; Finch et al 1998). In seeking to reduce the incidence of malnutrition in hospital and community practice, a variety of measures have been taken in the development of nutritional assessment tools and nutritional support for the general and elderly populations (Reilly 1996; Vellas et al, 1999; 2001).
The British Association of Parenteral and Enteral Nutrition (BAPEN) Malnutrition Advisory Group (MAG) developed a nutritional assessment tool called the Malnutrition Universal Screening Tool (MUST) in 2000 (BAPEN 2000a; 2000b). It was launched publicly in November 2003 (BAPEN, 2003) and is available from the BAPEN website.
There is also a growing interest in the areas between assessment of nutritional status across the lifespan and assessment of the individual’s requirements for nutritional support. One of those areas is the assessment and maintenance of independent eating skills.
Eating skills tend to be taken for granted from childhood. By the time we reach adulthood we have forgotten what a complex set of skills they were to learn. They are psychomotor and social skills that are vital to our survival as an individual and in society. It is important therefore to distinguish between changes that may need to be made to adapt to normal ageing while maintaining healthy nutrition, and the development of pathological changes.
Little seems to have been written about the effect of natural ageing processes on eating skills but there has been an increasing interest in eating problems in diseases such as dementia (Watson and Deary, 1997), and stroke (Carr and Mitchell, 1991; McLaren, 1996; 1997). There is also a considerable amount of occupational therapy literature which may be of help.
Definitions of eating and feeding
The ‘Eating-feeding continuum’ (Eberhardie, 2000), as shown in Table 1, consists of four major stages: independent eating, assisted eating, assisted feeding and dependent feeding. In the literature ‘independent eating’ and ‘self-feeding’ are terms that are loosely defined and often used indiscriminately to include truly independent eating and assisted independent eating. A patient can remain independent and self-feed even if he or she cannot cook, shop or clear away. A good example of this would be the individual who needs a Meals-on- Wheels service.
Independent eating skills can be defined as a series of independent activities which include:
- The desire for food and fluid
- The ability to recognise food
- The motivation to seek out, select and bring home food
- The ability to prepare food and drinks by cutting, chopping, mixing, cooking and serving a meal or snack
- The ability to move food from a serving receptacle such as a plate, fork, spoon or cup to the mouth
- The ability to maintain body posture
- The ability to open the mouth, close the lips, bite, chew and form a bolus
- The ability to swallow safely
- The ability to clear away the waste and maintain hygiene by washing up.
Assisted eating is the maintenance of independent eating by modifying any of the elements identified above if they are weak or absent, for example by taking a person to the shops by car so that they do not have to carry heavy bags, cutting up the food, providing eating aids or modifying the texture of the diet to assist swallowing.
It is in this stage that much can be done to promote independence, quality of life and a healthy individual. The other elements of the ‘Eating -feeding continuum’ can be seen in Table 1.
The biology of eating
In order to assess eating, the skill needs to be broken down into its component parts to identify the physical and mental processes involved. How do we recognise food? How do we choose what to eat and when? What are the psychomotor skills involved in shopping? What drives us to eat? How do we prepare food? How do we know that it is safe? How do we transfer food from plate to mouth? How do we prepare food for swallowing?
A brief answer to these questions is given in Table 2, which shows the gross anatomical structures that are involved as well as the major physiological processes required to eat independently. It also shows how, at each stage, the natural ageing process can affect the healthy individual’s desire and ability to eat.
In assessing patients and planning good nutritional support, it is essential to understand the detail of the process in order to identify any problems at an early stage. Early assistance can include advice on how to maintain a nutritious diet by adapting lifestyle, or on equipment to assist independent eating. For example, an older person or carer could prepare and freeze meals for microwaving in order to have a nutritious diet within a limited budget. In this way nurses can play a significant part in the prevention of malnutrition and its consequences, which are depression, tissue breakdown, poor healing and increased risk of infection.
