Hydration - Sutton CCG€¦ · 5.0 Supporting nutrition and hydration in residents with dysphagia...

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Version 1.0 - 10 November 2017 (Review date 2019) Hydration and Nutrition Information and Guidance for Nursing and Residential Care Homes Incorporating National Evidence-Based Guidelines

Transcript of Hydration - Sutton CCG€¦ · 5.0 Supporting nutrition and hydration in residents with dysphagia...

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Version 1.0 - 10 November 2017 (Review date 2019)

Hydration

and

Nutrition

Information and Guidance for Nursing and Residential Care Homes

Incorporating National Evidence-Based Guidelines

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Introduction to using this resource folder

This folder contains comprehensive information about the assessment, monitoring and

maintenance of nutrition and hydration for care home residents. For many residents,

maintaining adequate levels of nutrition and hydration can be a challenge, however both are

essential for health and wellbeing. This folder contains information, advice and plenty of ‘top

tips’ to ensure your residents remain well-nourished and well hydrated. You may want to

print some of the appendices to make them easily available to all staff.

This resource folder has been developed by the Sutton Homes of Care Vanguard in

partnership with The Royal Marsden Hospital Community Services and Sutton Clinical

Commissioning Group. The contents of this folder represent best practice in this area of

care; however, the safe and effective management of residents’ needs remains the legal

responsibility of the care home.

Contents Page 1.0 Hydration

Why is it important to stay hydrated?

How much fluid is recommended?

How do I know if my residents drink enough?

What may happen if my resident doesn’t drink enough?

How do I help my residents to drink more?

What can I do if my resident is still not drinking enough?

3 3 3 4 5 5

2.0 Nutrition

Why is nutrition important?

What is a healthy balanced diet?

6 6

3.0 Malnutrition

What is malnutrition?

How do I know if my resident is malnourished (or at risk)?

Interpreting the MUST score- what to do next

How to write a care plan for nutrition

How do I help my residents to eat more?

What can I do if my resident is still not eating enough?

7 9 9 10 11 12

4.0 Supporting nutrition and hydration in residents with dementia 13 5.0 Supporting nutrition and hydration in residents with dysphagia 14 6.0 Supporting nutrition and hydration in residents approaching end of life 16 7.0 Oral and dental health 17 8.0 Residents transferring between care settings 18 9.0 How to utilise the NICE quality standards for nutrition 18 References 20 Acknowledgements 20

Appendices Page A Example food and drink record charts (5 pages) 21 B Reference card- Preventing and Managing UTIs 26 C MUST tool (6 pages) 27 D Basic food fortification 33 E Replacing oral nutritional supplements with nourishing drinks 35 F Using finger foods 38 G Using snacks 39 H Dysphagia diet food texture descriptors (6 pages) 40 I Audit tool using NICE quality standards 46

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1.0 Hydration

Why is it important to stay hydrated?

Water is necessary for life. As adults over half of our body is water!

Water has lots of different functions in the body. It is an essential component of blood and so

helps to transport nutrients around the body, it forms urine and so help to remove waste

products and it also acts as a lubricant and helps to absorb shocks in joints.

Older people can often be at risk of poor fluid intake and dehydration. This could be due to

limited mobility so they do not have access to drinks, or it could be due to cognitive decline

whereby they forget to drink. Thirst is an indication of dehydration, however older people

may also have reduced thirst sensation (feeling a need to drink) and it is important to

regularly remind, prompt and encourage residents’ to drink, providing assistance where

needed. Fluid intake does not necessarily mean just water and can also include hot drinks

such as tea and coffee, fruit juice or squash

If a person is unwell, has diarrhoea and/or vomiting, they will be losing fluid from the body

and therefore will need to drink more to replace what has been lost.

When the weather is hot (or the central heating is on high), the body sweats more and

similarly, fluid is lost from the body and needs to be replaced.

Dehydration can result in drowsiness and confusion, in addition to having an impact on risk

of falls, constipation and skin integrity so it is important to keep hydrated throughout the day.

How much fluid is recommended?

It is recommended for adults to have around 1.6l (for women) and around 2l (for men) daily.

This is equivalent to around 3-4 pints or 8 -10 cups or glasses. This does not have to be

pure water; tea, coffee, milk and fruit juices all count as well. Fluid is also available in foods

such as soup or ice cream and fruits like melon.

For some residents with specific health conditions such as kidney failure or heart failure,

their doctor may have recommended a fluid restriction. This will be the maximum amount of

fluid the person should consume in 24 hours. Any resident who is on a fluid restriction must

have their intake monitored using a fluid chart and the GP must be consulted if you have any

concerns regarding their hydration.

How do I know if my residents drink enough?

Monitor their fluid intake

It is important to monitor how much your residents’ are drinking and encourage them to

reach the targets above. For some residents, particularly those who cannot tell you how

much they have drunk, it may be an idea to complete a fluid chart to monitor their intake and

an example fluid chart can be found in Appendix A. It is important to know how much fluid

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the cup, glass or beaker contains so you can estimate the quantity taken more accurately.

Please be aware that for some residents such as those with urinary catheters or kidney

failure, it may be necessary to record how much urine they are passing (urine output). In this

situation you will need a different fluid chart that records how much the person is drinking, in

addition to how much urine they are passing.

Monitor the colour of urine

If your resident is well hydrated, urine should be a pale yellow colour. If it is dark yellow or

brown, the resident is not drinking enough. Use the colour chart below as a guide (see

Appendix B) and remember, “Healthy pee is 1-3, 4-8 you must hydrate!”

Observe for other signs

There are physical signs that indicate a person is dehydrated, these include wrinkled or

cracked lips, dry skin, dry mucous membranes like the tongue and lining of the mouth, new

or increased confusion, tiredness, loss of balance and falls. The person will also have low

blood pressure and a faster heart rate.

What may happen if my resident doesn’t drink enough?

Dry mouth is one of the first things to happen. This can cause mouth sores and infections

like thrush which may in turn negatively impact on eating and drinking, causing weight loss

and continued dehydration.

Tiredness and headaches are also common if not enough fluid is consumed. These

symptoms can be accompanied by confusion, dizziness and irritability which can in turn

cause imbalance leading to falls, slips and trips.

Constipation is often associated with a poor fluid intake and can also lead to confusion,

discomfort and rectal bleeding.

In the long term, poor fluid intake can cause kidney damage and repeated urinary infections,

which may also then lead to confusion and falls.

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How do I help my residents to drink more?

It is important to always have fresh water/drinks available at all times. A ‘hydration station’ is

an area where fresh drinks are easily available to residents, however some residents will still

need prompting or support to get drinks from the hydration station.

Many residents need reminding to drink, encouraging to finish their drinks or be supported to

drink. If the resident has any swallowing difficulties (see section 5, page 15), ensure you

follow the recommendations from the speech and language therapist, which might include

using a teaspoon or straw or adding a thickener to drinks.

Around 20% of our daily intake of fluid is contained within our food, so encourage your

residents to eat foods high in moisture such as fruits and vegetables which are up to 90%

water. When the weather is hot, ice lollies, jelly, ice cream and chilled fruit such as melon or

pineapple are good ways to increase fluid intake to replace what has been lost through

sweating.

