BetterConduct

The themes identified are as follows:

1. The client’s mood and anxiety level, even if the client is not sure what is bothering him/her.  This can also be influenced by whether the preferred carer is present or not.

2. Time of day.

3. Cleanliness and/or comfort of the individual.  Are their needs for clean hands, face, clothing, etc. met?

4. Customs in early life – when, what, where they ate, etc.

5. Independence factor.  This is one of the few areas an individual can still influence and make decisions such as “I can decide what not to eat and not eat lots” (p. 5).

6. Health issues such as infection, tooth and dental issues, sores in mouth due to craving glucose, sore throat, stomach issues, even not being able to see the food clearly. 

7. Side effects of medications. 

 

In determining what is triggering changes in eating habits, start with least restrictive factors first.  Examine physical/health issues initially, including pain and discomfort.  Addressing these may solve the problem without further intervention.

 For ease in addressing issues other than physical, five intervention categories were compiled.  They are environment, materials, technique, patient-based, and social.  Some overlap in categories is expected; interventions have been placed in the category that most closely matches the reason for the presenting variable.

 

Environmental Strategies

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•  Setting tables in the dining room in different ways for different meals.  Ex.  Floral tablecloths, linen napkins for lunch, etc.

• Soothing background music.

• Sufficient space between tables.

• Comfortable room temperature.

• Adjust lighting and colors to evoke atmosphere/mood.  One study turned mealtime bibs into tuxedo look-alikes for the gentlemen and ‘necklaces’ for the ladies!

• Recognize some individuals may be noise sensitive. 

• Use artificial aromas such as coffee, cherry almond bake, fresh bread, roast lamb.  These can evoke pleasant memories. 

• Plan themed days around celebratory events that promote eating and drinking such as birthdays, movie events, holidays, tasting days, cultural awareness, afternoon teas, and ice cream days.  In the Murphy et al (2017) study, one resident started speaking fluent French on their French-themed day!  Whether it was the array of different foods, the aromas, or the berets they wore, something struck a chord with the resident.

• Improve lighting to address vision changes.

 

Materials

 

• Attractiveness and appeal of pureed foods needs to be maintained to include color, aroma, and presentation/appearance.

• Availability of food and drinks.  Both should be accessible and offered day and night.  Allow choices.  Do not restrict to a menu. 

• Many will have preferences for sweet, salty, spicy, or sour foods due to taste changes.

• Provide finger foods to help client retain some independence.

• Use of oral nutritional supplements vs. smoothies and milkshakes to enhance energy intake.

• Offer hot and cold drinks due to loss of thirst sensation.

• Options to increase fluid intake:  Popsicles, sundaes, jellies, cool drink and water machines, smoothies, fruit juice, mini-cartons, oranges, melons, cucumbers, salad, fruit bowls, etc. 

• Use plate guards, modified cutlery that is easier to grasp, mugs with two handles.  Camping mugs can be much lighter in weight.

• Contrasting colors of plates and bowls.

 

Technique

 

• Engage client to eat when most alert and interested.  Dinner might be a more difficult time to encourage eating.

• Deformalize mealtime to decrease expectation of eating.  Instead, offer mini meals, grazing food and snacks in different settings. 

• Offer beverages irrespective of whether they have recently had a drink or not. 

• Vary drinks.

• Involve in food-related activities such as gardening, baking, shopping, preparing meals, cake decorating, etc.

• Do not leave food in front of the client if it cannot be seen or is difficult to access (i.e., must lift lid or drink from a cup if they are used to a straw).

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Patient-based Interventions

 

• Provide reassurance to increase comfort level.

• Address cleanliness (hands, person, clothing).

• Address client comfort including preference of clothing, room and food temperature, chair height and padding, etc. 

• Honor customs from earlier life.  This could be dietary, order of meal items, food preferences.

• As mentioned previously, address health issues including dental hygiene.  A sore throat, toothache, sores in mouth, infection, and denture issues can all affect appetite and eating.

• Investigate medication side effects.

• Client might need additional assistance on a ‘bad’ day.

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Social

 

• Preferred caregiver can greatly influence eating and drinking.

• Use encouragement, prompting, and patience.

• Honor whether the individual wants to eat alone or in the company of others. 

• Family member feeding/presence during mealtime can have both positive and negative effects. 

  • Positive effects may include familiarity, evoking past mealtime experiences, and encouragement.

  • Negative aspects can include unintentional pressure to eat, especially if the family member is not eating concurrently.

• Build up anticipation to a meal.  Have a conversation about what meals/items/themes are being served or celebrated.

• Increased time and attention from caregivers during meals may positively affect eating behavior, intake, and nutritional status (Biermaki and Barrrat, 2001, and Wong et al, 2008)

• Shared meals including both caregiver and individual may have a positive effect on body weight and eating behavior (Charras and Fremontier, 2010).

• Encouraging participation in activities around mealtimes to generate interest and appetite.  Examples include gardening, meal preparation, and recreational activities. 

 

Sources:

Biermaki C, Barratt J.  Improving the nutritional status of people with dementia. Br J Nurs. 2001; 10:1104-14.

 

Charras K, Fremontier M.  Sharing meals with institutionalized people with dementia: a natural experiment. J Gerontol Soc Work.  2010;53:436-48.

 

Murphy JL, Holmes J, Brooks C.  Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes.  BMC Geriatrics, 2017;17:55.

 

Wong A, Burford S, Wyles CL, Mundy H, Sainsbury R.  Evaluation of strategies to improve nutrition in people with dementia in an assessment unit. J Nutr Health Aging.  2008; 12:309-312.