1. DEM 302: Understand and meet the nutritional requirements of individuals with dementia
Sheena Helyer

2. Learning Outcomes
Understand the nutritional needs that are unique to individuals with dementia
Understand the effect that mealtime environments can have on an individual with dementia
Support an individual with dementia to enjoy good nutrition
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3. CQC Essential Standards of Quality and Safety Outcome 5
Reduce the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration
Provide choices of food and drink for people to meet their diverse needs, making sure the food and drink they provide is nutritionally balanced and supports their health
Explain the role the CQC plays in maintaining standards of care
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4. What is nutrition and hydration?
Nutrition and hydration means eating the right foods and drinking the right fluids to live well and be healthy
Good nutrition and hydration levels are essential for health; inadequate nutrition or hydration can lead to ill health
Malnutrition has been on the increase in the elderly in recent years
An estimated 3 million people in the UK are either malnourished or at risk of being malnourished
The majority of these (97%) are in the community
Malnutrition costs the NHS an estimated £13 billion annually
People who have dementia are at higher risk of malnutrition
Ask the group what they think is meant by nutrition and hydration. Allow several people to give suggestions before revealing the answers. Then ask the learners to think about the reasons why elderly people with dementia may be malnourished
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5. Effects of Malnutrition on Elderly People
Increased risk of infection
Low energy levels
Weakness
Muscle wasting
Lower blood pressure
Slower pulse
Increased risk of falls
Poor wound healing
Anaemia
Lethargy/Apathy/ Depression
Ask the learners to discuss in pairs the possible consequences of malnutrition for an elderly person
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6. Nutritional content of a Functions of the body Well balanced diet
Carbohydrates Main source of energy
(330g daily) Fibre is good for health
Protein Growth and repair
(100g daily)
Fat Energy, storage, synthesis
(75g daily) Repair of cell parts
Water Solvent, lubricant, medium
(2000g daily) for transfer, temp control
Vitamins Enable chemical reactions
(<300mg daily) in the body
Minerals Aid enzyme functions,
(5-10g daily) electrical balance, nerves
Ask the group what they think are different types of nutrient. Allow some discussion before revealing the points one at a time. For each element, ask them what they think carbohydrates are important for, etc.

7. Preserving the health giving properties of food
Eat food fresh
Eat food raw
Store in the fridge
Do not boil vegetables for long periods
Do not over cook
Frozen while still fresh
Tinned food and food with high levels of salt or preservatives is not so healthy
Ask the group to discuss how food can be served in a way which preserves the nutritional value of the food. Then ask them to discuss the ways that their clients cook and prepare food.
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8. Food types: Protein, fat and carbohydrate
Check that the learners can identify the different food types. Ask them to give further examples of each type
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9. Vitamins and minerals
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10. A healthy balanced diet
Ask them to consider whether the service users they visit have a healthy balanced diet and to discuss their dual role of encouraging choice while at the same time trying to promote good health. Ask them what they can do if one of their service users is making unhealthy choices
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11. Brain functions involved in eating and drinking
COGNITION
Sensation of hunger
Recognising food
Choosing what to eat
Memory of how to eat
FUNCTION
Taste and smell
Motor skills to handle utensils
Communication skills
Chewing and swallowing
EMOTION
Eating and drinking gives sensation of pleasure or dislike
Elation or depression may affect appetite
Calm / agitation/ anxiety
Ask learners to think about the damage which occurs to the brain with dementia: brain shrinkage, enlarged ventricles and damage to specific areas. Ask the learners to consider how this may affect the ability of the person with dementia to eat and drink
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12. How can you encourage the person with dementia to plan a healthy diet?
The person may want familiar food with recognisable brand names
They may find it difficult to plan ahead for meals and need help to write a list
They may need prompting to make healthy choices
Their food needs to be attractive and culturally appropriate
Ask the learners if they can share how they manage menu planning with service users who have dementia
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13. How can you help the person with dementia to shop for food and drinks?
The person with dementia may need help to find their way around shops
They may become more easily distracted and need reminding why they are there
They may only have the energy for a short trip
They may need help to manage money/cards /chip and pin
Pictures could be used to guide their choices if shopping on line
Ask learners to describe how they help people with dementia to go out and shop. How do they get there? How do they get around the shop? How do they get money? How do they carry the shopping back home? Etc.