For residents with dementia, either use a clear glass/cup so that they can see what’s inside or use a brightly coloured glass/cup to draw attention to the drink. Some residents will have a specific cup/glass they like to use. The person may need reminding what type of drink is in the glass/cup. Find out what your resident’s favourite drinks are as this will encourage the person to drink.

Residents who always have difficulty getting enough to drink should have a hydration care plan. Care plans should be written in discussion with the resident and their family and should be specific, measurable, achievable, realistic and time-framed (SMART). The care plan should outline the following:

How much fluid you are aiming for e.g. 8 glasses/cups per day

Frequency and quantity of drinks e.g. do they always drink a whole cup or only a half

a cup, are you aiming for 8 whole glasses or 16 half-glasses

How you will monitor what the person is drinking e.g. fluid chart or equivalent

If there are certain times of the day the resident likes to have a drink

What assistance they need to have a drink e.g. a straw, teaspoon, someone to lift the cup/glass

Preferences on how they take drinks e.g. use a specific cup/glass, what drinks they like, what drinks they don’t like

Any variation to normal drinking pattern e.g. does resident need a drink at different times to the norm

If there is any advice from the speech and language therapist (for those with difficulty swallowing)

What can I do if my resident is still not drinking enough?

If you have tried everything and you still don’t think your resident has been drinking enough, it is important to get advice, either from the care home liaison nurse, district nurse (for residential homes only) or GP. They will want to know how much the person is drinking and what strategies you have already tried so be sure to keep a fluid chart and include different fluids offered. See the example fluid chart in Appendix A.

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2.0 Nutrition

Why is nutrition important?

A healthy balanced diet is essential for everyone. A healthy diet should provide us with the

right amount of energy (calories) to maintain energy balance (where the calories taken in

from the diet are equal to the calories used by the body, therefore weight remains stable)

and the right nutrients to maintain health. Energy is important for all the functions of the

body, including walking and moving about, breathing, thinking, keeping warm and pumping

blood around the body. Vitamins, minerals and other nutrients have various functions to

keep both the mind and body healthy and functioning optimally.

As we get older, the sense of taste and smell can change which may affect appetite and

enjoyment of food. The body’s ability to absorb some nutrients also becomes less efficient

with age so it can be harder to get all the necessary nutrients for good health. Older people

tend to have lower energy requirements due to a decrease in basal metabolic rate (the rate

at which the body uses energy while at rest to maintain vital functions such as breathing and

keeping warm) and often decreased levels of physical activity. It is important for older people

to eat a varied diet to ensure an adequate supply of all the essential vitamins and minerals,

and enough food to cover their energy requirements. Dietary recommendations are the same

for older people as for the rest of the population and similar healthy eating guidelines apply.

A range of factors may influence the nutritional status of older people. This might include

general frailty, ill health and other medical conditions, poor appetite, altered vision, drug-

nutrient interactions, lack of mobility, less independence and dexterity, low mood and poor

oral health (see section 7). Due to these factors, older people, including those living in care

homes are at risk of malnutrition (see section 3).

What is a healthy balanced diet?

No matter what age we are the body needs a diet made up of lots of healthy and nutritious

foods in order to function correctly. The basic components of any diet should include a

combination of the following:

Protein from meat, fish, eggs and pulses.

Five portions of fruit and vegetables per day.

Carbohydrates from brown rice, potatoes, cereals, whole-wheat pasta and couscous.

What we need to avoid also remains the same as we age and it is advisable to limit the

amount of salt, alcohol and sugar we consume.

There are certain vitamins, minerals and food groups which become particularly important as

we get older. These are outlined in Table 1 overleaf.

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Table 1: Important nutrients for older people.

Nutrient Why is it important? What foods is it in?

Calcium Maintaining healthy bones and teeth

as we get older, calcium may begin to be reabsorbed back into the body from the bones (osteoporosis), leading to weak and brittle bones that are more likely to fracture

milk and dairy foods such as yogurt and cheese

leafy green vegetables

Calcium-fortified breakfast cereals.

Fibre Maintaining a healthy gut and digestive system

as we get older, less physically active and drink less fluid, constipation becomes an issue

plenty of fluids also help the gut to function properly

wholegrain cereal and bread

porridge

brown pasta and rice

fresh fruit and vegetables

Beans and pulses.

Vitamin D Helps the body to absorb calcium thus slowing the rate of calcium loss from bones

exposure to sunshine

oily fish e.g. sardines, salmon, tuna

egg yolk and liver

Vitamin D-fortified foods e.g. some breakfast cereals, milk and yoghurts.

Zinc Maintaining a healthy immune system meat and shellfish,

wholemeal bread and pulses

Iron Makes haemoglobin, which helps to store and carry oxygen in the red blood cells from the lungs to the rest of the body.

without iron, the body organs receive less oxygen than they should, leading to tiredness and lethargy

meat,

some vegetables

dried fruit

Vitamin C Helps the body to make collagen, which is needed to make skin, ligaments, blood vessels and tendons, heal wounds and repair bones and teeth

fresh fruit and vegetables

3.0 Malnutrition

What is malnutrition?

According to BAPEN (British Association for Parenteral and Enteral Nutrition);

“Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy,

protein, and other nutrients causes measurable adverse effects on tissue/body form (body

shape, size and composition) and function, and clinical outcome.”

According to NICE (The National Institute for Health and Care Excellence), a person is

malnourished if they have:

A body mass index (BMI) of less than 18.5 kg/m2,

Unintentional weight loss greater than 10% within the last 3-6 months, OR

A BMI of less than 20 kg/m2 AND unintentional weight loss greater than 5% within

the last 3-6 months

Malnutrition is extremely common in older people due to a number of factors discussed

above. It is estimated that about 35% of people living in care homes across the UK are

malnourished (BAPEN 2015), compared to about 10% of people over 65 living in the

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community who are malnourished or at risk. Malnutrition is both largely preventable and

treatable; it is not a natural consequence of older age and has a wide-ranging impact on

people’s health, wellbeing and quality of life. Sometimes malnutrition can develop as a

result of a medical condition, such as dysphagia (difficulty swallowing). See section 5 for

further information on supporting residents with dysphagia. The signs and causes of

malnutrition are outlined in Tables 2 and 3 below.

Malnutrition increases the risk of:

developing infections

ill-health and hospitalisation,

delayed recovery from illness

developing more health problems

Malnutrition has an impact on:

mood, anxiety and depression

reduced muscle strength and energy levels resulting in fatigue, lethargy and

increased risk of falls

impaired wound healing

constipation

risk of falls

further weight loss

quality of life

Table 2: Signs of malnutrition

D Decreased mobility Dry mouth

H Hair Loss Hollowed temples, cheek bones and clavicle

I Increased Infections and falls

E Emaciated (looking very thin and frail)

E Eyes (sunken) L Loose dentures, clothes and jewellery Low mood (depression, irritability etc.)

T Tiredness P Pale complexion,

Poorly (feeling poorly)

S Sores (and other skin conditions)

Table 3: Causes of Malnutrition W Wounds L Loss of memory, motivation or interest

Loss of ability (to self-feed or to choose foods)

E Emotional changes (low mood, depression, anxiety)

O Oral Factors (dentures, oral thrush, etc.)

