Oxfordshire Skills and Learning Service

Unit 108 (3565) (DEM302 4222-366) Knowledge WorkbookUnderstand and meet the nutritional requirements of individuals

with dementia

Learner name: C&G Reg. No:

Learner signature:

Date completed:

Recommended GLHS: 26

Assessor name:

This unit is about understanding that individuals may have specific nutritional needs because of their experience of dementia. Learners will develop their knowledge and skills in meeting these nutritional requirements and be able to provide evidence of their competence to enable individuals with dementia to eat and drink well Learning outcome 3 needs to be assessed in the workplace environment You must understand your organisation’s policies and procedures before attempting to answer the learning outcomesRead the guidance on the terms used in this workbook before you start.

Page 1 of 21

This page is blank

Page 2 of 21

Learner Assessment RecordUnit Number: 108Unit Title: Understand and meet the nutritional requirements of individuals with dementiaDate Workbook submitted: 1st ………………………….. 2nd …………………………..

Assessment Criteria

Assessor Feedback 1st Submission OutcomePass/Refer

2nd SubmissionOutcomePass/Refer

1.1

1.2

1.3

1.4

1.5

2.1

2.2

2.3

Learning outcome 3 must be assessed in a real work environment and your Assessor will agree additional methods to cover these, including observation of your practice

Page 3 of 21

Assessor comments to Learner

Target date and action plan for resubmission (if applicable)

Outcome of second submission

I confirm that this assessment has been completed to the required standard and meets the requirements for validity, currency, authenticity and sufficiencyAssessor Signature: Date:

I confirm that the assignment work to which this result relates, is all my own workLearner Signature: Date:

Internal Verifiers Signature: Date:

Page 4 of 21

Additional guidance

An individual is someone requiring care or support

Person-centred approach:This is a way of working which aims to put the person at the centre of the care situation taking into account their individuality, wishes and preferencesMeal times:

Meal planning Food shopping Food preparation Pre- and post-meal activities Dining Snacking

Well-being: Appropriate weight gain/loss Improved sleep patterns Reduced confusion Improved physical health Improved emotional state Reduced infections Reduced constipation

For more detailed information please research:

www.alzheimers.org.uk

http://www.scie.org.uk/publications/dementia/index.asp

http://www.logontocare.org.uk/e-learning0/

Page 5 of 21

Assessment Criteria 1.1: how cognitive, functional and emotional changes associated with dementia can affect eating, drinking and nutrition

1Dementia can greatly affect a person's relationship to food and eating. The behavioural, emotional and physical changes that take place as dementia progresses can all have an impact upon a person's eating habits and on their intake of food and drink.

It is important to do what you can to make sure that the person you are caring for enjoys their food and eats a healthy, balanced diet. As dementia progresses eating can become difficult for some people. However, by making a few changes you can help keep mealtimes as enjoyable and stress free as possible.

A person with dementia may no longer recognise the food in front of them. They may struggle to use a knife and fork as co-ordination becomes difficult. The person may not open their mouths as food approaches and may need reminding to do so. Food may be difficult to chew or swallow or they may not want to accept assistance with eating.

If you are supporting a person with dementia at mealtimes it is important to remember that these reactions are not a deliberate attempt to be 'difficult', or a personal attack. The difficulties are likely to be related to changes caused by the person's dementia. When supporting a person at mealtimes it can be a challenge to identify what the problem is, particularly if the person themselves is finding it difficult to find the words to explain.

Assessment Criteria 1.2: how poor nutrition can contribute to an individual’s experience of dementia.Assessment Criteria 1.3: how other health and emotional conditions may affect the nutritional needs of an individual with dementiaAssessment Criteria 1.4: the importance of recognising and meeting an individual’s personal and cultural preferences for food and drinkAssessment Criteria 1.5: why it is important to include a variety of food and drink in the diet of an individual with dementia

People with dementia need to make sure they eat a healthy balanced diet. A balanced diet provides all the nutrients the body needs in the right amounts to stay healthy.

As dementia progresses, changes in a person's eating habits and ability to eat often take place. Difficulties swallowing, changes in taste and smell or a poor appetite can

1 www.alzheimers.org.uk

Page 6 of 21

make it increasingly difficult to ensure that an adequate amount of nutritious food is eaten.

A healthy diet is only as healthy as the food that is eaten. It is therefore important to take into account the person's likes and dislikes and their ability to manage certain foods. Consider ways of preparing food to stimulate interest, particularly if the person's appetite is poor.

Remember, eating healthily does not mean that certain foods have to be avoided. Everything in moderation and a little bit of what you fancy is the key to enjoying food and staying fit and well.