Prevention of malnutrition will help to protect the older person if he or she develops one or several of the many diseases or disorders associated with old age such as dementia, cardiovascular disorders, arthritis or continence difficulties (Van Nes et al, 2001). Good nutrition promotes a sense of well-being, diminishes the risk of infection and mental disorder and plays a role in the prevention of specific disorders such as osteoporosis, cancer, diabetes mellitus and cardiovascular disease.
The NHS recently introduced benchmarks for nutrition in The Essence of Care (Department of Health, 2001). This has at least ensured that every patient has his or her nutritional status assessed on admission to hospital. However, the recording of height, weight and body mass index (BMI) alone is not sufficient in older people. In fact, recording height and weight may be difficult to measure accurately in those with severe arthritis or osteoporosis. Measurements such as demispan and half-arm span can be helpful in estimating height (Hickson and Frost, 2003). Knee height is also a measurement that can be used to estimate height. None of these three measures correlates well with standing height. Table 3 shows how these measurements are calculated.
The validity and reliability of a number of nutritional assessment tools has been discussed elsewhere (Green and McLaren, 1998). Eating skills and behaviour have been discussed mainly in relation to dementia and stroke, leading to the development of assessment tools related to those two problems. Watson (1996) developed and validated The EdFED2 scale for assessing eating behaviour in dementia. It was later evaluated for its reliability as an assessment tool (Watson et al, 2001). As with many assessment tools, the validity and reliability are often tested but not its practicality for everyday use with a particular client group.
Attempts have been made to develop nutritional assessment, especially for patients over 60 years. The Mini Nutritional Assessment (MNA) (Guigoz et al, 1994) has proved a valid and reliable clinical screening and assessment tool for older people and has been used frequently in nutritional research in this age group. Van Nes et al (2001) used it to predict outcome of hospitalisation, confirming that patients with a low MNA have an increased rate of mortality or a longer hospital stay than those with a high score.
The Malnutrition Universal Screening Tool (BAPEN, 2003) has been recommended by the European Society for Parenteral and Enteral Nutrition (ESPEN) (Kondrup et al, 2003a) particularly for use in screening for malnutrition in the community. It is a valid and reliable screening tool. They also recommend Nutrition Risk Screening (Kondrup et al, 2003b) for use in hospital and the Mini Nutritional Assessment (Vellas et al, 1999) for use in elderly care in nursing homes and hospitals.
It would be interesting to follow up their research with an audit of the operational issues involved in using these three tools. How much training is required to ensure inter-rater reliability? This may be an issue in parts of Europe where screening is devolved to health support workers rather than health-care professionals due to staffing shortages.
Maintenance of independent eating
In the community, there are many ways people can be helped. Some councils run subsidised buses to and from supermarkets. In some shops assistants will help with shopping and packing and can arrange delivery. Family, friends and neighbours are often available to help with heavy shopping. Some people move house on retirement not only to cope with a reduction in financial status but to be nearer to family, transport or shops.
Visual impairment can be a major issue in safe shopping, food preparation and eating. It may mean that the individual is unable to go shopping and cannot read food labels and use-by dates. Food may be left in a refrigerator too long and decay or mould may not be recognised, which could lead to gastrointestinal infections. Not being able to see dials on the cooker can lead to burnt food or even fires. A combination of a poor sense of smell and visual impairment presents the greatest danger.
Regular eye tests and appropriate spectacles can be of some help. Clear white symbols or raised surfaces, indicating the on/off and temperature settings on cookers, good lighting and uncluttered surfaces promote safety in the kitchen.
Preparing meals and cooking is something that can be adapted as the person ages. This should be included in pre-retirement courses. Learning to use a microwave oven or switching from gas to electricity for cooking can prolong independence for many. Storing a few essential tins in the store cupboard and fitting an electric tin opener can be a life saver when the weather is treacherous and a visit to the shops could result in a fractured femur.
The value of food supplements is widely debated at present. The Food Supplements (England) Regulations 2003 is a new Act implementing the EU Directive 2002/46/EC on food supplements. It defines a food supplement as: ’Any food the purpose of which is:
- To supplement the normal diet and which is a concentrated source of a vitamin or mineral or other substance with a nutritional or physiological effect, alone or in combination and
- Is sold in dose form.’
