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
Norwich NR4 7UY