Malnutrition in Aged Care

 

A healthy diet is important for everyone. We all know that babies and young children need enough of the right food to grow and be healthy. But did you know that very old, along with the very young, are most vulnerable to the effects of poor diet?

Malnutrition in Older people

As we age our bodies start to change. While the outward signs are visible in the mirror there are also many internal changes which can impact on nutrition. Many older people mention one or more of the following:

  • Loss of teeth and poorly fitting dentures which makes chewing difficult.
  • Food tastes like cardboard, as they lose their taste and smell. They may also have a dry mouth (often due to their medications) so food becomes less appetising.
  • Food becomes more difficult to swallow.
  • Their digestive tract is sluggish. Food may not be absorbed as well.
  • Constipation is common – and contributes to poor appetite.
  • They no longer tolerate the foods they used to enjoy.
  • They have one or more health conditions, and take a number of medications, which can impact on their nutrition needs.
  • Loss of muscle mass leads to loss of strength, slower pace and poor balance. Recent research shows that older people actually need more protein than young people to help conserve their muscles.
  • Loss of bone mass so that the bones become more brittle. Many older people are not getting enough calcium or vitamin D needed to slow down bone loss.

When you combine the above with substandard meals sometimes served in residential aged care it is not surprising that many older people are not eating as well as they should be. In fact, research from around the world suggests that up to 50% of people in residential aged care are malnourished. In a future BLOG we will take a closer look at identifying Malnutrition in Aged Care.


The impact of malnutrition can be far-reaching and includes:

  • Loss of energy and strength.
  • Reduced mobility with an increased risk of falls and fractures.
  • Lower immunity leading to frequent infections (UTIs, colds, coughs and even pneumonia).
  • An increased risk of developing pressure injuries.
  • Low mood and loss of enjoyment of life.
  • They require more nursing cares.
  • Increased health care costs.
  • Increased complaints.

The question is “how do we best nourish our aged care residents?”

Most people recognise the importance of eating lots of vegetables and fruits, healthy grains, some protein-rich foods and cutting back on unhealthy fats and sugars. A wholegrain salad sandwich with a big, crunchy apple would be a great choice for a healthy young woman, but it won’t suit the frail 85-year-old with poorly fitting dentures!  On the other hand, most frail older people don’t want to eat bland, pureed foods slopped into a bowl.

So what should we be serving our older, frail residents? It would be fair to say the meeting the nutrition needs of older people in aged care is complex and requires knowledge and skill.

Aged Care Dietitians teams up with food service experts and executive chefs to provide skills-based food and nutrition training seminars and workshops for Residential Aged Care Providers. We cover a range of tops: special diets, food preparation for aged care, menu planning and nutrition and hydration in our workshops and seminars. See our FaceBook page. for news of our latest workshops.

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Terence Austin demonstrating preparation of delicious texture modified meals to participants at our Aged Care Nutrition Workshop a Fresh Look at Soft and Puree meals in Auckland.

Food is only nutritious if it is eaten! Meals should look, smell and taste good, as well as provide sufficient variety and meet the residents’ nutrition requirements and preferences. This is a tall order, and how do you assess this? The best place to start is having a Menu Audit undertaken by a dietitian with expertise in aged care nutrition! We offer a cost-effective aged care menu audit service so that you can be reassured your menus meet aged care accreditation standards.


Yes, we want a fantastic menu with delicious meals served to all residents. Even so there will be those people with special diet needs, or really poor appetites who continue to lose weight. Our dietitians are skilled at assessing and treating residents with special diet needs, including enteral tube feeding (PEG and NG feeds). Where appropriate we arrange for oral nutritional supplements. Aged care Dietitians provides on-site or SKYPE clinical consultations.

To find out more, email us: admin@dietitianz.com

Creating tasty and appealing puree meals for adults.

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Preparing puree meals for adults is an art and a science. We need to consider nutrition as well as appearance, taste and flavour. Most of all we need to ask: is this food that I would enjoy eating?

