Is your resident losing weight despite taking nutritional supplements? TROUBLESHOOTING

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1 Is your resident losing weight despite taking nutritional supplements? TROUBLESHOOTING QUESTIONS TO CONSIDER Does your resident often refuse the meals? POSSIBLE CAUSES SOLUTIONS SUPPORTING LINKS / DOCUMENTS Changes in dietary behaviour Tastes can change, resulting in different food choices and ways of eating. Spoiled foods may be eaten. People sometimes forget to eat or drink or forget they ve just eaten. With advancing dementia, people can lose the ability to eat independently. Some people eat non-foods. The person with dementia might be unable to ask for foods/fluids or describe problems such as dental pain or heartburn. Ensure the resident receives the high energy and protein/fortified menu options Provide alternative meals or snacks that the resident is known to often eat well. This may involve providing single-texture foods or sweet foods (e.g. custard, ice cream, soup, semolina, porridge, cake and custard) Boosting the Calories Recipe Adaptation ideas Increase the Calories Eating well: supporting older people and older people with dementia practical guide, published by The Caroline Walker Trust, available at ACTIONS TO ADD TO YOUR RESIDENT S CARE PLAN Dementia can affect mood. And loss of appetite may indicate low mood. Food refusal can be part of the disease process in advancing dementia. Medications can have side-effects such as feeling sick, stomach cramps, constipation and sedation. Others can increase appetite, causing weight gain and high blood glucose levels. Provide full assistance and prompting at mealtimes from staff. If the resident does not like to be assisted at mealtimes, consider specialist aids eg deep lipped plates, Alzeimers Society Resources: ad/downloads/id/1799/factsheet_eatin g_and_drinking.pdf Eating well: supporting older people and older people with dementia practical guide, published by The Caroline Walker Trust, available at Consider making a referral to Occupational Therapy

2 Stress or anxiety can negatively impact on a resident s appetite and intake. Also, Eating and drinking worries can be stressful for families and carers, putting pressure on relationships. If the resident has end-stage dementia, or is medically deteriorating, expectations about improving their intake and weight may be unrealistic and should perhaps be revised and this documented in residents notes & inform GP. Please refer to the Nutrition in Palliative Care/End of Life resource. If this is the case, appropriate goal would be to minimise weight loss and to facilitate a good quality of life by providing food and drink they tolerate/ enjoy. The resident does not like the food maybe it is too bland or foods they dislike. If the resident has mental capacity then ask them why they are refusing food. Ask them what foods they do like and provide them. non-slip place mats, adapted cutlery, wide necked mug If the resident eats better for their family, ask the family if they can make their visits during mealtimes and help to feed the resident. Supply the resident with finger foods to eat at the table during mealtimes or to snack on during the day. If the resident has missed a meal, provide a homemade milkshake Provide a small portion (e.g. on a teaplate) Consider the eating environment would the resident prefer to eat in their room or in the dining room?, Would calm music at mealtimes help? Ensure the food is seasoned well as taste reduces with age Finger Foods leaflet Homemade milkshake Non- Cow s Milk Nourishing Drinks leaflet - Nourishing Drinks recipes Nutrition in Palliative Care/End of Life ad/downloads/id/1799/factsheet_eatin g_and_drinking.pdf Alzheimer s Society guide to catering for people with dementia, published by the Alzheimer s Society, available

3 at Does your resident often refuse the nutritional supplements? Dislikes the supplement they are given. Dislikes milky drinks. Supplement is given at the wrong time of day (e.g. may be still full after a meal). Difficulties handling cup or swallowing problems If the resident has end-stage dementia, or is medically deteriorating, expectations about improving their intake and weight may be unrealistic and should perhaps be revised. Document in residents notes & inform GP Suggest family/friends bring in any favourite treats Do any of the medications the resident takes have side effects that could be affecting their appetite or cause them to burn calories quickly? If so, ask the GP to review the medications and try alternatives if possible. Add calories to the drinks they do accept such as making all tea and coffee up using all milk or 75% milk and 25% water. Try a homemade milkshake or a non-milk shake. Or ask the resident s family to bring in some over-the- counter or shopbought milkshakes. For example, Mars Milkshake, Complan Shake, Weetabix on The Go Drink, Frijj milkshake, Nourishment Original, Slimfast Rich, Gulp Vanilla Drink. Homemade Milkshake recipe. Non-milk drinks recipes If this is the case, appropriate goal would be to minimise weight loss and to facilitate a good quality of life by providing food and drink they tolerate / enjoy. For your resident that requires nutritional support, try making the powdered shakes (e.g. Aymes, Foodlink Complete) in a different way. E.g. serve warm, frozen as ice lollies or add the shake powder to Angel Delight, Rice pudding, or Custard. See Company websites for recipes for their products: Neutral or savoury flavours of Aymes can be added to mashed potato, soups, stews, curries etc.