I Illness (sickness, urine infections, chest

infections)

S Swallowing (texture modified diets, pain on

swallowing)

G Gastrointestinal problems (diarrhoea, constipation, nausea, vomiting)

S

Sensory (reduced taste, sight, smell or hearing)

H Habits (food preferences, meal timings)

T

Tablet and medication side effects

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How do I know if my resident is malnourished (or at risk)?

Every resident should have their risk of malnutrition assessed using the MUST tool

(malnutrition universal screening tool). This should be completed on admission to the care

home and then reassessed at least every month. If your resident has been in hospital (or

another care setting), it is good practice to reassess their risk of malnutrition (and other risk

assessments)on their return to the care home in case they have changed whilst in hospital.

The risk of malnutrition should also be reassessed when there is a clinical concern or

change in the person’s health, for example in the following situations:

unintentional weight loss, loose-fitting clothes or loose dentures

fragile skin

poor wound healing

apathy or more sleepy

altered bowel habit e.g. constipation or diarrhoea

muscle wasting (decrease in muscle mass)

change to appetite

change to ability to eat/drink, e.g. dysphagia, sore mouth, loss of independence

prolonged or recurrent illness or infection

To complete MUST you will need to weigh your resident and know how tall they are in order

to calculate their BMI. You will also need to know whether they have had any unintentional

weight loss in the last 3-6 months. The MUST tool and guidance for completion can be found

in Appendix C.

Unintentional weight loss is an indication of malnutrition risk and noticing changes to your

resident will help identify this. For example are their clothes becoming looser, do they seem

sleepier or have less energy, do they take longer to eat their meals, is their skin or lips dry

and chapped? Observing that something has changed provides a good opportunity to

reassess the resident’s level of risk.

Interpreting the MUST score- what to do next

The actions required will be different depending on whether your resident has scored 0 (low

risk), 1 (medium risk) or 2 (high risk). BAPEN have made recommendations for the

management of residents at low, medium and high risk of malnutrition and these are detailed

in Table 4 over the page.

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Table 4: BAPEN guidelines for the management of individuals identified at different levels of risk of malnutrition

LOW RISK, score = 0

Screen monthly

Encourage to maintain a healthy diet

If BMI is greater than 30kg/m2, provide healthier alternatives to promote weight loss

MEDIUM RISK, score = 1

Screen monthly

Monitor nutritional intake carefully and investigate reason for score

Plan care appropriately (see care plan section below)

Document intake for at least 3 days; be specific when notating food quantities eaten (see example food chart in Appendix A)

PROVIDE at least 2 nourishing drinks, snacks OR a fortified diet (fortify ONLY ONE dish per meal). The goal is to increase oral intake by 500 calories and 20g protein per day.

HIGH RISK, score = 2

Screen monthly – adjust care plan if ‘MUST’ score changes

Monitor nutritional intake carefully and investigate reason for score

Plan care appropriately (see care plan section below)

Document intake for at least 3 days; be specific when notating food quantities eaten (see example food chart in Appendix A)

PROVIDE at least 2 nourishing drinks, snacks AND a fortified diet (fortify ONLY ONE dish per meal). The goal is to increase oral intake by 500-1000 calories and 30g protein per day.

Residents whose weight remains stable or increases after one month of following a fortified

diet plan (as outlined on page 12) should be continued on the plan until the ‘MUST’ score is

lowered. Once ‘MUST’ score is back to 0, fortification can be lessened or removed. MUST

screening should continue to be conducted routinely for every resident, ideally on a monthly

basis.

Residents who continue to lose weight after one month on a fortified diet plan must be

referred to a dietician.

How to write a care plan for nutrition

Residents who are at medium or high risk of malnutrition need to have a care plan that

concisely outlines what specific support is required to enable that person to gain weight and

reduce their risk score. Care plans should be written in discussion with the resident and

their family and should be specific, measurable, achievable, realistic and time-framed

(SMART). The care plan should outline the following:

What food intake and frequency you are aiming for e.g. breakfast, lunch and dinner

and 2 snacks at 3.30pm and before bedtime

Any variation to normal food patterns e.g. does resident need meals at different times

to the norm

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How you will monitor what the person is eating e.g. food chart or equivalent

If they require any assistance to eat e.g. prompting, food cut-up, full feeding

Preferences on how they take meals and food e.g. use a fork or spoon, need

adapted cutlery, use a specific plate (see section on dementia below)

If they require feeding, how much time do they need, how will you know if they are

getting tired or full-up

Do they need a special diet e.g. gluten free, suitable for diabetics

Do they have any dietary allergies/intolerances e.g. nuts

What are their favourite foods or foods they particularly dislike

If there is any advice from the speech and language therapist (for those with difficulty

swallowing) e.g. pureed diet/thickened fluids (need to specify how many scoops of

thickener), feed only when alert and sitting upright

If there is any advice from the dietician e.g. use of nutritious shakes/snacks

If they are on prescribed supplements e.g. calogen, the details should be specific i.e.

the type, frequency, volume, the time to be administered and where to document

when it has been given

How you will monitor whether the care plan interventions are successful e.g. Monthly

weight and MUST reassessment

What to do if interventions are not having the impact expected i.e. when to refer to

dietician (if not already known)

How do I help my residents to eat more?

Care and interventions that improve or maintain nutritional intake are known as nutrition

support and there are several ways to provide this. For most people eating meals is a

pleasant and social event therefore it is important that residents are offered food that they

enjoy, food that looks tasty to eat (presentation) and in a pleasant environment conducive to

eating. Involving family and friends at mealtimes enhances the social aspect of eating and

for many residents, will improve the quantity of food they eat. Strategies to optimise nutrition

intake are based on the ‘Food First’ principles’ outlined below:

Increase … the Calories and Protein in food and drink

Increase … the Amount eaten

Increase …the Frequency of intake

Increasing the calories and protein in food and drink

It is quick and easy to increase the amount of protein and number of calories by using food

fortification. Food fortifying is when small quantities of regular foods, such as cream, milk

powder, butter or milk are added to a food dish to increase the energy and nutrient content

without increasing the portion size. This means that every mouthful your resident eats is full

of nourishment. Lots of ideas for how to add extra calories and protein can be found in

Appendix D and E.

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Increasing the amount eaten and frequency of intake

This can be achieved through the use of snacks and finger foods. Snacking between meals

is very helpful if your resident has a small appetite, is easily distracted during mealtimes or

gets tired trying to eat a whole meal. Snacking helps to increase the overall intake of food

and nutrients and providing several smaller meals is as good as providing 3 larger ones. Get

to know your residents favourite foods and if possible, provide what they enjoy the most. Try

to provide 2-3 snacks between meals in addition to the normal diet, encouraging small

amounts to be eaten regularly- for instance, breakfast, morning tea, lunch, afternoon tea,

dinner and supper. Although residents may enjoy a biscuit with their cup of tea, this is not

enough in terms of calories.

Finger foods include anything that can be eaten with your fingers. Like snacks, finger foods

may be particularly helpful for residents who have a small appetite, are easily distracted or

get tired quickly when eating. Some ideas for finger foods can be found in Appendix F and

ideas for snack foods can be found in Appendix G.

