Illinois Council on Long Term Care

Nutrition: Strategies for Helping Residents at Risk

If monitored improperly, elderly residents can very quickly become malnourished, often leading to a myriad of physical complications including pressure ulcers, circulatory problems, heart and kidney ailments, and increased infections. Residents' medical progress may be hindered because the malnourished body tends to heal more slowly than the well-nourished body. Nutrition also may affect a resident's emotional well-being and willingness to participate in daily activities.

The Health Care Financing Administration has recently developed more intensive survey protocols and probes regarding nutrition as part of sweeping changes in its certification guidelines. Nursing facilities are more closely examining the issues surrounding resident nutrition to effectively meet residents' medical needs and comply with federal expectations. The following information outlines important considerations on how staff members can more successfully optimize resident nutrition.

Nutrition, Long Term Care, and Aging

Moving to a nursing home has profound effects on a person's eating habits. After eating certain foods in a particular way for many years, people who enter nursing homes may have to make changes in what they eat, the times of day for their meals, and their style of dining. These changes in food consumption patterns greatly affect a resident's nutritional status.

A study by Clarke-Wakefield of 99 nursing home residents discovered that the more residents had changed their nutritional habits, the lower their nutritional scores and well-being. The underlying message to caregivers is to obtain residents' diet histories and preferences and use this information to create meals that they are accustomed to and will enjoy. Families can be a great resource for learning about residents who cannot communicate their food preferences.

Many of the changes associated with aging and illness have a significant impact on residents' nutritional well-being. According to the chapter of "Meeting Residents' Nutritional Needs" in Long Term Care Educator, these changes may include:

• Reduced salivary secretion leading to longer oral clearance time

• Decreased taste acuity, especially for salt and sweet flavors

• High prevalence of tooth loss: about one-half of the elderly are without their own teeth and one-fifth have serious gum disease

• Decreased sensitivity to thirst and hunger

• Slower travel of food down the esophagus

• Decreased gastric secretions leading to high risk for indigestion and impaired absorption of iron, protein, and vitamin B12

• Vision impairment that can interfere with eating

• Memory deficits that may cause residents to forget basic eating skills

• Depressive symptoms that lead to poor appetite

• Respiratory illnesses that can cause residents to become exhausted by the act of eating

• Arthritis, strokes, and other health problems that can interfere with functional independence

Because of these changes, it is imperative that nursing facilities regularly assess resident's nutritional well-being and develop individualized care plans to address issues of concern. All members of a facility's interdisciplinary team should be involved in devising creative ways to enhance resident nutrition, such as activity professionals offering healthy snacks during daily programs, therapists providing foods during their therapy sessions, or nurses providing high nutrition liquids during med passes.

Steps to Enhance Resident Nutrition

Promoting good nutrition for nursing home residents starts with an understanding of the types of foods they would like to eat. It is important to interview residents upon admission to ask about food preferences, eating and cooking habits, family traditions, religious customs or cultural food preferences. Every effort should be made to accommodate the residents' wishes. In addition, the dietary department should periodically survey the residents about their food choices and use the data in the development of future menus.

Forming a resident food council is an excellent way to formalize communication with the residents regarding dining services. The food service department head should chair the council and select a group of residents who are diverse in background and personality. Monthly meetings should not be complaint sessions, but constructive meetings to resolve issues of concern, try new food items, discuss new styles of service, and be the conduit for communication with other residents about their food needs.

It is important to plan menus so that food items are not repeated often. Many facilities rotate menus from three to five weeks so that residents do not become bored with their meals. A clever idea is to include food items based on the residents' own recipes. Menus could feature items such as "Jane Olsen's Famous Apple Pie" to spark resident interest and enhance nutrition.

Providers are realizing the value of liberalizing residents' diets. Diets that restrict sodium, fat, or sugar can sometimes diminish appetite and total calorie intake. Doctors are becoming more lenient in restricting what residents can eat, recognizing the importance of promoting food consumption and maximizing nutritional well-being.

Some Illinois Council facilities are trying new approaches to the ways that meals have been served in the past. Residents with dementia, who may find it difficult to utilize utensils correctly, are being served more finger foods such as chicken nuggets or sandwiches. For residents who are independent, a few facilities have incorporated "family-style" meals for special occasions, whereby foods are passed in serving bowls rather than on trays, with great success. In some individual resident cases, it may be helpful to serve several small meals instead of three large meals, due to an inability of these residents to eat a large quantity of food at one sitting.

Breakfast is a wonderful opportunity to increase resident caloric intake and enhance nutrition. Many residents of the World War II generation are used to eating a big breakfast of such items as bacon, eggs, and potatoes before heading to work or doing household chores. Some nursing homes are doubling portions during breakfast time to reflect this lifetime pattern and enhance nutrition. For people daunted by large servings, breakfast affords an opportunity to serve fortified cereals packed with calories.

Residents who are not yet independent with their dining skills, can be supervised by an occupational therapist during a special "restorative meal program." The therapist can utilize this time to reinforce self-feeding techniques, proper positioning and posture, and the use of adaptive equipment such as weighted utensils, non-slip materials to keep dishes on the table, and handles that help with diminished grips.

