Domain 6 – Nutrition
This is all about food and drink. If someone doesn’t eat for a couple of days, then although this isn’t good for them, unless they have other underlying health issues, they can usually survive the fast. Fluids are different and if someone didn’t drink for a few days, this would have much more dramatic consequences. Particularly in light of the fact that, in general care homes are quite warm, so dehydration would set in without too much difficulty.
As far as nutrition goes though, it is also about the quality of nutrition, where it is possible to have a preference. A balanced diet including 5 fruit and veg a day is good for everyone, no matter who you are, what your health is like or where you live. So a diet of junk food, is not as good as a balanced diet, but may be preferable to no diet at all for someone underweight.
As a huge over generalisation, people with dementia (if they live long enough with it), will forget everything, including how to eat and will become very thin. I have had lots of clients who have had dementia and died skeletal. The loss of memory around food doesn’t go immediately, but happens over a period of time, so it starts with people needing more encouraging with their food. They may have other issues, including mobility issues, which impact on their ability to use cutlery successfully and to feed themselves.
The low levels of need on the Decision Support Tool are about them needing reminding to eat and drink or having a degree of support by way of a slightly enhanced diet or partial feeding. Often the very elderly just get tired and can eat the first bit of their meal, but need the last bit to be fed to them.
As dementia or Parkinson’s progresses the ability to swallow often becomes impaired. There are a number of other conditions which may lead to an impaired swallow, but these are common ones. So as the swallow becomes impaired, someone may need a softer diet, which could be mousse textured or it could be even more fluid than that. If feeding takes a long time, which often happens as dementia progresses, then this would score moderate.
If someone is PEG fed (a tube directly into the stomach), often this resolves issues of being underweight. The food that is given in a PEG is specially designed to be nutritionally balanced and because it is given without the need to go through the mouth, it doesn’t matter what it tastes like. It is also given in sufficient quantities to maintain weight. So assuming that there is no problem with the PEG tube, this can make things much easier and would be considered moderate needs.
Problems with PEGs can arise, they can be pulled out by accident and they can leak on occasions. I’ve never had a case of subcutaneous fluids, but I’m sure they happen. There are not many elderly with an eating disorder, but again, I’m sure they happen.
The three most common issues I come across in the category of high needs is being underweight, unintended weight loss or a risk of choking.
If someone has lost lots of weight, which is usually considered to be more than 5% over a 3-6 month period and more than 10% over the same period would be of real concern. Using the MUST tool, which is the most common tool used, anyone with a BMI under 19 is considered underweight, which is far slimmer than the average size in the UK. There are charts that can calculate BMI, but it is weight in relation to height. Underweight (BMI 19 or below) would be considered “nutritionally at risk”. This status of nutritionally at risk has an impact on other domains, as without the necessary calories going into a person, it will impact on their skin for example, so they will be more at risk of pressure damage and if they have issues with their skin will have difficulty healing it, due to lack of calories to do so.
If someone can’t swallow properly and are at risk of choking, if food goes into the lung, it can cause pneumonia or the person can’t breathe properly, both are very risky. This can often go with a skilled feeding regime. They can have their fluids thickened, which whilst I’ve never drunk one, it sounds unpleasant. People at risk of choking often need to be sat upright to be fed, they take small spoonfuls and then need to be kept upright for half an hour or so to allow the food to digest properly.
I’ve never had a client come close to scoring severe in the nutrition domain, as they are likely to be in hospital or have specialist input and probably Continuing Care funding would already be in place. I’ll let you know if I ever meet one.
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