Most of us have some experience with feeding babies. We blend together a mixture of bland foods and baby hungrily eats up. When it comes to feeding adults it is a different story altogether. What suits baby will not please most adults! First of all, adults have different nutritional needs to babies.  Secondly, as adults we are used to more complex flavours in our food. Eating a puree diet as an adult should not equal plain tasteless foods. A pureed diet can and should be rich in nutrients, colour, taste and flavours. In this blog we show you that this IS possible!

Reasons for requiring puree diets are varied and complex. In the short term, a soft or puree diet may be helpful for someone having jaw or major dental surgery. Or, a Speech Language therapist may prescribe a puree diet for someone with a swallowing problem who is at risk of aspiration or choking. If you’re the patient, life isn’t over just because your meal texture needs to be modified.

If you’re the cook make sure that the puree meals you serve are nutritious, delicious and uphold residents’ dignity as an adult. The tips below will help you make tasty and appealing puree meals for adults.


1. The basics…There’s no reason to puree all the food together. This creates a grey or brown slop, with a cacophony of flavours. Unless it’s a casserole, puree each meal component separately. This means keeping the meat separate from the vegetables and the starch and so on. Gravy should preferably be poured over at the time of service.

Puree meals should never look like this!

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2. Colour…We all ‘eat with our eyes’ and this continues when you’re on a puree diet. Colour is important in stimulating the appetite. Aim for as many different colours in the puree meal as you can. Vegetables like beetroot and pumpkin are great for using as a base for sauces and add extra colour.  Puree fruits such as berries and mangoes to garnish milk puddings and ice cream.


3. Shape…Puree foods don’t need to be sloppy, or served up with ice-cream scoop mounds. Using a variety of moulds we can create life-like pureed foods. Think puree peas shaped like whole peas, pureed beef in the shape of a steak, and milk puddings can be set in fun moulds. The limit is your imagination. Moulds and piping bags are helpful tools to have around when plating puree meals.


4. Nutrients… A poorly managed puree diet can be the start of a slippery slope to malnutrition.Many puree meals are low in protein, vitamins, fibre and calories.  Often people on puree diets eat poorly because their food is not appealing. So they’re not getting the energy and nutrients they need. Some cooks use water to puree the meal. This not only waters down the nutrients but also the taste.  Choose a liquid high in nutrients if you need to add liquid. Think milk, yoghurt, gravy or a rich sauce. If the person is losing weight your dietitian may suggest adding extra cream, oil or nut butters. Contact a Dietitian immediately if a person on a puree diet begins to lose weight.


5.Menu Planning … don’t forget the puree meals when planning your   aged care menu.  Often these are just an after thought and adapted from the main menu. This can mean that the person on the puree menu misses out. Although most foods can be pureed, some foods won’t work as well. Puree meats work best when they have been slow cooked until tender. The liquid from the cooker can be used to puree it. Specify the puree meal and snack items. If you get stuck a Dietitian can help.


6.Snacks … older people enjoy (and need) their mid meal snacks. However, snacks typically served in aged care facilities are not suitable for people on puree diets. These include pastries, cakes, scones, slices and sandwiches. Milk puddings and dairy products can make good snacks and can be an important way to get more protein into the diet. Other options are nutritious smoothies, gelled cakes and sandwiches. to find out more come to our workshop.


7.Dignity… Always think about the dignity of the resident. Many residents needing a puree diet also need feeding. Put yourself in their shoes and think what it would be like to be fed as an adult? Feeding older adults is a skill. Help them freshen up before the meal. Say grace if that is their custom. Be patient. Take your time. Talk to them. Explain what is on the plate. Gently encourage them to eat. Provide the opportunity to eat at the table with everyone else.


8.Learn More… Aged Care Dietitians is running a workshop with an emphasis on Soft and Puree meals. We will cover everything from – reasons for a puree diet, nutrition, planning the menu and practical tips to preparing and serving the food. For more information contact us today!

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Menu Planning in Aged Care

We all plan our menus, whether we realise it or not –  even if it just deciding what’s for tea when arriving at the supermarket car park!

