For ladies and gents living with Dementia, there are complex interactions with the mealtime environment plus many eating difficulties which can affect nutritional intake.
Jo Bonser, MD of HCSUK, speaks from personal experience on this very prevalent challenge, as she helped to care for her own Mum who was living at home with Vascular Dementia.
Jo says: When I first began to care for my Mum in December 2016, Mum was very poorly; she’d had three falls, urinary and chest infections, had lost a dramatic amount of weight and had no appetite or interest in eating and drinking, and was completely dependent on her carer to assist her at mealtimes. We were told by care professionals to prepare ourselves for the worst, that Mum had given up and wouldn’t be with us for Christmas.
I started to observe Mum’s mealtime behaviours to see what I could do to improve her dining experience and ultimately her nutritional levels. I noticed several things about Mum’s mealtime behaviours and, using an online mealtime assessment tool to guide me, I received a list of suggested interventions based on my answers to which I chose several to trial with Mum. Interestingly, several of these concerned the environment and providing a calmer setting with less distractions and the decluttering of the dining table. I was also able to introduce some adaptive crockery and cutlery to help her and encourage her to eat independently again.
At first, Mum was physically turning her face away when offered food, with no desire to even pick up a spoon and fork to eat herself, no appetite, there was just no interest there, and this is a lady who all her life had loved and enjoyed cooking, loved her food, she was a feeder!
I took responsibility for her mealtime experience, so we would eat together – and I remember her saying to me one day what a difference it made to her when her family member, somebody familiar, was sitting with her and eating with her and taking the time to make it a social occasion.
Within a matter of days, Mum started to pick up her spoon and eat on her own, with her left hand. But not only that; Mum was right-handed but, because of her posture, she would lean to the right when she sat, so she actually learned to pick up her left hand and, using an adaptive spoon that we’d worked with and assessed her for, she started to eat independently. Because we understood and realised that it was a slow process, one of the biggest revelations to me was the use of a keep-warm bowl – there’s nothing worse than eating cold food, and this can be a major barrier to people’s nutrition, particularly if it is taking them a long time to be able to eat independently. So, one of the pieces of adaptive crockery that we introduced was a keep-warm bowl that would keep it hot for longer, so that Mum was able to enjoy her food warm for longer – such an important point! Who of us likes to eat cold food?
So, Mum gradually gained weight. She started to enjoy her food again and her engagement in life was transformational. It was a life-changing experience for her and me.
Having seen the results that I’d been able to achieve with Mum, I wanted to share my experience in a positive way with others who are also caring for people with dementia to help them experience more independent and dignified mealtimes. I felt I could speak from a position of real authority; I lived it, I experienced this, I understand the challenges that there are and I really wanted to share that to benefit as many people as I could.
So, I think the first major thing that I learned is that improving the dining environment and the mealtime experience can really have a positive impact in minimising eating difficulties for people with dementia. So, the first thing I would say is the need to take a step back and review your dining areas.
Eating Environment
Dining rooms should be welcoming and homelike, and everything about them should prompt recognition that it is time for a meal. Environment changes can cause anxiety and confusion to people living with Dementia, for whom disorientation and bewilderment are a common experience. Identifying the dining rooms can help to improve the environment and support good care.
Make sure that the dining room areas are adequately lit, particularly in the evenings. It’s great to also make eating a social activity, so try and sit down and eat together where possible. Many care homes I visit now, who offer a truly superb mealtime experience, have members of their team sitting at each table encouraging conversation and laughter, and it also gives them an opportunity to monitor how people are eating.
Think about noise levels. A noisy environment can be distracting for people living with dementia – one of my care homes actually did a noise audit at mealtimes, and the results were amazing.
They noticed that by making simple changes to the way they managed the mealtime experience, their residents were much less distracted and were clearing their plates, rather than picking at their meals, so they were delighted to be seeing improved levels of nutrition and less wastage.
Enhancing Mealtimes
Make mealtimes a sensory experience. Try and incorporate all of the senses to help stimulate appetite – use things like familiar sounds, such as the tinkling of cutlery, or the rattling of pots and pans. Smells of cooking are great, too. I have seen really good examples where people have brought hot trolleys into the dining area to allow the smells of mealtime – there’s nothing like walking into a room full of a delicious smell to help captivate the appetite and get the old salivary glands working.
Each person’s mealtime experience is unique to them – their likes, their dislikes. Use a person-centred care plan to really get to know that person, and what is going to work for them to get the most amount of nutrition.
You can even think about little details such as where would people like to sit? Let them choose. Some people like to sit in a group and be social whilst they’re eating. Others would prefer to be more on their own and independent and would rather sit at a separate table. Either way, that’s okay – if it results in them eating more and improving their nutritional intake, then that’s their experience. Facilitate and allow that to happen for them.
If people need assistance at mealtimes – not “feeding”, a word which I hate as it reminds me of feeding animals at a zoo, and these are human beings who deserve the utmost dignity, and that includes in the language that you use – sit with them at eye level, either in front of them or to the side so they can see you. And take the time to engage with that person and be present with them while they’re eating – not shouting to your mate at the other end of the room. Really engage with that person.
Again, I have seen some great, great examples of situations in care homes, in an end of life unit, where it was one-to-one at mealtimes, and the support and the encouragement to eat from the carer to their resident remained throughout the meal. They chatted to them – even though they weren’t able to communicate – they were encouraging to them to eat, they were telling them what they were eating, they were explaining, and they kept them fully in the loop.
A Visual Experience
Food should always be visually appealing, incorporating different colours and presentation. We all eat with our eyes first and, depending upon what we see, can determine how much we eat.
So, with my Mum – even though I knew that she needed me to cut up her meal, and towards the end maybe mash her meal – my practice was to take the meal in to her, present it to her in its entirety as it would look on a plate normally and explain to her what she had. And then I would ask her permission; ‘Would you like me to cut this up into smaller bite-sized chunks for you?’ I got her agreement, I didn’t assume, I took her feelings and her dignity into account.
Interaction
Interacting during mealtimes and asking questions maintains people’s independence with eating and drinking, so conducting proper mealtime observations for people who are unable to eat independently and understanding their difficulties can really empower them – they get the correct tools to enable them to have an independent and dignified mealtime experience.
Don’t underestimate how massive this can be for the individual. People can become very embarrassed about the fact that they aren’t able to eat independently and withdraw, physically and socially.
Have you ever had to be assisted at mealtimes yourself? And how did that make you feel? Really take some time to understand people’s mealtime routines and what it means to them.
A mealtime assessment may indicate that an individual needs some adaptive cutlery or crockery, a non-slip mat, a keep-warm plate, or a special cup to facilitate them to eat and drink independently. That is massive.
Use colour to help support the person. Brightly coloured crockery makes food and drink much more visible and appetising, which enables improved nutrition and enjoyment of the social benefits of mealtimes. White crockery doesn’t usually provide a sufficient tonal contrast to enable people to see certain foods on their plate. Some foods which are white are the most calorific part of the main meal – for example, if you look at carbohydrates, you have potato, pasta and rice; or in protein, you have got fish, chicken or pork. Whilst there are no guarantees that one colour will always work for each individual, a tonal contrast can be a real help for most people.
For more information on nutrition and hydration for people with Dementia, reducing the risk of weight loss, overcoming motor difficulties, managing dysphasia and minimising sensory function changes, why not download our Dignified Dining Solutions Guide, which I have written as part of wanting to share my experience with my Mum to help people with Dementia to eat better.
Image source: Unsplash