Good nutrition is an essential ingredient for wound healing and prevention.

Did you know that pressure injury prevalence has been reported to be 16-23% in combined hospital and residential aged care populations? (1,2)

Chronic leg ulcers affect 1-3% of people aged over 60years, with incidence increasing up to 5-10% in the 80+ age group. (3,4).

The term “wounds” refers to pressure ulcers, wounds post-surgery or trauma, and wounds or ulcers as a result of Diabetes.

The presence of wounds can result in a reduced quality of life for many reasons including:

Research consistently reveals that poor nutrition, weight loss, low body weight, under-nutrition and malnutrition are associated with an increased risk for pressure injuries, and that inadequate nutrition and low body weight are associated with wounds that are slow to heal or non - healing.

Good Nutrition is Essential for Wound Healing and Maintenance of Skin Integrity

Eating a variety of foods from each of the food groups and consuming a well-balanced diet will ensure you are getting all of the nutrients your body needs for good health and quality of life.

Individuals with wounds have increased needs for a number of nutrients, as listed below, and these should be included daily. Your Dietitian can tailor your dietary intake and choices to meet your increased nutrient needs.

Nutritional Support & Recommendations

The National Aged Care Mandatory Quality Indicator Program makes it compulsory to report about the presence of pressure injuries over a 3-month period for all residents in aged care homes.

All elderly clients, residents should be screened to identify those at nutritional risk.

Screening and treatment with adequate nutrition is essential for the prevention and healing of pressure injuries, wounds.

Those identified as being at risk of malnutrition should cease dietary restrictions, and commence on a High Protein/high energy diet, including fortified foods and HPHE milkshakes.

A referral to a Dietitian should be included as part of treatment.

References:

  1. Martineau J, Bauer JD, Isenring E& Cohen S (2005). Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients. Clinical Nutrition; 24(6): 1073-1077.
  2. Middleton MH, Nazarenko G, Nivison-Smith I, SmerdleyP (2001). Prevalence of malnutrition and 12 - month incidence of mortality in two Sydney teaching hospitals. Internal Medicine Journal; 31:455-461.
  3. Neumann SA, Miller MD, Daniels L & Crotte M (2005). Nutritional status and clinical outcomes of older patients in rehabilitation. Journal of Human Nutrition and Dietetics; 18: 129-136.
  4. Patterson A, Young A, Powers J, Brown W &Byles J (2002). Relationships between nutrition screening checklists and the health and well-being of older Australian women. Public Health Nutrition; 5:65.

Helping someone to eat can significantly improve the experience of mealtimes for everyone involved.

Remember helping someone doesn’t necessarily mean physically assisting someone to eat. Wherever possible, everyone is encouraged to eat independently if they can.

Here are some tips to empower you in helping beyond ‘feeding’ someone. Be mindful, each person will benefit from different combinations of the below and the same person may require different strategies on different days.

Eats too fast

Slow eating and prolonged mealtimes

Eats other people’s food

Interrupts food service or wants to help

Give the person a role in the meal service- such as setting the table, pouring water or helping others to the table

Plays with food

Distracted from eating

Stares at food without eating

Shows impatient behaviour during or before a meal

Have you ever seen the same recommendations provided after each Speech Pathology swallowing assessment and wondered ‘why?’

1: Here we breakdown the common Safe Swallowing or Aspiration Reduction Strategies:

Alert and upright at 90degrees for whole duration of meal and at least 20 mins after intake.

2: Regular mouthcare at least twice daily and check mouth is clear after meals

Mouthcare is the cornerstone of reducing aspiration pneumonia. Research has shown that it is typically food debris, liquid and saliva in combination with BACTERIA in the mouth due to poor oral hygiene that can be aspirated and leads to chest infections.

3: Minimise distractions and background noise during meals (e.g. turn TV/radio off, minimise conversations/talking with person during eating/drinking)

We all know that multitasking has its pros and cons, but for people with dysphagia, multitasking during mealtimes can be a recipe for disaster! When someone’s attention is divided between two or more activities whilst eating and drinking, it means they have less awareness on the swallowing mechanism. By removing distractions and supporting the person to focus on each bite you can help optimise their swallowing ability.

4: If signs of aspiration (throat clearing, coughing, wet voice, reduced chest status, increased temperature), or increased difficulty in swallowing, document and inform SP.

Prompt referrals at the first sign of increased difficulty or changes in swallowing is essential for dysphagia management. If left untreated and unmanaged the complications of swallowing difficulties can be distressing and life-threatening. Beyond choking and chest infections, dysphagia can result in malnutrition, dehydration, increased anxiety, reduced social engagement, among other factors.