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14. How can you help the person with dementia to store their food safely?
Help them to store food where it is easily accessible and where the person with dementia can find it.
Pictures or labels on the cupboard doors make it easier to find things. Transparent jars and glass doors in cookers and cupboards may help.
The person may need prompting to get rid of expired food or food in the fridge which is not fresh
Do the learners have any experience of people with dementia getting confused and losing things in the kitchen. How have they helped them?
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15. How can you help the person with dementia to prepare food?
Encourage the person to purchase food in packaging which is easy to open
Cook recipes together so that help can be given
The person may need a reminder that it is mealtime e.g. telephone call or recorded message.
A talking clock could remind the person about meal times
Preparing food can be an enjoyable activity for a person with dementia but help may be needed.
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16. How could you help the person with dementia to cook food?
The person could be given simple written instructions
Ready meals might to easier than cooking a full meal
They may need someone to cook with them
They may need someone to place all the equipment on a table in front of them
Microwaves and cookers may need to be risk assessed for safety of use
Learners need to be able to make careful risk assessments of whether people with dementia can safely use kitchen appliances.
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17. How could you help the person with dementia to eat and drink ?
The person may need prompting to eat or a companion
The environment should help them to focus on eating
Provide them with appropriate cutlery and drinking cup
Do not put out condiments if it causes confusion
The person may need assistance to eat
The person may prefer to eat frequent small snacks rather than a big meal
Strong smells may help to stimulate the appetite
The group could have experience of feeding each other a variety of foods and textures. They could then discuss what was helpful and what made the experience unpleasant.
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18. Things which the person with dementia may find difficult
Using utensils in the correct way if they lack coordination
Sitting for a long time if they are anxious or agitated
Explaining their likes and dislikes
Knowing what is edible
Eating food which is hard or chewy
Following socially accepted ‘table manners’
Ask the learners about the people they care for with dementia. Do they have difficulties sitting and enjoying a meal. What changes have had to be made to help them.
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19. The meal time environment can help a person with dementia to eat well
Avoid distractions such as the television
Remove distracting clutter
Choose attractive and appropriate cutlery and crockery
Contrasting colours may be helpful but avoid over busy patterns which may confuse
Quiet music in the background may relax the person
Encourage the learners to discuss the way the food has been presented in the above photos. Also discuss how a formal or informal carer can support a person with dementia to eat well. Sometimes there can be tensions generated between a couple which make meal times fraught. How could a carer help to defuse the tension?
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20. Eating Out
A person with dementia may enjoy eating out with friends and family provided the environment is sympathetic to their needs
Many areas have dementia cafes which offer a welcoming and supportive environment to people with dementia and their carers.
Discuss with the group the kinds of problems which might occur when someone with dementia is eating out.
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21. Mealtimes and snacks
Mealtimes are a high point of the day for many and every effort should be made to make these relaxed and enjoyable occasions
Mealtimes should be well spaced throughout the day
Snacks may need to be provided or made accessible throughout the day and night
Ask the students to think about what foods might be appropriate for snacks
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22. Special dietary needs -To prevent constipation or High fibre
Some people with dementia may have special dietary needs: They may need help and prompting to eat and drink appropriate food.
High fibre
Low fat
Low calorie
Reduced sugar
Reduced protein/
Low salt/restricted fluids
-To prevent constipation or
manage diverticular disease
-To reduce risk of cardiac disease and lower blood pressure
-To lose weight
-To control diabetes
-Kidney failure
Ask the learners to suggest reasons for these diets before revealing
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23. Food and drink choices
We all have food and drink preferences and it is important that people with dementia also have choices about their diet
Providing options and enabling a service user to have autonomy and freedom of choice is a key theme running through the Essential Standards and the Health and Social Care Act In the context of Outcome 5 this includes a real choice of what, when and where to eat and drink. People with dementia may still be able to make valid choices. If they cannot ‘best interest decisions’ should be made on their behalf.
a choice for each meal that takes account of their individual preferences and needs
access to snacks and drinks throughout the day and night
mealtimes that are reasonably spaced and at appropriate times, taking account of reasonable requests including their religious or cultural requirements
information on what constitutes a balanced diet to help them make an informed decision about the type, and amount, of food they need.