What can I do if my resident is still not eating enough?

If you have tried the ideas above and your resident is still losing weight, or you are still

concerned, it is important to get advice from the dietician. They will want to know what the

person is eating, how much they are eating and what strategies you have already tried. This

information should be documented for 3-4 days prior to the dietician visiting to enable

calculation of calorie and nutritional input and provision of specific advice. An example food

chart can be found in Appendix A.

The dietician will make recommendations based on the amount of calories and types of food

the person is eating, their preferences and choices and any health issues that they may

have. Sutton has adopted the Food First principles in all care homes and the dietician will

first recommend trying homemade nourishing drinks and/or puddings (see Appendix D and E

for recipe ideas). It is important to provide a homemade ‘supplement’ from real food first

before resorting to Oral Nutritional Supplements like Foodlink. Real food ‘supplements’ made

in the kitchen can provide the same number of calories, cost less and are fresh. If, after

trying the Food First approach it is determined that ONS are still needed, the dietician can

provide advice on the best option for your resident. They may make a recommendation to

the residents GP to start ONS for example, complan or fortisip to enhance the amount of

nutrition your resident consumes. Oral nutritional supplements generally should be stopped

when the resident is established on adequate oral intake from normal food.

As discussed in the section above on causes of malnutrition, if your resident develops a new

health related problem, for example, recurrent illness, a wound, difficulty eating/swallowing

or frequent gastrointestinal problems (such as vomiting or diarrhoea) it is important to obtain

advice from the dietician to support your resident to make a fast recovery to wellness.

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4.0 Supporting nutrition and hydration in residents with dementia

Dementia affects individuals in different ways but it will have an impact on your resident’s

ability to drink enough to remain hydrated and eat enough to maintain good nutrition.

Dementia can affect nutrition and hydration in the following ways:

The sense of being thirsty is reduced- prompting may be needed

The sense of taste alters, many people prefer sweeter options or those with a strong

flavour

Reduced appetite or interest in food

Not recognising different foods, or plates, cups, cutlery

Reduced concentration span and attention affects the ability to finish a whole meal

Disorientation to time may mean they don’t realise it is time for a meal

Some residents may be very fidgety or move around a lot- they may be using up

more calories that they are taking in

Swallowing difficulties resulting in eating/drinking less

Tips on how to help the resident with dementia get enough to eat and drink

(from the Alzheimer’s Society)

To encourage appetite:

Give the person foods that they like. Get to know their preferences and make a record of them.

Allow dessert even if the person has not eaten their savoury meal.

Food that has cooled will lose its appeal. Make sure food stays warm by using a plate warmer or a microwave to reheat food.

Try different types of foods/drinks if the regular meal does not seem to be what they want. Sometimes milkshakes and smoothies are very appealing!

Experiment with herbs and spices. Sometimes with dementia a person’s food tastes will change, so trying stronger or sweeter flavours may help.

Provide gentle reminders to eat, and of what the food is (they may not recognize it).

Try to provide a stress-free atmosphere that is friendly and relaxed. Sometimes soft music may help.

If the person refuses to eat, stay calm and try again a little later.

It is very important not to assume that the person doesn’t want to eat.

When there are problems with physical co-ordination:

If a person is having difficulty managing a fork and knife, cut up the food so that it’s small enough to eat with a spoon.

Try finger foods. These may be easier to manage when co-ordination becomes a problem.

Let the person eat where they are most comfortable.

Arrange for some non-spill cups or specially adapted forks, knives and spoons, if needed.

To encourage hydration:

Whenever the person is eating, have something to drink available as well.

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Use a clear glass so that what’s inside can be seen or use a brightly coloured cup to draw attention to the drink.

Remind the person what type of drink is in the cup.

Offer a variety of drinks – both hot and cold – throughout the day.

Don’t forget that foods that are high in fluid like gravy, jelly, ice cream, etc. can count toward a person’s overall fluid intake.

When eating habits have changed:

Always try to do what is in the person’s best interest. If a person is suddenly eating unusual food combinations, let them. Strange combinations of food are unlikely to cause harm and at least the person is eating!

Provide naturally sweet foods like fruit, carrots, sweet potato if a person in indicating they prefer sweet things.

Add small amounts of honey or sugar to savoury foods.

Serve sweet sauces or chutney with a meal to add sweetness and interesting flavour.

If you notice the person trying to eat an item that is not food (like a bar of soap or a tissue, for instance), try offering food instead. They may not recognize the item that they are trying to eat and they may be hungry!

Issues with Overeating:

Split the original portion in two and offer the second half later on if the person asks for more.

Make sure that most of the plate is comprised of salad and/or vegetables. Reduce the portion sizes of meats and starches.

Provide bite-sized healthy snacks like grapes, chopped apple slices, chopped banana slices, cherry tomatoes, etc. for snacking.

Try offering a milkshake or other tasty beverage instead of more food.

The eating environment:

Keep clutter off of the eating surface.

Keep noise to a minimum. A noisy room can be very distracting.

Sometimes calm music can help a person relax.

Ensure the room is well-lit as the person may not be able to see very well. Describe the food to them if necessary.

If possible use plates and tableware (like tablecloths or placemats) that are plain and that contrast with each other; for instance, a green tablecloth and a red plate. Avoid patterned plates.

If a mess is made, so what? Remember that the goal is for the person to eat rather than be neat.

Provide plenty of time for the person to eat their meal.

Consider having a ‘slow-eaters’ table for those who need a bit more time.

5.0 Supporting nutrition and hydration in residents with

dysphagia

Dysphagia is a swallowing difficulty which can affect the ability to swallow food, drink and

saliva. It is one of the more common medically-related causes of malnourishment: some

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48% of people with dysphagia are also malnourished. Signs of dysphagia are outlined in

Table 5 below.

When a person finds it difficult to swallow, they will naturally eat less. Mealtimes can become

a struggle, as eating can become both a slow and scary process. Residents with dysphagia

can have a higher risk of choking or aspirating (when food/fluid particles go into the lungs

rather than the stomach), which can lead to frequent chest infections and in some cases

pneumonia.

Residents with dysphagia would benefit from a review by a speech and language therapist

who will assess their swallowing and if needed, make recommendations regarding the types

and consistency of food/drink they should be eating/drinking in order to reduce their

swallowing difficulties.

Often the speech and language therapist will recommend thickened fluids if the resident is

having difficulty swallowing liquids. The thickened fluids may be recommended in different

consistencies – each consistency requires different amounts of thickener powder to be used.

It is important to follow the recommendations from the speech and language therapist, which

will also be on the back of the thickener powder tin in order for the drinks to be the

appropriate consistency for the resident. It is also important to note that when making drinks,

some thickener powder is added in before the fluid and some are added in after (please

follow instructions on the tin).

The speech and language therapist may also recommend a texture-modified diet, such as

fork-mashable or puree consistency. Unfortunately pureed food can be visually unappealing,

which can fail to trigger salivation, making swallowing even more difficult. For someone with

dysphagia, larger portions may appear more intimidating and may be unlikely to be finished.