If you’re not sure if someone would benefit from Speech Pathology input, we strongly encourage liaising with your clinical lead/manager or speaking with us. We are here to help and we’re on your team.

For individuals with dementia, it is very important to maintain good nutrition in order to prevent deconditioning and malnutrition. It is common for people with dementia to find eating meals a challenge as dementia progresses, and this can contribute to weight loss.

Individuals with dementia may experience:

Good nutrition

For those over the age of 65yo, having a varied and well-balanced diet including, daily:

As dementia progresses and various changes and challenges present themselves, it is common for weight loss to occur. For people who experience an increase in physical activity such as wandering or pacing, or those with various medical conditions or other energy expending conditions such as wounds, higher protein and calorie intakes are needed to prevent weight loss.

To minimise the stress associated with meal times and to assist with improving nutrition, the following suggestions may be of benefit:

Poor appetite

Loss of appetite can occur due to any of the following: difficulties with chewing and swallowing, poor dentition (including poorly fitting dentures), changes in tastes and smell, reduced physical activity, stress associated with reduced function, depression, impact of medication, and bowel issues such as constipation.

To improve intake, try these suggestions:

Chewing and swallowing difficulties

Dry mouth and taste/ smell changes

The thirst response reduces as you age, meaning you can be dehydrated before you even notice you are thirsty. This can affect how much you eat.

Meal time challenges

It is common for meal times to become a challenge. Sitting at the table, using cutlery, remembering how to eat, can become difficult over time.

Tips for improving meal times:

The dining environment

Making small changes to the meal environment may help to keep the person with dementia engaged in the meal time experience, maintaining their independence and dignity.

Dementia is unpredictable, with some goods days and some bad. Maximising eating opportunities on the good days can help to balance intake over the longer term. If after trying the above suggestions, a resident’s intake and weight loss are still a concern, seek assistance.

Your Dietitian can provide additional nutrition and meal options.

Here are some simple and effective strategies to support communicating with people who have dementia. It’s as easy as remembering the word FOCUSED.

Face the person - maintain eye contact and say their name before talking.

Orient to topic - use repetition, use names, remind the person of the topic

Continue the topic - stay on the same topic of conversation for as long as possible, restate the topic, signal when you’ll change the topic (e.g., ‘Now we are talking about…’).

Unstick communication blocks - help the person overcome communication breakdowns and keep conversation flowing. Rather than ‘testing’ or correcting the person, provide help by clarifying e.g., Julie says to you ‘My mother came to visit’ you say ‘Oh do you mean your wife?’

Structure questions - use closed-choice questions (e.g., tea or coffee?), ask yes/no questions

Exchange conversation - encourage interaction- maintain conversation, be an active listener (e.g., ‘oh’, ‘uh-huh’, use simple comments), provide clues about how the person could respond (e.g. ‘how are you?’ ‘are you well?’)

Direct statements - provide short, simple and direct sentences, use specific names e.g. ‘Bob’ instead of ‘he’), use gesture and pointing to help the person understand.

Most to least effective strategies:

Research has shown that not all strategies are equal in usefulness. In fact, one strategy has shown to have a NEGATIVE impact on communication and therefore should NOT be used. Here we rank, as per research, most to least effective:

MOST EFFECTIVE:

Eliminating distractions (e.g., turn off TV and radio, have conversations in areas with limited background movement/actions (have conversations in quiet room rather than in busy, open space close to nursing station).
Provide simple sentences
Use yes/no questions

LEAST EFFECTIVE (AVOID):

Speaking more slowly. Research has shown this can have a negative impact on the interaction between the caregiver and person with Dementia. It is believed that due to speaking slower and making the length of the sentence longer, it requires greater working memory therefore more complex and challenging.

This is based on the caregiver training program FOCUSED which was created by Ripich, Wykle and Niles (1995). Aimed for nursing assistants working closely with patients with dementia.

Have you ever been cooking at home and the delicious smell of the food makes your mouth water with anticipation?

Have you ever been out at a restaurant, seen your delectable meal arrive and just the look of it makes your stomach grumble louder?

This is our digestive system and more importantly our swallowing mechanism working even before the food reaches our mouth.

We know that swallowing is a complex and intricate process but sometimes we forget the importance of seeing and smelling food has on our swallowing.

Dysphagia Research

Research has shown that the sensory input (seeing, smelling, and at times touching our foods or drinks) is critical for ‘priming’ and getting the swallowing structures ready.

