Food Scientist and nutritionist Joanne Holmes’ interest in nutrition and later life led to her doctoral research exploring the myriad factors that affect the complete meal experience for those living in care. We talked to her about the importance of socialisation, stimulation and choice to encourage healthy appetite in older people.
Your research focuses on the meal experience for older people in social care. Why is this so important?
As a nutritionist, I became aware of the fact that there was growing evidence that under-nutrition, commonly known as malnutrition, is a prevalent problem for older people. The figures show that up to about 45 percent of older people living in residential care are at risk of under-nutrition, and for those over 75 years old living on their own, it runs between 35-40 percent.
It was apparent that we were good at monitoring and assessing the fact that people were undernourished – what wasn’t so clear was what was happening to follow that up and move people from being undernourished to an acceptable weight.
I wanted to understand what and how much people were eating and drinking and whether or not it was the mealtime experience that affected that.
There are usually a series of events that are linked to undernourishment when someone goes into care. What generally happens is that someone will struggle at home, for one reason or another – perhaps there might be a dementia diagnosis, and they can’t continue to live on their own, or they fall and aren’t able to get around. They eventually end up in hospital, and then in long-term residential care. But once they’re in care, it’s tough to try and get them eating again.
I come from a food science background, and I think a lot of the work to-date has been done by looking at undernourishment from a clinical point of view. I wanted to come at it from a food angle and look at enhancing the eating experience for those in care.
What have your findings been around the needs of the mealtime experience for older people?
It’s complex. Firstly, in places such as residential homes, there are technical influences: these are things like what food and drink is on the menu, the sensory appeal and the number of choices that are offered.
So, are snacks available 24 hours a day or only in small pockets of time, like tea and biscuits in the morning, for example? Are people able to ask for food and drinks at odd times – such as if they wake in the middle of the night?
Importantly though, mealtimes and drinks, are embedded in our socialisation and culture. The move to a residential home sometimes means that people have to give up those social activities around food. Mealtimes become a prescriptive event, like medication rounds, and older people are sort of ‘expected to eat’.
In fact, mealtimes should be something that we enjoy, and having that opportunity to socialise and have visitors come in and enjoy that meal with someone is good practice.
What lessons can we take from that into the live-in care space?
Socialisation is key – and if the carer is also able to encourage visitors to come and have meals with the person they are caring for then that retains that social dynamic. Being able to take them out as well will help encourage them to eat through social activity, perhaps just for a coffee or a nice pub lunch.
Meal times are the highlight of the day for many older people, so those meals have to perform. If you spend all morning or afternoon looking forward to something, and then it doesn’t taste very nice, or it’s been sitting to one side, and it’s become congealed or dry then those things can contribute to a feeling of deflation and a reluctance to eat.
The other thing to note is that the eating experience starts before we sit down to the meal. With older people, their gastric juices will begin to work when they can smell the food that’s being prepared in the kitchen and evoke those feelings of hunger – rather than a carer just appearing with a microwave meal which may not be as tantalising to the senses.
Another way to stimulate interest in food is to allow them to join in with food-based activities: getting involved with food preparation, being able to lay the table, helping to make cakes, decorate biscuits, pick herbs or pod peas.
So many older people have been main food preparers all their life, or they’ve grown their own fruit and vegetables – so if they can just connect with those food-based activities again, it can help enhance their sense of hunger, which again will increase food intake because they will want to eat.
How important is food choice in encouraging healthy appetite?
Food and drink choices are often the last thing you can have some control over as you get older when other things get taken away due to ill health and frailty.
In care, you can start to lose autonomy, but having a say in what you eat and drink is something that you can retain. However, I have observed in care homes that the idea of having to choose from a menu – sometimes even 24 hours ahead of time – about what you want to eat doesn’t always work to support this.
Choice can be complicated as well if you are living with dementia. People who are struggling with cognitive ability can start to lose the ability to recognise the names of different foods, so showing people the foods is another way to enhance that experience.
So, taking that analogy back into caring for someone in their own homes, a carer might offer Mrs X her favourite dish, shepherd’s pie, but even though she loves it, she might not remember what it is. So visually, if there are pictures of a shepherd’s pie that can be shown to her, then she might be more inclined to eat it.
You also talk about the importance of proper fluid intake in your research – how can we encourage older people to drink enough?
Dehydration is difficult to assess and involves quite invasive tests. There are a few simple indicators to look at though, like if the colour of their urine is particularly dark or how dry or sunken their skin looks.
Older people have to be encouraged to drink regularly to avoid these problems, and again, the activity of having a drink with somebody can really help if someone is losing cognitive ability. The copycat action of somebody drinking in front of them will encourage a person to pick up a drink themselves.
Having the drinks people prefer as well is important – orange squashes, water, teas, coffees – as is serving them regularly. Don’t leave drinks lying around and expect somebody to drink it two hours later. It’s not what we would want to happen, and it’s not what we should expect older people to have to put up with either.
Does encouraging positive mealtime and drinking practice have to be an active experience for carers?
Absolutely. When people are living on their own and have no social interaction, then often they will stop or reduce their eating because the enjoyment starts to go. I can’t over-emphasise the importance that care staff have in creating the kind of social environment that will encourage people to eat and drink.
A carers knowledge of the people they are caring for is fundamental too, so care plans should be regularly updated particularly around food and drink preferences because we don’t always remember absolutely everything that we like to eat and drink.
There is also the possibility that the older person just has a small appetite, so putting pressure on them to eat when they just don’t have the desire for it can add to mealtimes being prescriptive, rather than enjoyable.
Personally, I feel you have to consider all the different aspects of mealtimes that we’ve touched on to make that meal experience a pleasant one. And then I would like to think that eating and drinking more frequently would follow as a natural course.
What are important things to remember when you’re trying to encourage an older person to eat?
Having small meals is sometimes less daunting for older people than having large meals. So maybe moving to five very small meals a day rather than three large meals would be beneficial. And if somebody wants to have a snack at 11 pm then let them.
As cognitive decline occurs, people also tend to switch to sleeping more in the day and being awake at night, which would potentially affect what time they feel hungry and need to eat. In all cases, adapting to the individual and their situation is the best way to deliver successful, person-centred care.
This interview was part of a series brought to you by Elder. Wherever you may need a live-in carer in the UK, Elder can help.
For some useful training material developed by Joanne Holmes and Dr Jane Murphy, click on Understanding Nutrition and Dementia where you’ll be able to download a workbook ‘Eating and Drinking Well: Supporting People Living with Dementia’.
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