If a resident is on a pureed diet, it may be more palatable to offer smaller, more manageable

portions of puréed meals. It is recommended to puree all foods individually and place on the

plate, rather than mixing all of the foods together and if possible, shape the foods to look like

a meal. A resident with dysphagia will need food/drinks that are not only the right texture, but

also visually appealing to help maintain interest in eating and drinking.

To reduce the risk of malnutrition in residents with dysphagia, food fortification can be used

(see Appendix D) and there are many snacks that are a soft or puree consistency (see

Appendix G).

Whenever dysphagia is identified, a detailed medication review needs to take place to determine how the resident’s medicines should now be administered in light of their swallowing difficulties. A pharmacist must be involved to ensure an appropriate formulation is prescribed and adequate directions are given (bearing in mind drug stability, compatibility with certain foods and drinks, palatability and licencing). This is also the case for residents who have been prescribed thickener and are taking medications in liquid forms, including those which are mixed with water prior to administration. Further information regarding the descriptions for fork-mashable and puree diets can be found in Appendix H. These will be very useful to help staff in the kitchen when preparing residents’ meals.

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Table 5: Signs that your resident may have dysphagia

Obvious indicators of dysphagia

Less obvious indicators of dysphagia

Difficult, painful chewing or swallowing Regurgitation of undigested food Difficulty controlling food or liquid in the mouth Change in drooling (increase) Gurgly/Wet voice quality Hoarse voice Coughing or choking before, during or after swallowing either foods, drinks or both Globus sensation (feeling of a lump in the throat) Nasal regurgitation (food coming out of the nose) Feeling of throat obstruction Unintentional weight loss

Xerostomia (dry mouth) Change in eating habits – for example, eating slowly or avoiding social occasions Frequent throat clearing Recurrent chest infections Atypical chest pain/ heartburn

Change in respiration pattern Unexplained temperature spikes Hoarse voice

Residents exhibiting any of the above signs may benefit from referral to a speech and language therapist for a full assessment.

6.0 Supporting nutrition and hydration in residents approaching

end of life (from the National Council for Palliative Care)

As residents approach the end of their life, the body starts to slowly shut down and there are

certain bodily changes that signify a person is likely to be close to death. It is normal for

these signs to come and go over a period of days.

The person’s appetite is likely to be reduced. They may no longer wish to eat or drink

anything. This could be because they find the effort of eating or drinking to be too much. But

it may also be because they have little or no need or desire for food or drink. Eventually, the

person will stop eating and drinking, and will not be able to swallow tablets. If they stop

drinking, their mouth may look dry, but this does not always mean they are dehydrated. It is

normal for all dying people eventually to stop eating and drinking

As a person is dying they may become much sleepier, spending more time asleep and can

be drowsy even when they are awake. If the person is conscious and they want something

to eat or drink, you can offer sips, provided they can still swallow. You can give some

comfort to a person with a dry mouth by:

offering a drink through a straw (or from a teaspoon or syringe)

placing ice chips in the mouth

applying lip balm

moistening the mouth with a damp sponge

o special kinds of sponge are available for this purpose,

o the person may bite on this at first, but keep holding it, as they will let go,

o sponges can be purchased (nursing homes) or ordered through community

nurses (residential homes)

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please note: syringes and oral sponges need to be used carefully as they can pose a

risk to the person, seek advice from the care home liaison nurse or community nurse

A resident approaching end of life should have an individualised plan of care. This should be

written in discussion with the resident and their family and address their care needs, choices

and wishes. This should include a discussion about eating and drinking. Key things to

remember are:

The dying person has a right to food and drink, if they would like this

They may decide not to have it, as they may not feel like eating or drinking, or

because they are struggling to swallow

If the person wishes and would benefit from other ways of receiving food and fluids,

this can be discussed with the GP or palliative care team. However, these are not

usually considered when a person is in the very final stages of life, as the body does

not require food or extra fluid at this time.

The supportive care home team can provide further advice and guidance around

individualised care planning and support with these discussions.

7.0 Oral and dental health

One of the key determinants of dietary variety in later life is good oral health. If dentures do

not fit very well or are uncomfortable, this will affect the residents’ desire and ability to eat.

Similarly, a sore mouth (for example: infection, ulcers, thrush, abscesses or decaying teeth)

will affect an individual’s desire and ability to eat. It is therefore important to ensure that

residents are supported to keep their mouths clean and healthy and that if problems are

suspected, a dentist or GP is contacted for advice.

The following guidance, published in ‘Delivering Better Oral Health’ (full reference below)1 is

recommended to maintain good oral health in adults:

Brush at least twice daily, with a fluoridated toothpaste

Brush last thing at night and at least on one other occasion

Use fluoridated toothpaste with at least 1350ppm fluoride

Spit out after brushing and do not rinse, to maintain fluoride concentration

The frequency and amount of sugary food and drinks should be reduced

This document also includes further guidance for individuals whose oral health is causing

concern and can be accessed online (see link at foot of page).

If a resident has Dementia, teeth brushing may be a challenge. They may not want to open

their mouth and they may resist their teeth being brushed. If the resident has dysphagia,

they may show signs of discomfort or coughing during brushing. In this situation, it may be

1

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/601833/delivering_better_oral_health_summary.pdf

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beneficial to gain advice from a speech and language therapist on the best way to provide

oral care to residents.

The most significant effect of nutrition on teeth is the development of dental caries (tooth

decay), which can be affected by the frequency and amount of sugar intake, especially in the

absence of good oral hygiene. Root caries, in particular, occur more frequently in older

people because they are more likely to have exposed tooth roots as a consequence of

periodontal disease and gum recession.

Older people may also suffer from dental caries and periodontal disease as a result of:

Long term conditions that can limit an older person’s ability to carry out their usual

daily activities, which may impact on their oral hygiene routine and diet

Taking medication; for example those that cause a dry mouth or contain sugar

Between-meal snacks

Choice of snacks is important as many snacks do not need to contain extra sugar, see

examples in Appendix G. If you are concerned, discuss your resident’s diet with their

dentist, or ask the care home dietician for further advice.

If you’d like to understand more about providing mouth care, an e-learning module is

available on the e-learning for health website:

https://www.e-lfh.org.uk/programmes/improving-mouth-care/

8.0 Residents transferring between care settings

For residents who have an identified difficulty with either eating or drinking, it is important

that this information is communicated if the resident has to go to another care setting e.g.

hospital, outpatient appointment, day centre, hospice or other. Staff in these settings will be

responsible for ensuring your resident eats and drinks whilst they are there however they will

not know the specific preferences and care requirements for your resident. In these

situations, it is important to send with them the MUST score, swallowing/dietary

recommendations and copies of their nutrition and hydration care plans. For residents who

have particular needs, for example using adapted cutlery, a specific cup/plate or needing

thickener in their drinks, these aids should be transferred with the resident. This will ensure

your resident can maintain their nutrition and hydration whilst they are out of your care.

9.0 How to utilise the NICE quality standards for Nutrition

The NICE quality standard for nutrition support covers adults in hospital and the community

who are at risk of malnutrition or who have become malnourished, and adults who are

receiving oral nutrition support, enteral or parenteral nutrition. It requires that all care

services take responsibility for the identification of people at risk of malnutrition and provide

nutrition support for everyone who needs it. The 5 quality standards are:

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1: People in care settings are screened for the risk of malnutrition using a validated

screening tool.

