Improving nutrition

Wilshaw House in Ashton under Lyne is a specialist day centre providing support for people with dementia seven days a week.

The focus is on encouraging social interaction, independence, regaining basic life skills and restoring self esteem. Activities are many and varied and include arts and crafts, reminiscence groups, exercise, life skills, music appreciation and quizzes.

When Housing & Care 21 took over the care contract in 2007 care staff noted that service users were uninterested in food or eating. They would leave the table without finishing their lunch and would spend much of the afternoon sleeping. Getting them to engage in stimulating activities after lunch was an uphill struggle.

Improving nutrition

The challenge to staff was to find a solution that would:

  • restore service users' interest in food
  • provide them with a choice
  • stimulate the desire to eat
  • ensure a healthy and balanced diet
  • encourage participation in the social and practical activities surrounding the preparation and service of meals.

The day's menu choices had always been written up on a board, with staff also asking service users at the beginning of the day what they would like for lunch.

The problem with this method is that people with dementia can lose the ability to think for themselves and will often say the same thing as the person sitting next to them, believing that this is the correct answer. A fairly simple solution was to create picture menu cards showing the day's meal choices.

It has been suggested that we 'eat with our eyes', therefore it is helpful to see what food looks like. We will choose what we think looks nice. The words 'shepherd's pie' may not mean anything to a person with dementia, until they see and recognise exactly how this looks.

The menu cards were produced by sticking pictures of food onto card. It didn't involve any costly design or printing because pictures of food are fairly easy to come by. Old cookery books, magazines, websites and digital photographs provide an excellent source of culinary images.

A typical day's lunch menu consists of a choice of main meal, for example roast chicken or lamb stew and vegetables or and a lighter option such as sandwiches or jacket potatoes.

Many pictures show complete meals but it is known that this is of little help to those with tunnel vision resulting from glaucoma, so a lot of the cards now break the meals down into individual items. It is important to recognise that people with dementia also have other conditions that commonly affect the elderly and these can contribute to confusion and other effects of dementia if not taken into account.

Particular attention is paid to the following:

  • menus offer food rich in the essential vitamins that are recommended for dementia sufferers
  • a bowl of fresh fruit and selection of yoghurts is always available
  • a light option is always available (as some service users have an evening meal at home)
  • there is a variety of selections from day to day.

Whilst the menu cards had clearly stimulated service users' interest in food - it was immediately obvious that people had started to choose for themselves - it was also apparent to staff that even more could be done, this included supporting them in shopping for the ingredients and helping to prepare and cook the food.

Stimulating interest in food

Integral to the success of this project was to maintain this interest in food. The team were already familiar with devising activity programmes designed to encourage social interaction and mental stimulation. The solution was to take this a step further and engage service users in other aspects of eating - such as shopping, preparation and cooking - by incorporating these as activities in the 'daily living' group.

Taking small groups out at a time, staff found that a daily trip to the supermarket soon became a welcome addition to the day's structure. The simple act of selecting fruit and vegetables was an enjoyable task with double benefits - not only rekindling an interest in food but helping to improve self esteem as well.

Wilshaw House has a second kitchen, much smaller than the large catering kitchen which is used for main menu preparation. This second kitchen is used by service users to prepare and cook the food that they've bought and it is equipped with everything you would find in a domestic kitchen.

Stimulating this interest in food has extended outside, where a small area has been turned into a sensory garden with herbs such as mint and another area designated for growing vegetables. Now links have also been made with a local allotment so service users can grow even more fruit and vegetables.

Experiencing different places to eat, such as an outing to the local pub for Sunday lunch, a curry evening or visit to the local fish and chip shop have also proved to be popular. One such successful outing to a Chinese quarter allowed a few of the service users to experience new flavours for the very first time.

The Dining Room

Fundamental to this project are the objectives of giving people choice, control and independence. So service users are enabled and supported to help themselves to vegetables rather than having these put on the plate for them. In this way they are choosing the size of the portions as well. Staff guide and encourage service users to choose a balanced diet being but are careful not to institutionalise meal times or introduce stressors to the event.

A programme of staff training was introduced to ensure that staff were aware of the social, cognitive and dexterity requirements involved in maintaining and enjoying a healthy diet as well as the basic nutritional requirements of older people with dementia. The simple acts of peeling a banana or taking the lid off a yoghurt pot are frequently forgotten by people with dementia. To help address this problem staff, who used to eat separately, now join service users at the table. This has the benefit of encouraging service users to copy or follow their example. By observing staff they are able to undertake tasks that many of us take for granted.

It also appeared that service users were taking their cue from the people around them. Therefore, if one person finished their meal and left the table, it was not unusual for others seated with them to follow suite. The provision of a slow-eaters table has overcome this problem and encourages those needing a bit more time to finish their meal at their own pace.

Liaison with colleagues in other services and family carers is important to ensure that intelligence is shared and effective practice is adopted by all. To promote consistency of approach, outreach domiciliary care from the centre is being developed to provide service users with continuity of care at home. This also means that care at the centre can reflect their lifestyle and choices in the home environment.

Monitoring and evaluation

Regular meetings are held with the service users to obtain their feedback on the mealtime menu. Individual objectives and outcomes are reviewed with the service user by the key worker. This will include assessment of behaviour, mood and general health as well as the service user's satisfaction with the service. Approaches to care will be adjusted accordingly.

Staff meetings are held to discuss concerns about individual service users and to identify strengths and weakness in service delivery. The feedback clearly supports the impression that service users and staff are now thinking more about food and making more suggestions for menus.

Both service users and staff are encouraged to make suggestions and express preferences. Some comments are very helpful, for example requesting vegetarian options. Some suggestions are not necessarily the healthiest option, for example a preference for deep fried chips over oven chips. What is most important though is the interest in food and in eating; the occasional deep fried chip is unlikely to do much harm.

Small groups of service users also help to plan the menus for the following week, coming up with new ideas, such as dishes from other countries. This is particularly important when working with an ethnically diverse group of service users.

Results

It is noticeable that service users are more settled. They take their time to eat and enjoy their meals. It no longer appears that they regard lunch as a chore or something to fear or dread.

They stay seated longer at the table and the tea or coffee that follows lunch is taken in the dining room, which also makes them inclined to take more time. Whereas most would wander away from the table before finishing their meal, almost all now stay seated.

One of the most noticeable benefits is the improvement in attention span following lunch. They want to take part in activities and have more energy to do so. No service users now take afternoon naps. This indicates that energy levels are being sustained and the increased alertness means they are enabled to participate in other activities that provide mental and physical stimulation and maintain fitness and well-being.

The amount of wasted food has reduced dramatically. Approximately 2.5 litres of uneaten or leftover food used to be discarded on a daily basis. This has reduced to around half a litre. This is a clear indication of satisfaction with the food being provided and evidence of increased consumption.

Whilst food wastage has reduced, fluid intake has increased. Service users always receive a drink on arrival, at mid morning, with their lunch and at afternoon tea. Jugs of juice and water are available all day and service users are encouraged to regularly make a cup of tea or coffee, sometimes doing this for one another.