Of course, when we are catering for residents in the care home menu planning does become more complicated. There are many different aspects to consider, such as:


Nutrition, nutrition, nutrition! – If you provide three meals a day, your residents depend on you to meet their total nutritional requirements. This can seem like an intimidating. Don’t do it all on your own. Our team of Dietitians are here to help you! Remember that your menu needs to be audited by a Dietitian at least every second year. Besides looking at the paper menu, we ask to see shopping receipts to work out portion sizes. We also visit your facility to see what the meals actually look like.  An important benefit of the menu audit is that you will get lots of useful feedback, to help improve your food service. Need more info about the Menu Audit? See out blog: 5 good reasons to get your aged care menu audited by a dietitian.


Finances – Even Michelin Star chefs have a budget. Start with knowing the dollar value per person and work backwards. Calculate how much your average meal needs to cost and use this as a guide. Time spent getting things right here will save you money down the line and stop you from blowing the budget.

 


The Cycle Menu: Most facilities have a cycle menu which rotates every 4-6 weeks. Initially setting up the cycle menu can seem daunting; but once your underway you’ll see that a good menu is worth its weight in gold, and save a lot of time and money down the line. If you are not sure where to start contact us for a menu planning template.

 


Choice – Your residents will appreciate some choice at meal times. Increasing choice empowers residents, they are more engaged and more likely to eat what is on their plate. Think of your resident profile and what sort of choices they would prefer. Obviously, providing increased choice can be challenging when catering to large groups of people. Some simple ways to increase choice are to offer:

  • a selection of different sauces / gravies at meal times,
  • different flavours of ice cream,
  • different dessert toppings (ice cream, custard, cream),
  • a variety of biscuits or cakes,
  • two types of soup at dinner (e.g. a broth or a cream soup),
  • making the vegetarian option available to all residents.

Texture Modified Diets: Don’t forget the residents on texture modified diets when planning your menu! It’s not good enough to just blend together the food from the main menu – soft, minced and puree options should be specified on the menu. You need ensure your texture modified menu offers a variety of flavours and colours to avoid menu fatigue.


Is it appropriate for your resident group? – You may pride yourself on your Pad Thai, but is this the kind of food your residents want to eat? On the other hand, don’t assume that your residents just want meat and three veg everyday. Think about what kind or meals your residents are used to eating and then just how far you can push their taste buds. If you’re not sure about their preferences, then brainstorm at your residents meeting, or ask family members.


Equipment – It’s great to be ambitious about your menu, but make sure you have the tools and space to make the dish in the first place!


Time – Same as Yes, homemade marmalade would be nice, but do you have time to pick the oranges?


Don’t re-invent the wheel – Unless you’re opening a new aged care facility, it’s likely that there is already some kind of menu in place. Use this as a guide for your new and improved menu. Pull out what was good about the last one and scrap the dishes that always went into the scraps!


Will your menu sell? – It’s not uncommon for potential residents to ask to see the menu while they tour your facility. So your menu may be the difference between a new client or one that takes their business elsewhere. Maybe this is something you remind your manager of before your budget is finalised!


‘If it ain’t working, fix it!’ – You probably won’t get it exactly right the first time and that’s OK. Let your customers guide you as to what needs to stay and what needs more work.


Get some extra help – Have a look at the resources on this site so that you are best set up to menu plan. Contact us, our dietitians have expertise in Menu Planning for Aged Care


Happy planning!

 

5 good reasons to get your aged care menu audited by a dietitian

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As dietitians working in aged care we frequently get panicked phone calls from facility managers: “The auditors are coming next week and I need a menu audit done ASAP, how much do you charge?”

So, it seems that some facilities only think about getting a menu audit done when their certification audit is due, and preferably at the lowest quote. Sure, the auditors look for a dietitian menu audit as an important component for assessing compliance with Health and Disability Services Standards and DHB Accreditation.  But hold on, the menu audit offers so much more than just a quick look over the menu to make sure you’ve ‘ticked the all the right boxes’.

Food is only nutritious if it is eaten! Meals should look, smell and taste good, as well as provide sufficient variety and meet the residents’ nutrition requirements and  preferences. This is a tall order,  and how do you assess this?