2: People who are malnourished or at risk of malnutrition have a management care plan that

aims to meet their nutritional requirements.

3: All people who are screened for the risk of malnutrition have their screening results and

nutrition support goals (if applicable) documented and communicated in writing within and

between settings.

4: People managing their own artificial nutrition support and/or their carers are trained to

manage their nutrition delivery system and monitor their wellbeing

5: People receiving nutrition support are offered a review of the indications, route, risks,

benefits and goals of nutrition support at planned intervals.

The quality standards can help you in the following ways:

measure the quality of care

demonstrate you provide quality care

identify gaps and areas for improvement

understand how to improve care

An audit tool has been developed to support you to assess the service you provide against

the quality standards (Appendix I). Further information about using NICE quality standards

can be found at https://www.nice.org.uk/standards-and-indicators/how-to-use-quality-

standards#initial.

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References:

British Association of Parenteral & Enteral Nutrition (online). 2011. The ‘MUST’ Explanatory Booklet. Available at: http://www.bapen.org.uk/screening-and-must/must

Malnutrition Task Force (online). Preventing Malnutrition in Later Life. Available at: www.malnutritiontaskforce.org.uk

National Association of care catering (online). 2011. Dysphagia Diet Food Texture Descriptors. Available at: http://www.thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20Industry%20Final%20-%20USE.pdf

National Institute for Health and Care Excellence (online). 2006. Clinical guideline 32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Available at: www.nice.org.uk/guidance/cg32

National Institute for Health and Care Excellence (online). 2012. Nutrition support in adults: Quality standard. Available at: https://www.nice.org.uk/guidance/qs24/resources/nutrition-support-in-adults-pdf

Public Health England (online). 2017. Delivering better oral health: an evidence-based toolkit for prevention: Summary guidance tables. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/601833/delivering_better_oral_health_summary.pdf

The Alzheimer’s Society (online). Eating and Drinking. Available at: https://www.alzheimers.org.uk/info/20029/daily_living/10/eating_and_drinking

The National Council for Palliative Care (online). 2015. What to expect when someone important to you is dying: A guide for carers, families and friends of dying people. Available at: http://www.ncpc.org.uk/sites/default/files/user/documents/What_to_Expect_FINAL_WEB.pdf

Acknowledgements:

This guidance document was supported by information provided by the community dietetics team at South Essex Partnership University NHS Foundation Trust and the care home dietician from Newcastle-Gateshead Care Home Vanguard.

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Appendix A: Example food and drink record charts

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Res ident's Name:

How to complete: Week beginning:

For each meal write down what was eaten and the quantity of the meal eaten (tick box)

Day Sunday Monday Tuesday

1/4 1/4 1/4

1/2 1/2 1/2

3/4 3/4 3/4

Al l Al l Al l

None None None

Snack

1/4 1/4 1/4

1/2 1/2 1/2

3/4 3/4 3/4

Al l Al l Al l

None None None

Snack

1/4 1/4 1/4

1/2 1/2 1/2

3/4 3/4 3/4

Al l Al l Al l

None None None

Breakfast

Lunch

Amount Eaten

(Tick Box)

Amount Eaten

(Tick Box)

Amount Eaten

(Tick Box)

Dinner

Supper / Snack

Food Chart

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Day Wednesday Thursday Friday Saturday

1/4 1/4 1/4 1/4

1/2 1/2 1/2 1/2

3/4 3/4 3/4 3/4

Al l Al l Al l Al l

None None None None

Snack

1/4 1/4 1/4 1/4

1/2 1/2 1/2 1/2

3/4 3/4 3/4 3/4

Al l Al l Al l Al l

None None None None

Snack

1/4 1/4 1/4 1/4

1/2 1/2 1/2 1/2

3/4 3/4 3/4 3/4

Al l Al l Al l Al l

None None None None

Amount

Eaten

(Tick Box)

Amount

Eaten

(Tick Box)

Breakfast

Lunch

Amount

Eaten

(Tick Box)

Amount

Eaten

(Tick Box)

Dinner

Supper /

Snack

Food Chart Res ident's Name:

Week beginning:

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Appendix B: UTI reference card

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Appendix C: BAPEN Malnutrition Universal Screening Tool (6

pages)

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Appendix D: Basic Food Fortification

Fortifying is when small quantities of regular foods, such as cream, milk powder, butter or

milk are added to a food dish to increase the energy and nutrient content without increasing

the portion size. This means that every mouthful your resident eats is full of nourishment.

Some examples of how easy it is to fortify a diet with common foods:

FOOD One Serving Calories Protein

Skimmed milk powder 1 tbsp. (9g) 30 3.3 g

Skimmed milk powder 1 tsp (3g) 10 1.1g

Butter/Margarine 1 tsp (5g) 35 0g

Full Cream Milk 8 tbsp. (120g) 72 4g

Double Cream 1 tbsp. (16g) 79 0.2g

Single Cream 1 tbsp. (16g) 30 1g

Cheddar Cheese 10g 42 2.5g

Jam, Honey 1 heaped tsp 50 0g

Sugar 1 tsp 20 0g

Fortified recipes:

Porridge with Whole Milk (150g) Add 2 tsp milk powder,1 tsp double cream, 1 tsp sugar and 2 chopped dates: 368kcal and 10.9g protein (before fortification: 170kcal and 7.2g protein)

White Sauce with Whole Milk (30g) Add 1 tsp double cream, 2 tsp milk powder and 10g cheddar cheese: 157kcal and 6.2g protein (before fortification: 45kcal and 1.3g protein)

Scrambled Egg with Whole Milk (120g) Add 1 tsp butter, 2 tsp milk powder and 45g cream cheese: 603kcal and 15.8g protein (before fortification: 308kcal and 13.1g protein)

Boiled Carrots (30g) Add 1 tsp of butter and 2 tsp of honey: 90kcal and 0.2g of protein (before fortification: 7kcal and 0.2g protein)

Custard with Whole Milk (150g) Add 2 tsp milk powder and 2 tsp double cream: 262kcal and 7.3g protein (before fortification): 142kcal and 4.7g protein)

Mashed Potato (60g) Add 1 tsp butter, 2 tsp milk powder and 1 tsp double cream: 170kcal and 3.5g protein (before fortification: 62kcal and 1.1g protein)

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How to make a large batch of Fortified Milk:

Add 4 tablespoons of dried skimmed milk powder to 1 pint of full fat milk and blend/mix until

smooth. Chill in the fridge and then use on cereals, in porridge, to make up sauces, soups,

desserts, jellies, or milky drinks, etc.

Difference in Nutrition with full fat milk vs fortified full fat milk:

Pint of Full Fat Milk Pint of full fat milk with skimmed milk powder

Calories = 380 Calories =565

Protein = 18g Protein = 40g

A glass of full fat milk has the same calories as eight cups of tea! When possible try to serve

nourishing drinks in place of tea or coffee.