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24. Cultural needs
People with dementia may have cultural or religious dietary needs and these should be supported and respected.
Ask about the group’s experience of providing food for people from a different cultural or religious background. Ask them to think about the practicalities of preparing food they are not familiar with.
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25. Assessing nutritional needs
An assessment should be made of the person’s preferences and requirements.
Find out how much help the individual needs to eat and drink.
Where a risk of malnutrition or dehydration is identified appropriate action should be taken to encourage a healthy body weight.
The results of any screening and assessment should be entered into the plan of care and regularly reviewed
Ask the learners to describe the assessment which is made of their service user’s nutritional needs
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26. Hydration
Many elderly people do not drink enough. This may be due to :-
Mobility problems
Worry about being incontinent
Lack of motivation
Not understanding the importance
Good hydration is essential for the health and wellbeing of older people, not only in helping to make people more alert but also helping to prevent confusion, constipation, pressure sores, kidney stones, blood pressure problems and headaches. In addition, evidence suggests that hydration can also promote healing and help to prevent falls, obesity, depression, inactivity and fatigue.
Ask the group why they think service users can sometimes be reluctant to drink water. This is often because some elderly people worry about possible incontinence, particularly close to bedtime. Where older people worry about incontinence care it may be possible to access suitable equipment for them and they should not be encouraged to drink close to bedtime.
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27. Good hydration will result in:-
Fewer falls
Less constipation
Less GP call out
Less agitation
Healthier skin
Fewer urinary infections
Reduction of obesity, depression and fatigue.
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28. How can you encourage people with dementia to drink well and safely?
Provide drinks they enjoy
Leave drinks within reach
Assess whether the person is safe with very hot drinks
Make sure that they can access the toilet when needed
Offer jellies, ice lollies and other foods which have a high fluid content
Ask the students to suggest ways of increasing the fluid intake of a service user with dementia.
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29. Soft diets
A number of conditions including dementia may interfere with chewing and swallowing
The individual may need to be provided with softer foods or puréed food.
Where necessary seek advice from a speech and language therapist
The SALT therapist may recommend exercises, techniques or a specified texture for food.
Updated nutritional care guidelines for older people published by the Social Care Institute for Excellence (SCIE) in March 2009 state that where puréed foods are used, they should be made to look appetising. Where the texture of food needs to be modified due to swallowing difficulties the guidelines state that providers should seek advice from a speech and language therapist.
The guidelines remind providers that not all food for people with swallowing difficulties needs to be puréed and that it is important for the quality of the eating experience to keep different foods separate and not mix them all together.
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30. Dysphagia diet food texture descriptors March 2012
B Thin puree dysphasia diet
C Thick puree dysphagia diet
D Pre-mashed dysphagia diet
E Fork mashable dysphagia diet
These descriptors have been developed by the National Safety Agency (NPSA) in association with Cardiff university. They are intended to be a nationally recognised standard.
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31. Where puréed foods are used they should be made to look appetising
Discuss with the learners how pureed food can be made to look and smell appetising by serving it hot, preparing it in moulds and keeping the food types separate on the plate.
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32. Food supplements can be prescribed by the GP if a resident is malnourished or unable to take a normal diet If a person with dementia is losing weight or malnourished it is good practice to weigh them, work out their body mass index and MUST score
Learners could be encouraged to calculate their own BMI and MUST score
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33. You may then be asked to calculate the person’s ‘MUST’ index
Explain how MUST can be used as a useful tool to identify people ‘at risk ‘ of malnutrition
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34. Helping people with dementia to eat
People with dementia should have the appropriate help if they need assistance with the process of eating or drinking
When giving such help it is vitally important to preserve an individual's dignity and independence
Seat the person comfortably and do not rush. Check that the food is being swallowed safely
People who require assistance with eating or drinking should have their needs fully assessed and discussed with them. A suitable plan of care should be agreed, with specialist input as required, which clearly identifies any assistance needed. Some people may need encouragement to use a spoon or pick up food. Others may start eating when they see someone eting and can copy them.