The best place to start is having a Menu Audit undertaken by a dietitian with expertise in aged care nutrition! A good way is to think of the Menu Audit as a comprehensive ‘WOF’ (warrant of fitness) of nutrition practices in your facility. Like the WOF for your car, your dietitian should use a comprehensive checklist to audit your menu, which is why we recommend that all dietitians use the 2016 Dietitians New Zealand Menu Audit Tool. The menu audit will provide reassurance when you are on the right track, and can also help to identify issues and potential problem areas. As with your car, knowing the issues helps you to be proactive in putting plans and strategies in place to avert major problems down the line.

Done properly, the menu audit covers many different aspects of food, nutrition and hydration. Key components of the Dietitians New Zealand Menu Audit include:


  1. Checking whether your menu is likely to meet the nutrition needs of your residents? To answer this your dietitian should check that the menu includes sufficient daily serves of the core food groups. Next up, we would look at your food orders. Using this information, we work out the average daily serve for key food items, per resident and compare this to the Ministry of Health guidelines. Although this does not guarantee the intake of the individual resident, this information does confirm whether your menu has the potential to meet residents’ nutritional needs.

  1. Seeing how varied your menu is. Most people enjoy meals where there is a variety of flavour, texture, colour and type of food. Some red flags of poor menu planning would be:
    • Colour: such as having only white food served on a white plate (e.g. steamed fish with white sauce, mashed potato, cauliflower and vanilla blancmange).
    • Texture: like only having only ‘sloppy’ food on the place.
    • Flavours: do they complement or clash, or is the whole meal bland and tasteless?
    • Foods / menu items: for instance, serving some variation on minced meat every other day.

Once we have identified any issues we will give you practical suggestions on how you can make the menu more varied and appealing to your residents.


  1. Are your residents special diet needs being met? This can be complicated. In a facility we may find residents needing diabetic, renal, vegetarian, food allergy, gluten-free as well as modified texture diets. Fortunately, your dietitian is the expert in this field and can help you find your way around this minefield. We can advise how to adjust your menu to meet special dietary needs of all your residents, and where you need to offer alternatives. And sometimes, you may just need the reassurance that it’s ‘ok to relax the strict dietary rules”.

  1. As part of the menu audit your dietitian will want to visit your facility and meet with the Chef and other food service staff. This helps gives us a better idea of:
    • what are the issues your food service staff face?
    • how are meals prepared and served?
    • do staff have access to good recipes?
    • are residents provided assesistance with meals?
    • how inviting is the dining environment?

While the menu audit can’t solve all your food service issues, we can advise where to turn for expert advice.


  1. Finally, as part of the Menu Audit your dietitian will have a chat with nursing staff to get a brief overview of your facility’s nutrition policies and procedures, nutrition monitoring practices and how residents at increased nutritional risk are managed. We can work with you to plan strategies to address these issue.

So in summary, a well planned and executed Menu Audit is not just aimed at ticking the boxes. Your dietitian will work alongside you to achieve a quality menu, to support your food service. Nutrition is now recognized as a key component of aged care. Serving your residents delicious and nourishing meals will not only enhance their well-being and quality of life, but will also be a fantastic marketing opportunity for your facility.

For more information on how getting your menu audit done, contact us today!

 

 

 

Weight Monitoring in Aged Care

We all know the importance of maintaining good nutrition in our residents. A simple but effective way to check residents’ nutritional status is to track weight over time. Unplanned weight loss is linked to poor clinical outcomes, including: malnutrition, pressure injuries, hip fractures and death. Therefore, monitoring for unplanned weight loss is an important quality indicator in Aged Care.


How often should residents be weight?
All residents should be weighed on admission and at least once a month.
A resident at increased nutritional risk should be weighed more frequently.

By tracking your resident’s weight you can identify weight trends. The best way to do this is to record on a weight chart.

weight-chart

(Email us if you would like a complimentary copy of our weight chart).