Sensory input allows healthy saliva production which is critical to chew and breakdown our foods. It’s also critical during the eating and drinking process: we need intact sensory feedback whilst swallowing so our brain knows when the mouth is ready for the next mouthful and even to sense if there is any leftover food in the mouth that needs to be cleared.

So why is this so important to know and how can we use this wealth of knowledge in the real world?

Imagine for a moment, that you could no longer feed yourself and had to be dependent on someone else. Imagine if you were lying in bed, sleeping and suddenly someone turns on the lights, puts you upright and suddenly you have something in your mouth.

You can’t see or smell the food and you have no awareness that it’s even a mealtime.

Imagine how you would respond in this situation- you may spit out the food or not chew it at all.

This isn’t behavioural, rather it’s our bodies way of protecting itself.

We can help the consumers in our care, especially those with dysphagia or dementia have a more enriched and positive mealtime experience, simply by taking a few extra moments to set them up for success.

Practical steps to improve the sensory input and improve the mealtime experience:

Palliative care is an approach that improves the quality of life of individuals and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (WHO definition of palliative care).

Nutrition and hydration are important throughout all of the above life stages, including end of life. It can be a confusing and a difficult time for all.

There is often conflict about nutrition in the palliative phase. On the one hand, the family, friends, carers focus on the provision of food and fluids as an act of love. Providing food is one thing that they can do when all other aspects of their loved one’s care is out of their control. At the same time, the individual feels tension because they are grateful for the food offered, but are unable to eat and drink as they have in the past, and this can result in guilt because they can feel how stressed their family and friends are about their poor intake.

At this time there are often a number of problems that may be contributing to poor oral intake, including:

It is important to reach a stage where both parties are aware of the issues involved, and can come to a compromise about how nutrition and hydration will be managed, so that everyone can enjoy quality time together. Importantly, nutrition and palliative care must be a team approach which includes the individual, family, friends, carers, nurses, GP’s, members of the allied health team, such as Dietitian’s, Speech Pathologists, and the food services team.

Where palliative and terminal care are concerned, nutrition and hydration is less about the 5 core food groups and nutritional balance and adequacy, and more about the provision of food and fluids that are in keeping with the individual and family/ carer preferences, to achieve comfort and the best quality of life that is possible.

It is important that the focus of food be upon offering foods that the individual enjoys, in quantities that they are able to manage. Some of the following tips may be helpful

Most of all, respect the individual’s right to choose how they will eat and drink.

While it is preferable to try food first, nutritional supplements can provide nutritional assistance where required.

It’s a privilege to share in someone’s final journey – embrace your part in it.

Good bowel health is important for people of all ages. Emptying your bowels regularly and with ease is an important part of good bowel health. Some people may experience bowel problems as they get older and it is common for constipation to affect two out of three residents in Aged Care homes. Constipation is usually characterised by hard, dry stools that are painful to pass. A person may also feel bloated and experience abdominal cramps. Constipation can result in a decrease in appetite and intake which can then lead to malnutrition.

There are many reasons that a person may experience constipation such as:


To help prevent constipation, the following key factors should be considered:

1: Increase Fibre in the diet

Residents in Aged Care homes often have a diet low in fibre. This may be related to any one of the following: –


It is important to aim for 25-30g fibre per day from foods such as weetbix, All bran, wholemeal/grain bread and crackers, baked beans, prunes, barley soup, fruit, vegetables, nuts, seeds, legumes

2: Increase Fluids in the diet

On average, 6-8 glasses of fluids (preferably water) per day is required to assist with the prevention of constipation and also dehydration. As we age, the sensation of thirst can be reduced, and so the elderly can show signs of dehydration before they even feel thirsty. To increase fluids for those residents who struggle to consume 6-8 glasses of fluids per day, the following suggestions may assist:

3: Include daily exercise as tolerated

As the saying goes “any amount of exercise is better than none”. The abdominal muscles support gut motility and any form of exercise will assist with this.

Exercise will also help to stimulate hunger and increase appetite.

IN SUMMARY
It is important for staff to have a good knowledge of high fibre foods and to encourage residents to select them when choosing meals from the menu to ensure the recommended 25-30 grams of fibre is consumed daily.

Staff should encourage fluids at every opportunity and also take into consideration that some medications can cause constipation – hence the need to be extra vigilant with offering fluids.
Encourage regular exercise as tolerated and approved by the GP.

Dietitians Australia

Don’t let your residents or budget experience the side effects of malnutrition or dysphagia.
Call us on 1300 850 246 or email and request a call back.

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