In the shoes of…Sheila Merriman | Specialist Intermediate Services Dietitian | Norfolk & Norwich University Hospital

I was delighted when Sheila Merriman agreed to write a guest blog for our series, looking at dementia from different perspectives, as nutrition is such an important part of dementia care. We hear a lot about obesity in the media whereas malnutrition is a far more significant problem amongst older people, particularly those with dementia. Dorothy Hall and I visited the Care Show at the NEC last year and were really impressed by Sheila’s informative presentation, including such simple advice as using dairy products to increase calorific intake (but sadly only for those who need extra calories!)…

As a dietitian I find it distressing that it’s assumed it’s ‘normal’ for people with dementia to lose weight. And there seems to be a lack of knowledge on the deleterious effect of low weight on cognitive functioning.

I work in the community. Many of my patients, at home or in Care Homes, have dementia. They’re often referred to the dietitian when they’re so thin that I wonder how they’re maintaining their grasp on life. And when I ask the Carer why no-one asked for help when weight started to be lost, I’m told ‘Well, he/she’s got dementia’ as if it was a valid reason for not making any dietary interventions early on.

So what should Carers do? The basic action has to be regular nutritional screening. The NICE guidelines say that a screening tool should include current BMI and unplanned weight loss. The ‘MUST’ screening tool is a validated tool that does this. It can be downloaded, free, from www.bapen.org.uk

But it’s not enough just to screen for malnutrition. When it’s identified, interventions must be made. The first action should be food fortification. That means making the most of every mouthful that’s eaten. So, while it might be thought that fruit is good for you, I’d say ‘only if there’s lots of cream with it’. It’s the extra calories that will promote good health in someone who’s losing weight. Skimmed milk powder, margarine (or butter), cheese and cream should be added wherever possible to boost the calories. Sugar, honey or syrup can be added if there’s no diabetes. Maybe ‘finger foods’ will be eaten if cutlery is a problem. Focus on the high calorie ones like pork pies and chocolate biscuits. Always offer fortified milky drinks between meals (fortify milk by adding four tablespoons of skimmed milk powder to a pint of full-fat milk).

There’s an excellent CD available from www.mustlearn.org.uk that not only has the ‘MUST’ screening tool but also has sample Care Plans for a range of settings. From the CD you can learn how to assess for malnutrition, decide what an appropriate intervention would be, evaluate the effect of the intervention, and record all of this briefly and accurately.

What I’m working on at the moment are the problems that crop up when people have to have soft or puréed foods. One of the commonest problems is that if someone can’t manage snacks, such as biscuits, between meals they aren’t always offered an alternative, such as full-fat yoghurt. In a Care Home, snacks can contribute about 500kcal to the daily total. Miss them out and the resident will usually lose weight…

And don’t get me started on the effects of dehydration in dementia…

Sheila Merriman RD
Specialist Intermediate Services Dietitian
Norfolk & Norwich University Hospital
Colney Lane
Norwich NR4 7UY

Sheila.merriman@nnuh.nhs.uk

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About Gill Phillips - Whose Shoes?

Passionate about personalisation in health & social care. Creator of Whose Shoes? - an imaginative approach to helping people work together to improve lives. http://nutshellcomms.co.uk
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10 Responses to In the shoes of…Sheila Merriman | Specialist Intermediate Services Dietitian | Norfolk & Norwich University Hospital

  1. Yes, all of my dad’s care homes were very keen on high calorie dairy products. However, these caused massive problems for dad – too much richness with cream or milky drinks etc caused vomiting and tummy upsets, and because dairy is known to aggravate phlegm, it made his swallowing problem worse, contributing to chest problems. In the end, we found fortified oat milk (Oatly) was wonderful for him – they make an alternative to dairy cream too. He also thrived on drinking fruit smoothies, which thickened very well.

    He had to have a soft diet for many years, but careful thinking around mashing cakes etc meant he very rarely missed out on extra treats, and we would also take in special desserts for him as a snack. He maintained excellent weight until very near the end of his life, when pneumonia took over. All of my father’s homes were also very keen on supplementing with Calogen and Ensure drinks for those residents with a poor appetite.

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  2. Whose Shoes? says:

    Thanks for your excellent comment Beth, and for sharing your experience. For me, this is what personalisation is about. (1) Identify good practice – in this case, fortifying the diet to maintain weight and strength (2) Find a way to make it work for the individual, based on personal preferences, food intolerances etc.
    A great example and so glad your Dad was able to enjoy his food in this way 🙂
    For info: Beth’s own post in this series can be found : http://wp.me/p1enjT-u0

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  3. Thank you Gill. Sadly we had to battle for what dad needed. Educating the care home staff was a constant issue, and we found the dietician service very rigid. IE: One size solution fits all, no personalisation, just a blanket ruling from the dietician that everyone must have the same diet, which meant the home manager over-ruling us, despite the fact that clear documentation existed that vomiting occurred after particular foods/drinks. When other residents were losing weight, little was done to think around the problem, identify things they liked eating and build on that. Personalisation is vital in dementia, and never more so than where diet is involved. Everyone has their likes and dislikes, and as much as calories are important, food/drinks will be refused or cause other health problems if it goes against someone’s personal tastes and their bodily reactions aren’t taken into account. My father was forced to continue with a diet very high in rich, full-cream dairy products, against our wishes, for weeks until a dietician could visit him (service over-stretched and under pressure), and in that time aspirated on vomit and phlegm causing chronic chest infections. Personalisation is SO important.

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  7. Audrey says:

    This was helpful. My Mum has also lost her appetite and is also forgetting to eat. She still lives on her own but my sister sees her everyday. But even then she always won’t eat. Any ideas?
    Thank you. It’s so hard to see her disappear and feel helpless. Audrey

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    • I would say the key is finding things she loves – either old favourites or new tastes. As we get older, and particularly when someone is living with dementia, taste buds can need a bit more stimulation. In my dad’s nursing home the chef had great success with traditional classic dishes, homemade & full of flavour, but also (interestingly) more ‘modern’ meals like curry and sweet and sour that you wouldn’t associate with that demographic of residents (all very elderly, frail and many with poor/non-existent appetites and some with swallowing problems). Other tips I would suggest include checking that mouth/teeth problems aren’t hampering your mum’s eating, or that she hasn’t developed a swallowing problem. Finally – making mealtimes something you do as a family whenever possible, might also help. Sometimes people can forget how to eat, but laying a table and sitting down to a meal together can be very beneficial in combatting that. Also, the smells of food being prepared and cooked (like a good Sunday roast) could help. Do follow Gill’s suggestion & check out dementiachallengers.com. I also write a blog (following my dad’s 19 years with dementia) – this post may be helpful: http://d4dementia.blogspot.co.uk/2012/05/food-for-thought.html. All the best, Beth

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  8. Whose Shoes? says:

    Thanks Audrey – I’m glad you found this helpful and am very sorry to hear about your Mum. I can thoroughly recommend dementiachallengers.com, a wonderful new website for people caring for loved ones with dementia. If you cannot find what you are looking for, Lee, who developed it, is always keen to hear from you and try to source new material. I do hope you (and other readers) find this site useful. Gill

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