When does weight loss become a concern?
• As a rule of thumb, we would consider a weight loss of 3 kilograms or more over a three month period to be significant. So, if Ben weighed 75kg in January, and by April his weight was down to 71.5kg, we should find out why.
• Another way is to calculate percentage weight loss. A 5% weight loss over 3 months is significant. (Our Cheat Sheet takes the hard work out of calculating percentage weight loss. Cheat sheet) For instance, Mary weighed 60kg in May and was down to 56.9kg in August – the cheat sheet shows us that she has had a weight loss of more than 5% .
• If the resident is consistently losing weight over time. Even a small monthly weight loss adds up. It is always a good idea to look back at the admission weight. When Susan was admitted 3 years ago she weighed 75kg and her weight is now down to 63kg. Although Susan is still in the ‘healthy weight range’ she has been steadily losing weight since admission and we need to find out why.


Practical tips
• Many residents are unsteady on their feet and are not able to stand on a scale. A chair scale is a safe and reliable option for weighing older people. A hoist may be needed for residents who are not able to transfer safely to the chair scale. Another option is a wheelchair scale, which provides a convenient and safe method of weighing residents while they remain seated on their wheelchair.

• Train care staff responsible for weighing residents to ensure that standardised procedures are followed.

• It is important to calibrate the scale regularly (follow manufacturer’s guidelines).

• Although it is ideal to weigh first thing in the morning, this is not always practical. The important thing is to always weigh residents at the same time of day.

• Establish a routine for weighing residents e.g. the first Sunday of the month. Make sure that this recorded in the calendar, and any weight changes need to be followed up by senior staff.

• Weigh residents in light clothing, preferably no shoes or jackets.

• If there is a large unexplained weight gain, consider the following:
o measurement error – reweigh the next day
o fluid overload or oedema – alert the GP
o change in medication (e.g. diurectics)
o has the resident had subcut fluids charted?

• If there is a large unexplained weight loss, consider the following:
o measurement error – reweigh the next day
o dehydration
o change in medication (e.g. diurectics)


What to do if resident has lost weight ?
o Alert the Doctor that resident is losing weight.
o Refer to a Dietitian has lost more than 5% weight in the past month .

Contact us for more information

5 steps to manage weight loss in residents

In our previous blog, we discussed why weight loss is a concern for residents in aged care facilities. In this blog we discuss 5 simple steps to manage weight loss. Too often when a resident has lost weight, the immediate reaction is to prescribe nutritional supplements. In our view, while supplements have their place, there are many things we can try in the first instance.


5 steps to manage weight loss in residents

1. ‘Make every mouthful count ‘
Loss of appetite is common in older people. Eating can becomes a struggle and weight loss follows. When residents can only eat a small amounts, it is important that meals are high in energy and protein. We can ‘sneak in’ extra calories (kilojoules) by:

  • Adding extra cream, cheese and margarine / butter to food
  • Using full cream milk (rather than skimmed or low fat)
  • Serving rich and tasty sauces and gravies with meals
  • Using high fat salad dressings and mayonnaise

 

To make sure that protein needs are met:

  • Serve a high protein food with each meal, for instance: eggs, yoghurt, legumes, meat, fish or chicken.
  • Add skim milk powder to milk, porridge and sauces. (Or use a plant based protein powder).
  • Make peanut butter freely available as a spread.

2. Serve delicious and appealing meals
Nobody wants to eat ‘yuck’ food, and definitely not if they already have a poor appetite! Bear in mind that ‘food is only nutritious if it is eaten’. So we need to make sure that meals are:

  • Appealing and well presented. After all, we ‘eat with our eyes’! Taking a little bit of extra effort when dishing up can make the meal look much more appealing. Use garnishes to add colour, add a swirl of cream to soup – use your imagination!

 

  • Tasty and flavoursome. A common misconception is that older people need bland foods. Nothing can be further from the truth! Old people often complain of loss of taste , so we should serve well seasoned and flavoursome meals. Another frequent complaint is the lack of salt (in porridge and cooked foods). Using salt in moderation makes food taste better, and residents are more likely to enjoy their meals.