One of the biggest challenges that providers face is making sure that residents are eating all of their meals and have the assistance that they need during meal time. To meet residents' nutritional needs, facilities are taking an "all hands on deck" approach to dining. Staff members from several departments, family members and volunteers are helping bring residents to the dining rooms and are assisting with the passing and setting up of meal trays. In addition, those individuals who have been properly trained in feeding techniques are assisting residents with the consumption of their meals.

Environmental Considerations

Resident nutrition can be greatly enhanced by serving meals in an attractive, home-like environment. When improving the dining room setting, providers have a variety of options. Some facilities have gone so far as to decorate their dining rooms with carpeting, wallpaper, pictures, and chandeliers. But even a few special touches can make a world of difference. Possibilities include fresh flowers, soft music, nice dishes, linen tablecloths and napkins, place mats, and centerpieces. These simple changes can transform a dining room area into a comfortable and elegant setting.

Taste is an important element in the dining experience. As people get older, their sense of taste begins to decline. Therefore, it is vital to maximize food flavor. Using food items that are fresh and served close to their whole state helps to preserve their flavor. Adding seasonings and spices such as white pepper, lemon juice, bay leaves, cinnamon, orange, and tarragon can enhance many bland dishes. This technique is particularly helpful in improving the taste of foods for residents on low-salt diets.

The presentation of food also creates a big impact. Fine restaurants typically pay as much attention to the presentation of their food as the food itself. A plate serves as a picture frame for a meal. The plate should offer a tempting presentation of contrasting colors and textures, artfully presented. Foods that complement each other in terms of appearance, temperature, flavor, and odor should be included together.

Many Illinois Council facilities use garnishes to add a touch of class to a meal. Placing a sprig of parsley or slices of fruit on a plate makes the presentation of food seem much more professional. Adding sauce to a dish or sprinkling something like cheese over the top, makes dishes more appealing. Desserts such as cakes or tortes can be made special by placing them on plates with a sauce drizzled on them in a web-like design.

Dining as a Social Event

Since dining is a social experience, a resident's nutritional well-being is greatly enhanced by including several special events in activity and dining calendars. The holidays provide a wonderful time to create rewarding dining experiences, based on the residents' cultural and religious traditions. Ethnic meals are another way to add variety and interest. Including the residents' families in the event heightens excitement and promotes better consumption of all components of the meal.

Morning coffee clubs and afternoon socials give residents a chance to mingle with others and enjoy their favorite foods. Theme parties always are a big hit among residents. Illinois Council homes have designed theme parties to include special foods such as a pig roast at a Hawaiian luau or wiener schnitzel at an Octoberfest. During warmer months, residents may enjoy sitting outside for a picnic or barbecue. Regular trips to local restaurants are also helpful in making the dining experience more exciting.

Since dining is a social experience, a resident's nutritional well-being is greatly enhanced by including several special events in activity and dining calendars.

Creative activity programs offer many opportunities for nutrition enhancement. Cooking programs allow residents to enjoy a favorite pastime and bolster their nutritional well-being. Consider having a special program "for men only" which is based upon the foods they enjoy. This provides an opportunity to have them make a pizza or barbecue chicken and enjoy each others' company while eating their creations. Family members and staff can bring in their favorite dishes during a special "Taste" event. Have a chef from a well-known local restaurant come in for a cooking demonstration, with residents tasting the results. New food items from the local grocery store or bakery could be featured during an activity program. Children and residents could create recipes together during a meaningful intergenerational activity.

A gourmet dining experience can turn an evening meal into a very memorable affair. Some Illinois Council homes have sponsored gourmet meal programs with great success. Residents sit down to tables with fresh flowers, linen tablecloths and placemats, and wine glasses. Meals can feature such specialties as Chicken Kiev and London Broil. These programs create a fine dining experience that residents can share with family members and friends.

At the monthly meeting of the resident food council, the members can chose selections for a special "Residents' Choice Meal" that is prepared on a special day chosen by the residents. Members of this council are given the opportunity to develop the menu using their own ideas and input from their peers.

Each Sunday or Sabbath offers an opportunity to make mealtimes special. On this day, use linen tablecloths and napkins, special centerpieces, table-favors, and special china and place settings to create a "special occasion" atmosphere. A choice of special entrees, fancy vegetable combinations, double-baked potatoes, and elegant desserts brought out on a fancy "dessert cart" makes this dining experience very special!

Forming small group "dining clubs" offers an opportunity for residents to work with adaptive devices that facilitate independence when eating. These groups can be held in the rehab area and supervised by this staff. Care should be taken to enhance the dining experience by using tablecloths and napkins, and placing all food items on the table in front of each resident instead of utilizing the tray service. As part of the dining experience, the staff should encourage conversation and socialization as appropriate -- this is not appropriate when swallowing difficulties are present.

Adding "live music" during meals is a real plus. Invite staff, family members, volunteers, community members, etc. to come and play an instrument for the residents during mealtime. Sometimes this is done in conjunction with a specific theme, but soft music is appreciated anytime. The soothing sounds of a violin, subtle sounds of a clarinet, or familiar strains of a piano softly playing in the background can stimulate many wonderful mealtime memories for the residents.

Malnutrition is a serious problem that affects many long term care residents and can quickly lead to a host of dangerous health complications. Staff members from several departments should work together in utilizing their expertise and devising unique nutrition-enhancement strategies. By increasing staff members' awareness of the dangers of malnutrition and fostering their input in the development of innovative solutions, facilities can go a long way in improving residents' physical health and enhancing their overall quality of life.