Difference in Nutrition in Tea and Coffee using full fat milk vs fortified full fat milk:

Tea or Coffee with normal milk (no sugar) Tea or Coffee with fortified milk (and 2 sugars)

Calories = 15 Calories = 75

Protein = 1g Protein = 4g

More Tips for fortifying Foods:

Simply add dried skimmed milk powder directly to soups, puddings, custards, mashed

potatoes – use 2-3 teaspoons of powder per portion of food

Be sure you are using full fat and full sugar products rather than ‘diet’ ‘reduced/low fat’ or

‘low sugar’ varieties. Full fat/sugar options will provide more calories.

Adding knobs of butter, margarine, and oils like vegetable, rapeseed or olive oil will add

flavour and calories to foods such as vegetables, mashed potato, and jacket potatoes.

Adding grated cheese to soups, mashed potato, scrambled eggs, etc. will also provide extra

calories and flavour.

Use your imagination and knowledge of each resident’s likes and dislikes to add extra

calories and protein to dishes when fortification is needed!

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Appendix E: Replacing oral nutritional supplements with

nourishing drinks

Nourishing drinks can provide your resident with extra energy and calories as well as fluid to

keep them well hydrated. Keep in mind that many people fill up on drinks like tea, coffee,

Oxo, Bovril and water when they are feeling unwell. While there’s nothing wrong with these

drinks, and they do provide hydration, they actually offer little nutritional value. A more

nourishing option for residents who need it will provide far more energy and protein. In fact,

you may be able to replace a supplement with a nourishing drink. This will ensure that

your resident is still getting appropriate nourishment and hydration.

If your resident has been drinking Complan shakes (387 calories and 15.6g protein) or

Aymes shakes (388 calories and 15.8g protein), try:

If your resident has been drinking Fortisips (300 calories and 12g protein), try:

If your resident has been eating Forticreme desserts (200 calories and 11.9g protein), try:

Yogurt and Berry Smoothie

(384 calories and 22.5g protein)

1 small pot of Greek yoghurt

Handful frozen berries

1 small banana

150 mls full cream milk (blue top)

Combine and blend until smooth.

Malt Honey Milkshake

(291 calories and 8g protein)

200 mls full cream milk (blue top)

1 tablespoon honey

1 scoop ice cream

1 teaspoon (5g) malted milk powder (e.g. Horlicks)

Combine and blend for 15 seconds.

Chocolate/Strawberry Mousse (makes 4)

(Approx. 225 calories and 7g protein)

1 packet of instant mousse mix

¼ pint (145 mls) of whole milk

¼ pint (145 mls) evaporated milk

Mix all ingredients together. Pour into 4 bowls. Chill until set. Adding 1 tablespoon of double or whipped cream adds extra 120 calories.

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HOME-MADE NOURISHING DRINKS

The recipes below are quick and easy to make and provide ideas for maximizing fluid intake while also providing energy and protein.

Yoghurt and Berry Smoothie

Small pot of Greek Yogurt

Handful of frozen berries

1 small banana

150 mls full cream milk (blue top)

Blend until smooth Approx. 384 calories and 22.5g protein

Malt Honey Milkshake

200 mls full cream milk (blue top)

1 tablespoon honey

1 scoop ice cream

1 teaspoon (5g) malted milk powder (e.g. Horlicks)

Blend for 15 seconds Approx. 291 calories and 8g protein

Hot Chocolate

150 mls (1/4 pint) full cream milk

1 heaped tablespoon milk powder

2 tablespoons whipping or double cream

3 teaspoons of hot chocolate powder

Heat all ingredients together until simmering.

Approx. 450 calories and 5g protein

Milky Coffee

150 mls (1/4 pint) full cream milk

1 heaped tablespoon of milk powder

2 tablespoons of cream

1 teaspoon of coffee powder

Mix milk, cream, milk powder together. Heat until simmering. Add coffee powder and stir.

Approx. 350 calories and 4.5g protein

Banana Smoothie

200 mls full cream milk (blue top)

1 small ripe banana

1 scoop ice cream

1 teaspoon sugar

Mash banana, add all ingredients, blend and serve chilled.

Approx. 277 calories and 6g protein

Fruit Blast

100 mls fresh fruit juice

100 mls lemonade

1 scoop ice cream

1 tablespoon sugar

Mix together and serve chilled Approx. 216 calories and 0g protein

Orange Flavour Drink

150 mls of orange juice

1 banana

1 tablespoon of honey

4 teaspoons tinned peaches (in syrup)

Blend for 15 seconds. Approx. 300 calories and 2g protein.

Juice-style Nourishing Drink

180 mls fruit juice

1 sachet of egg white powder

40 ml cordial or squash

Mix cordial or squash into egg white (do not whisk!) then gradually add in fruit juice.

Approx. 256 calories and 9g protein

Pineapple Yoghurt Drink (makes 2 servings)

300 mls (1/2 pint) full cream milk

1 pot (50 g) thick/creamy fruit yoghurt

1 heaped tablespoon milk powder

1 tablespoon sugar

3 pineapple rings from tin

Blend for 15 seconds. Serve chilled. Approx. 345 calories and 15g protein per serving

Plain Old Milkshake

200 mls full cream milk

2 heaped tablespoons of milk powder

Milkshake syrup/powder to taste (e.g. Crusha or Nesquik)

Whisk milk and milk powder together. Add flavouring. Serve chilled.

Approx. 300 calories and 10g protein

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SUPERSHAKES

Super Shakes provide 500 calories or more in a single serving. They may be the boost your resident needs to gain weight. Always use super shakes or any nourishing drink recipe in addition to a balanced meal.

Berry Delight

2 x 50g pots of fromage frais yoghurt

100 ml cranberry juice

5 tablespoons double cream

1 tablespoon strawberry milkshake powder

Combine and serve. No blender needed.

Approx. 550 calories and 13g protein

Peanut Butter Shake (not for those with nut allergy!)

250 ml fortified milk

1 scoop ice cream

1 mashed banana

1 tablespoon peanut butter

1 teaspoon honey or sugar

Blend for 15 seconds Approx. 510 calories and 22g protein

Nice ‘n’ Nutty (not for those with nut allergy!)

200 mls whole milk

2 tablespoons double cream

2 tablespoons condensed milk

2 tablespoons hazelnut chocolate spread

1 tablespoon dried milk powder

Whisk together. Approx. 580 calories and 15g protein

Bourbon Cream Dream

4 bourbon cream biscuits, crushed into fine crumbs

200 mls whole milk

2 tablespoons condensed milk

1 tablespoon dried milk powder

Mix well.

Try replacing biscuits with custard creams or gingernuts for a change.

Approx. 560 kcals and 17g protein

DAIRY-FREE SUPER SHAKE

For your residents who dislike milk or have a dairy intolerance and also need extra calories to gain weight.

Virgin Pina Colada

100 ml tinned coconut milk

100 ml pineapple juice

2 ½ tablespoons apricot jam

2 ½ tablespoons icing sugar

1 tablespoon golden syrup

Combine and serve. Approx. 520 calories, 0g protein

Lemon and Lime Sublime

100 ml lemonade

100 ml lime cordial

2 ½ tablespoons lemon curd

2 ½ tablespoons icing sugar

1 tablespoon golden syrup

Whisk together and pour through strainer to serve.