This piece of legislation will come into effect during 2005. It will define food supplements for the first time, introduce a list of vitamins and minerals that may be used, and prohibit the sale of vitamins that are not listed and do not conform to the Food Labelling Regulations 1996.
Confusion, however, may remain. In the food industry food supplements usually mean nutrients added to foods, for example adding vitamins to refined flour or calcium to skimmed milk. In the mind of the layman, however, food supplements can be anything from sippable drinks prescribed by the dietitian or GP to give a complete set of nutrients in a concentrated form, to over-the-counter vitamin and mineral supplements. It could also include other nutrient remedies such as concentrated cranberries in capsule form and herbal remedies. The new Act may do little to dispel this confusion.
Criticism is not made of the supplements themselves but of the lack of discrimination in their use. Elderly people are at risk of toxic doses of some vitamins and minerals by taking highly concentrated doses. Without adequate assessment they are often prescribed unnecessarily. If the patient can eat solid food then fortified foods would be just as effective, more acceptable and cheaper to the health service. An example of fortified foods would be the addition of milk, cream, butter or cheese to scrambled eggs. Some patients do not find sippable drinks palatable but may not have been given other options (Gosney, 2003). Sip feeds are useful for those who are living alone, frail, malnourished and unable to cook or have fortified food cooked for them. They are also useful for those who require a balanced increase in diet rather than increased energy.
There is a tendency to be sparing in the number of eating aids readily available for use by patients. This results in three possible outcomes. The individual may alter the diet and exclude some foods, lose some independence and have to be fed by a nurse or carer or may refuse to eat.
Many hospitals accept that, in the past, eating aids such as padded spoons or plate guards have been locked up in cupboards or their use subjected to unnecessary bureaucracy. Allowing patients to use such eating aids, which can help maintain their independence, can only improve the situation.
There is ample evidence that the patient who refuses to eat or has an inadequate diet is at risk of malnutrition with all its costly sequelae (King’s Fund, 1992; Edington et al, 1996). The provision of common eating aids is likely to be a less expensive option than paying the salaries of nurses to feed a patient or the treatment of the consequences of poor nutrition such as pressure ulcers and repeated or multiple infections.
Useful eating aids should include padded cutlery, two-handled beakers, uni-valvular straws, rubber placemats, eggcups with a suction base, plate guards and tilting teapots. The Disabled Living Foundation website contains a number of factsheets on this area (www.dlf.org.uk/factsheets). Other useful pieces of equipment, including shopping trolleys and high-back chairs with head supports, are available.
Radical change: a call to senior nurses
There needs to be a radical change in the way nutritional status in older people is assessed. It has taken a long time to reach a minimum standard of routine nutritional screening but still patients in primary, secondary and tertiary settings are malnourished. It is totally unacceptable that, in a land of plenty, patients should be starving due to a lack of proper assessment and the waste of scarce resources.
Senior nurses in clinical, educational and managerial roles need to be more active in promoting health by making sure that patients have appropriate and quality nutrition. They can achieve this by ensuring that the assessment is holistic and the solutions to clinical and social problems are addressed.
Thorough assessment and clinical management is more cost efficient than employing unqualified staff to feed patients or dealing with the consequences of malnutrition. It costs more to treat a pressure ulcer than to prevent it. Nurses and support workers are not alone. They need to enlist the support of the community in the form of families, friends and voluntary organisations to promote independent eating skills wherever possible. Healthy older people are a good source of help in solving such problems. A multiprofessional approach needs to be adopted.
The cost of medication, hospital stays, waiting times and wound-care products could all be reduced if only senior nurses focused attention on enuring that patients receive adequate nutrition.
In order to reduce the risk of malnutrition health-care professionals need to consider the whole process of eating in order to assess adequately the patient’s nutritional intake and all the factors that may affect it. Helping an individual to maintain independent eating is not only a complex nursing skill but one that can influence the patient’s quality of life and reduce the risk of a variety of health problems from constipation and depression to pressure ulcers and vitamin deficiencies.
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