The provision of adequate support and assistance to eat and drink is specified in Regulation 14 as “support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs”.
This is supported by a number of Prompts (5A) including:
the provision of all assistance necessary to ensure service users actually eat and drink where they want to but are unable to do so independently
the need for staff to act with sensitivity and respect for service users’ dignity and ability
the need for service users to be enabled to eat their food and drink as independently as possible
the need to have adequate and appropriate supportive equipment available to enable service users to eat and drink independently, wherever needed
the need for staff to help service users into an appropriate position that allows them to eat and drink safely, wherever needed.
Staff who assist service users with eating and drinking should be appropriately trained and supervised and there should be adequate numbers of such staff on duty at mealtimes.
Privacy may be especially important for a person who has to have direct help with eating. This can be accommodated in a particular part of a dining room, in a separate dining room for those in need of assistance with eating or in the resident’s own room.
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35. Care Plan for nutritional needs
Any help needed should be agreed with the resident and added to their plan of care
Clothing should be protected from spillage.
Independence aids should be made available.
Privacy may be required
The carer should report any difficulty with eating or loss of appetite.
If the person is losing weight their food intake should be recorded.
At this point introduce the scenario exercise which will help the learner’s assessment skills.
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36. Equipment to help people with dementia to eat independently.
Specialist utensils may enable a person with dementia to maintain independent eating for longer. Ask the learners to look at the range of equipment available in a medical equipment/ rehabilitation catalogue. Encourage to share their existing knowledge of specialist equipment
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37. Food handling
Food poisoning is any infectious or toxic disease caused by consuming food or drink that has become infected with bacteria, viruses or parasites
Food poisoning and infections such as salmonella are easily spread through contaminated food and via infected food handlers
Staff preparing food should observe all relevant food hygiene and safety procedures.
People with dementia may be at higher risk of developing food poisoning because they have become forgetful and do not understand the dangers
Any storage or handling of food in a service user’s home raises a potential risk of food poisoning. It is therefore essential that, wherever food is prepared, handled, stored or served, the highest standards of hygiene are observed by all staff at all times, especially with regard to hand washing. The person with dementia may start to become neglectful of hand hygiene and basic food hygiene standards which could put them at risk of illness.
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38. Hand hygiene is very important
Care staff should wash their hands before and after handling food.
People with dementia should have the opportunity to wash their hands before and after eating.
Ask the learners to think of other ways in which infection might be spread in the home of someone with dementia and how
this could be avoided
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39. The person with dementia may need help with simple food hygiene precautions
Food should not be left lying around the house. People with dementia may sometimes store food in unusual places.
Food in the fridge should not be kept beyond its expiry date
Raw food should be kept separate from cooked food at the bottom of the fridge.
Meat must be served ‘hot’ and only reheated once.
Ask the learner’s to think about their own fridge and those of people they visit. Are they as safe and hygienic as they should be?
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40. Common health problems which affect the elderly and have an impact on eating and drinking Think about how you can help people with these problems to eat well
Visual impairment
Mobility problems
Arthritis
Dental health problems
Constipation
Urinary infection
Diabetes
Put the learners in pairs and ask them to think about one of these conditions and to feedback ideas to the group on how help might be given
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41. Monitoring the diet of people with dementia
Any individual who has special dietary needs, who needs help with eating or drinking or who is at risk of under-nutrition should be appropriately assessed and monitored
Concerns should be reported.
Where necessary a referral for specialist help and advice should be made , for example to :-
Dietician GP
Community psychiatric nurse
Speech language therapist
Alzheimer’s association
Admiral nurse
Ask the learners if they know what these professionals may be able to do to help, where they are based and how they can be contacted. Admiral nurses are specialist advisers in dementia care within the community but they are not available in all parts of the country.
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42. People with dementia should be encouraged to eat and drink well Mealtimes should be enjoyable!

43. Review of learning outcomes
You should now be able to :-
Understand the nutritional needs that are unique to individuals with dementia
Understand the effect that mealtime environments can have on an individual with dementia
Support an individual with dementia to enjoy good nutrition
DEM 302