Approx. 500 calories and 0g protein

Eton Mess

2 meringue nests (approx. 30 g)

150 ml soya milk

2 ½ tablespoons strawberry milkshake powder

2 ½ tablespoons strawberry jam

1 ½ tablespoons icing sugar

Blend for 15 seconds. Approx. 520 calories, 6.5g protein

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Appendix F: Using finger foods

Finger foods are a great way to promote eating when your resident simply cannot stay at the

table or when a change from the ‘norm’ is needed. Everyone can enjoy them and your

resident’s independence is increased. Remember to consider what consistency diet your

resident is on before offering these as some of the foods below will not be suitable for those

with dysphagia.

Tips for Success with Finger Foods

When preparing finger foods, think about convenience, size and shape. It’s important

that foods are not too big or too small.

Ensure that foods are easy for your residents to handle.

Temperature – ensure cooked food has cooled enough to hold comfortably in the

hand and to eat.

Leaving the skin on fruit will make it easier to hold and less slippery.

Be sure to peel hardboiled eggs before serving them as a finger food!

If offering sandwiches, ensure that the filling is moist so that the sandwich stays

together.

The following make great finger foods;

Apple Slices Banana Biscuits Cakes Carrot Sticks Celery Sticks Cereal Bars Cheese Cubes Cherry Tomatoes Chicken Drumsticks Chips

Crumpets Cucumber Fish Fingers Grapes Hardboiled Eggs Meatballs Pizza Slices Sandwiches Sausages Small Potatoes Toast

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Appendix G: Using snacks

Snacking between meals is very helpful if your resident has a small appetite, is easily

distracted during mealtimes or gets tired trying to eat a whole meal. Snacking helps to

increase the overall intake of food and nutrients and providing several smaller meals is as

good as providing 3 larger ones.

Tips for success with Snacks

Get to know your residents favourite foods and if possible, provide what they enjoy

the most.

Try to provide 2-3 snacks between meals in addition to the normal diet

Encourage small amounts to be eaten regularly- for instance, breakfast, morning tea,

lunch, afternoon tea, dinner and supper

Use snacks like those listed below, a biscuit with a cup of tea does not provide

enough calories or nutrition!

The following make great snacks;

Cheese and crackers

Dried fruit and nuts

Muesli bar or flapjack

Small packet of crisps

Sandwich with meat/cheese

Piece of fruit

Chocolate biscuits

Crackers and dip

Crumpets with spread

Cheese on toast

Scone with clotted cream and jam

Baked beans on toast

Scrambled eggs

Tinned fruit and ice cream

White crustless sandwich with creamy filling, like egg or tuna mayo/cream cheese/jam/smooth peanut butter

Very soft pastry/pie (not crumbly) softened with custard/cream

Soft moist cake/muffin

Yoghurt

Custard

Chocolate or fruit mousse

Milky Pudding

Mashed Banana and Custard

Creamed Rice

Jelly and ice cream

Fromage frais

Crème Caramel

Self-saucing pudding

Porridge/soggy cereal with milk/double cream

Soup with Milk/Double Cream

Glass of Full Fat Milk (blue top)

Glass of fortified milk

Glass of fruit juice

Fruit smoothie

Milkshake

Soft drinks or cordials

Nourishing drinks (see Appendix E).

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Appendix H: Food texture descriptors for dysphagia diets.

From the National association of care catering, full guidance available from:

http://www.thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20Ind

ustry%20Final%20-%20USE.pdf

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Appendix I: Audit tool using NICE Quality Standards

Guidance: To complete this audit, you will need to review resident assessments and care plans and observe practice at meal and snack times.

NB: Quality standard 4 is not included as it is not very relevant to care home settings

QS 1: People in care settings are screened for the risk of malnutrition using a validated screening tool. Screening is carried out by health and social care professionals who have undertaken training to use a validated screening tool Staff have access to calibrated equipment to enable accurate screening (e.g. weighing scales suitable for all residents)

Q1. Number of residents who have been screened using MUST in the last month X 100 = % of residents who have been screened.

Total number of residents Q2. How confident are you that ALL of your staff who complete a MUST assessment have been trained to use it? Not at all confident 1 2 3 4 5 6 7 Very confident Q3.

Do you have equipment for weighing residents who are: Mobile/ able to stand Less mobile/ sitting Immobile/ hoist

Yes/ No Yes/ No Yes/ No

When was the weighing equipment last calibrated for accuracy?

QS 2: People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their complete nutritional requirements. Care settings are able to provide appropriate nutrition support including artificial feeding when needed. NB: Artificial feeding is not included in this audit tool

Q4. Number of residents at risk of malnutrition (MUST score 1 or 2) and have a comprehensive nutrition management care plan X 100 = % of residents with

Total number of residents who are at risk of malnutrition a nutrition care plan Q5. How confident are you that ALL of your residents who require support to eat receive the required level of support at every meal? Suggestion: Observe a number of residents who require support at mealtimes Not at all confident 1 2 3 4 5 6 7 Very confident Q6. How confident are you that ALL of your residents who have additional food requirements (e.g. snacks, fortified food, nourishing drinks, supplements etc.) receive these?

Person completing:

Date of completion:

Nutritional screening tool used if not MUST:

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Suggestion: Observe a number of residents who require additional food items, review snack provision- does it include a range of energy-dense snacks (e.g. cake, full fat yoghurt, chocolate, nuts, fruit and cream)? Not at all confident 1 2 3 4 5 6 7 Very confident

QS 3: All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable), documented and communicated in writing within and between settings.

Residents screened for the risk of malnutrition have their results and nutritional support goals (if applicable) documented in their care plan. Residents screened for the risk of malnutrition have their results and nutritional support goals (if applicable) communicated in writing within and between settings.

Q7. Number of residents with an up to date MUST score documented on the older persons assessment form (or equivalent) X 100 = % of residents with a

Total number of residents with an up to date MUST score documented result Q8. Consider the last few residents who were admitted to hospital, how confident are you that their comprehensive nutrition management care plan went with them to hospital? Not at all confident 1 2 3 4 5 6 7 Very confident

QS 5: People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals. Residents receiving nutrition support who have the indications, route, risks, benefits and goals of their nutrition support reviewed at planned intervals.

Q9. Number of residents with a comprehensive nutrition management care plan that has been reviewed and updated in the last month X 100 = % of residents with

Total number of residents with a comprehensive nutrition management care plan a planned review Q.10. Consider the residents who are under the care of a dietician, how confident are you there is a documented planned review date? Not at all confident 1 2 3 4 5 6 7 Very confident

Tips for observing practice: When observing what happens in your care home around nutrition support and at mealtimes, consider the following best practice recommendations:

People should be encouraged to consume some form of nourishment ‘little and often’, e.g. every 2-3 hours throughout the day o What is the meal/snack pattern and frequency?

Providing energy-dense and nutrient-dense foods, snacks and drinks is an important strategy to increase calories/protein, without increasing volume and impacting on appetite

o are snacks energy-dense, are nourishing drinks provided at least once per day, is food fortification being used, if so what and how? o If a resident refuses a meal, are they offered a suitable alternative e.g. nourishing drink?