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Part I Introduction to Nutrition Care in Older Adults

to promote a calm and focused emotional state to max- imize independence (4). Cognitive Deficits

Cognitive deficits such as those resulting from dementia and cerebrovascular accidents (CVAs) can be very chal- lenging and can significantly impact eating abilities. Frequently observed problem mealtime behaviors asso- ciated with cognitive deficits include slow pace of eating, distractibility, and ineffective use of utensils (6). Those with dementia have impaired depth perception (for example, the person placing a cup on the plate instead of next to the plate) and spatial orientation. Other problems associated with dementia include ide- ational apraxia, which is the inability to use an object properly because the person has lost the ability to discern the object’s purpose. Delayed response to cues and sensory input is also a factor in dementia. Persons in end-stage dementia may have as much as a 90-second response delay (7). Allowing adequate response time and following a prompt hierarchy can be effective interventions.

Older adults with dementia may not recall that they have just eaten a meal. Offering second servings or snacks may help decrease stress in these situations. In addition, meal presentation may be visually confus- ing or overwhelming for the person suffering from dementia (6). Some older adults may not be able to remain seated at the table for an entire meal. Providing foods such as sandwiches and finger foods that can be carried and eaten on the go and allowing residents to change location or ambulate while eating (if safe to do so) may increase intake.

Paranoia can also be a component of some types

of dementia. A person experiencing paranoia may think their food is being poisoned (19). Providing canned and packaged foods that the person can witness being prepared may help. Once distracted, the older adult with dementia may not recall that he or she has eaten some of their meal and may believe they are being pre- sented with someone else’s half-eaten meal. Removing the plate and reserving the meal may help (7).

Finger-Food Diet

When an older adult is not able to or refuses to eat with utensils, a diet consisting of foods that can be easily eaten without utensils—and with limited risk of spill- ing—can be utilized, provided no other diet texture modifications are required (eg, pureed diet) and any other therapeutic diet requirements are followed (eg, diabetic restrictions and sodium restrictions) (20). In some instances, those on a mechanical soft diet may be able to handle some finger foods, but this requires

close supervision and monitoring. There are products available to assist in creating pureed foods that may be eaten with the fingers. Such a diet can meet the Reference Daily Intake (RDI) for older adults as defined by the National Research Council. Foods that are small and difficult to pick up (eg, peas or rice) and foods that are slippery (eg, noodles in sauce or canned fruits in syrup) should be avoided. Foods that may become choking hazards if chewing or swallowing is impaired (eg, raw carrots, whole hot dogs) should also be avoided. Such foods may be cut into bite-size pieces (fruit cocktail size) if appropriate. Many foods can be modified to comply with a finger-foods diet, including soups served in mugs or meat served in a pita or tortilla. A wide variety of foods can be made into a sandwich. (See Table 4.1 on pages 48–49.)

Decreased Sensation of Taste

and Smell Dementia and the effects of aging can also result in decreased perception of or sensation for taste and smell. Enhancing flavor by increasing the amount of extracts, herbs, or spices called for in recipes or by adding fla- vorings such as bacon, cheese, or maple may increase intake as well as enjoyment in eating (19). Increasing aroma by directing the smell of cooking foods into the dining room and by lifting a cover from the plate just before it is served can help increase appetite. “A group of older adult men and women living in a retirement home ate more food and improved their immune func- tion when several foods at each meal were enhanced with one of the following: meat, cheese, or maple fla- voring” (19). See Box 4.2 for interventions for address- ing cognitive deficits.

Prompt Hierarchy

Following a prompt hierarchy allows staff intervention to compensate for lost abilities (21). “Feeding tech- niques other than spoon feeding—including verbal and nonverbal prompts and physical guiding—can support the older adult’s participation in independent dining even when independence is no longer possible” (6). The prompt hierarchy breaks intervention down into individual types of cueing, beginning with the least invasive cue and progressing to physical assistance only when necessary. As mentioned previously, staff can create dependence for dining in as little as two days by doing the task for the person (7). Using the least invasive cue is vital to maintaining independence, as detailed in Box 4.3.