4 Are there behavioural issues that are affecting the resident s intake? e.g. clamping mouth shut, spitting out food or holding food in mouth Caused by the resident s clinical condition such as dementia. As dementia progresses some people find chewing or swallowing difficult or forget to swallow, resulting in pouching food. Coughing at meal/drink times, chewing continuously or repeat chest infections can be signs of a swallowing problem. A Speech & Language Therapist may need to assess and advise on suitable foods and drinks. Give cordial or fruit juice mixed with lemonade (not sugar free) Not suitable for residents with diabetes Serve the supplements at a different time of day such as an hour before bed, or instead of mid-morning coffee or tea. If they have a bottled supplement (e.g. Fortisip) try a powdered shake instead Try a fruit style supplement (e.g. Fortijuce) Replace one or two cups of tea / coffee with a milk based drink like Ovaltine, Horlicks, hot chocolate. Provide full assistance and encouragement with drinking the supplements Could there be a swallow, oral Candida, dentition or other problem causing the behaviour? If so, refer to Speech and Language, Dentist or other relevant agency Provide finger foods (if no swallowing issues) that are accessible to the resident throughout the day Could there be a swallow, dentition or other problem causing the behaviour? If so, refer to Speech and Language, Dentist or other relevant agency Ensure all staff are trained on identifying and managing challenging eating behaviours and feeding techniques. Finger Foods leaflet /training_for_organisations

5 Residents with dementia may display behaviours such as hiding or playing with their food. Staff require more training on identifying and managing challenging eating behaviours and feeding techniques. Is there a member of staff or family member that the resident eats better for? If so, try to ensure that person assists during mealtimes as much as possible. Also, ask that person for any tips or techniques they use to assist the resident during mealtimes that can be shared with all staff. Try the resident on a soft or pureed diet and add calories to this using skimmed milk powder, sugar, cream, chocolate spread, margarine etc. Soft Diet leaflet tients-public/adults/nutrition/links-andresources Does the resident burn up calories quickly? Pacing and wandering can burn off a lot of energy, which needs replacing with extra calories. Some medications which reduce pacing can over sedate which is likely to reduce food intake. Some conditions cause calories to be burned Ensure the pureed food is appealing by using moulds or presenting vegetables, potatoes, meat, fish, pasta etc separately on a plate rather than together in a bowl. Provide food and snacks that require minimal chewing such as custard, ice cream, yoghurt, mousse, Angel Delight, semolina, mashed potato with cream cheese, cake and custard/pouring cream, egg custard etc. Provide finger foods that can be eaten as the resident wanders. Provide full assistance at meal and snacktimes to encourage the resident to stay seated and to eat during these times. Pureed Diet leaflet tients-public/adults/nutrition/links-andresources Dysphagia snack recipes tients-public/adults/nutrition/links-andresources Finger Food leaflet.

6 up quickly such as COPD and cancers. Ensure the resident is having high energy and protein meal options and high energy snacks. Provide homemade milkshake, or powdered shake once or twice per day Boosting the Calories and Increase the Calories Homemade milk shake recipe QUICK MEAL IDEAS if the standard meals are being refused Weetabix and full fat milk Porridge or instant oats made with full fat milk and cream Rice pudding made up with full fat milk and cream Semolina made up with full fat milk and cream (smooth texture if the resident cannot manage lumps) Tapioca made up with full fat milk and cream Mashed potato with melted cheese Ice cream with banana Baked beans with cheese Pasta with cream and cheese sauce Cream cheese, jam, egg mayonnaise, tuna mayonnaise or chocolate spread sandwich Toast and margarine/jam/chocolate spread/peanut butter Soup (add full fat milk or cream) Cheese cubes and crackers Slices of quiche or pizza Cake with cream or custard Egg custard tart Cheese straw and cream cheese or hummus dip