 

  • There has been a lot of negative publicity about sugar in recent years. Some facilities still use artificial sweeteners / sugar substitutes in desserts and baking, which is now a No-No. Baking with artificial sweeteners can taste awful and is likely to be rejected by the residents. Sensible use of sugar helps food taste good and also boosts calorie intake. So, continue to allow residents to enjoy their sweet treats if they choose.

3. Tailored meals to the their tastes. We all have our unique food preferences. Research shows that residents eat better when they have more choice with their meals. For instance, if Mary has a poor appetite, ask her what she feels like eating. It could be something simple like poached eggs on toast. Serving Mary the foods she likes can improve her intake and help to combat weight loss.


4. Eat little and often –The thought of sitting down to a huge meals is particularly daunting to older people with a poor appetite. The secret is to serve small, fortified meals with nutritious between meal snacks and drinks. (More on this in future blogs)


5. Check weight regularly – if your resident has a poor appetite and is losing weight it may be time to put them onto weekly weights. This way you can keep a close eye on weight changes. Make sure the GP is aware of the weight loss. If their weight continues to drop then it’s time to call in the dietitian.


For more information contact admin@dietitianz.com

5 Reasons we should care about weight loss in aged care residents

Weight loss is common in older people. In our weight-obsessed society weight loss is usually seen as a good thing. But in older people any unplanned weight loss is bad, even if they are overweight.


5 reasons we should care about the weight loss in our residents

1. Weight loss may signal underlying illness. Alert the resident’s GP so this can be investigated further.

2. The resident may be losing weight because he is not eating enough, and becoming malnourished. Malnourished residents are more likely to develop:
• pressure injuries
• pneumonia and other infections
• low mood

3. When a resident loses weight they will also lose valuable muscle mass, which increases the risk of:
• falls
• broken bones
• pressure injuries

4. Weight loss can lead to increasing frailty and:
• a decline in mental and physical function.
• decreased independence
• needing more nursing cares

5. Older people with unplanned weight loss are more likely to die within one year


How about the resident who is overweight?
Unplanned weight loss is a concern, even if the resident is overweight. We need to find out why they are losing weight. Bear in mind that overweight residents can also become malnourished.


How do we know when a resident is losing weight?
The simple answer is to weigh all residents regularly. But, how often is ‘regularly’?

The following groups of residents should be weighed weekly:
• Underweight residents
• Residents who have been losing weight
• Residents who consistently eat less than 75% of their meals
• The doctor may ask for daily or weekly weights for medical reasons e.g. fluid overload.

All other residents should be weighed at least once a month.
Record weight on a weight chart, so that you can identify the residents weight pattern over time. See example of graphical weight chart below.


When does weight loss become a concern?
Weight loss becomes a concern when a resident has lost:
• 5% of their body weight over a three month period
• 10% of their body weight over six months or longer


What to do if resident has lost weight ?
• Start food charts so you can identify problem areas.

Offer extra snacks and milk drinks.

We will cover this topic in a future blog.

Alert the Doctor that your resident is losing weight

• Refer to a Dietitian if your resident has lost more than 5% weight in the past month (or 10% over six months); and extra foods / drinks have not reversed weight loss.


(Email us if you would like a complimentary copy of our weight chart).

weight chart

Possible causes of unplanned weight loss in Aged Care Residents

Diet and eating:

  • Poor appetite
  • Restrictive diets e.g. low fat
  • Quality of meals
  • Change in diet when moving into facility
  • Inability to self-feed
  • Difficulty chewing or swallowing food
  • Taste changes
  • Dry mouth

Psychological

  • Low mood
  • Bereavement
  • Confusion

Disease related

  • Acute illness e.g. a chest or urinary tract infection
  • Chronic disease such as heart failure, emphysema or Parkinson’s disease
  • Cancer
  • Dementia
  • Delirium
  • Bowel problems e.g. nausea,constipation, diarrhoea,
  • Chronic pain

Medications

Many medications can contribute to weight loss. Side-effects include dry mouth, nausea and constipation, which may reduce the resident’s appetite.

Many drugs can alter nutrient absorption and / or use.

Seek the advice of a Pharmacist when a resident has these side effects.

 


Find out more about referring a resident to one of our Dietitians.