Many foods provide a range of nutrients and similar foods are often grouped together into 'food groups'. Listed below are the different food groups and the nutrients they provide. Choosing a variety of foods from different food groups is the best way to ensure a balanced intake of all the different nutrients needed for good health.

Milk and dairy food

This group includes milk, cheese and yoghurt and foods made with milk, such as custard, milky drinks or milk puddings.

These foods are a good source of protein, which is needed to build and repair body tissues. They also provide a rich source of calcium, needed for strong bones and teeth.

To help the body absorb calcium from food, we need vitamin D. Vitamin D is mainly formed by the action of sunlight on the skin, but can also be found in foods such as oily fish, margarine and eggs. However, for older people who are housebound, or spend little time outdoors, a vitamin D supplement may be required. Check with the GP or dietician.

Meat, fish and alternatives

This group includes meat, poultry, fish, offal, eggs, nuts, beans, lentils and soya products such as tofu.

These foods are a good source of protein and also provide some of the B group vitamins (see Bread, cereals and potatoes).

Foods of animal origin, such as meat, fish, offal and eggs, are good sources of vitamin B12. Vitamin B12 is needed for a healthy nervous system and the formation of red blood cells.

Page 7 of 21

Folate and iron are also needed to keep the blood healthy. Liver is a good source of folate (see Fruit and vegetables) and iron can be found in red meat, oily fish, liver, kidney, beans and lentils. Eating fruit and vegetables that are rich in vitamin C can help with the absorption of iron from food (see Fruit and vegetables).

Oily fish, such as salmon, mackerel, herring and sardines, is a rich source of essential fats called omega-3 oils. These oils play an important part in maintaining the health of the heart and the nervous system. Eating oily fish at least once a week is recommended.

For those who choose not to eat meat or fish, foods such as pulses (beans, peas and lentils) nuts, eggs, cheese and soya can be eaten instead. A variety of these foods should be eaten to ensure a good range of nutrients. Some people who avoid all animal foods - meat, fish, eggs and dairy foods - will probably need a vitamin B12 supplement. Check with the GP or dietician.

Bread, cereals and potatoes

This group of foods provides energy and is a good source of B group vitamins. As well as keeping the blood and nervous system healthy, B vitamins break food down to release energy. Foods in this group include:

Bread (wholemeal or white), including chapatti, nan and pitta bread; crackers; crumpets; muffins, and teacakes

Pasta, such as spaghetti or macaroni; noodles, and rice Potatoes, plantain and yam Breakfast cereals and flour. Breakfast cereals are fortified with added vitamins

and minerals, such as folate, vitamin B12 and iron. Served with milk, they provide a nourishing snack that can be eaten at any time of the day, not just in the morning!

Wholemeal bread, wholemeal pasta and wholegrain breakfast cereals are all good sources of fibre. Examples of wholegrain breakfast cereals include porridge oats, bran flakes and whole wheat biscuits. Fruit and vegetables

This group includes all fruit and vegetables, dried fruit and fruit juices.

Fruit and vegetables are packed full of fibre and vitamins - in particular, the antioxidant vitamins C, E and beta-carotene. These vitamins help to protect the healthy cells of the body from damage and support the immune system to fight infections. Beta-carotene is found in yellow and orange fruit and vegetables and in dark green leafy vegetables. Once in the body, it is converted into vitamin A as

Page 8 of 21

required. Vitamin A can also be found in animal foods such as liver, eggs, cheese and butter.

Vitamin E is present in green leafy vegetables, vegetable oils, butter and nuts.

Vitamin C is needed to keep gums, teeth and skin healthy. It also helps the body absorb iron from food (see Meat, fish and alternatives). Citrus fruit, such as oranges, strawberries and kiwi fruit, and tomatoes and potatoes are good sources of vitamin C. For those who find it difficult to eat or prepare fruit and vegetables, drinking a glass of orange juice every day is a good way to ensure an adequate intake of vitamin C.

Green leafy vegetables, Brussels sprouts, oranges and other citrus fruit are all good sources of folate.

A general guide is to try to have five servings of fruit and vegetables a day to ensure a good range of nutrients for health. However, individual dietary needs can vary, particularly for people with dementia, and may be influenced by the stage of dementia, ability to eat certain foods, the person's medical condition and other circumstances. This guide may not be appropriate or achievable for all people with dementia. However, every little helps, so encourage and accept what each person can manage.

Fats, oils and other foods

This group includes margarine, butter, ghee and vegetable oils such as sunflower oil and olive oil.

These foods are concentrated sources of energy, so are not needed in large amounts. They do provide some vitamins. Margarine contains vitamins D and E and vegetable oils are a good source of vitamin E.

'Other foods' include cakes, pastries, biscuits, confectionery, crisps, and soft and alcoholic drinks. These foods are not nutrient rich. They mainly provide calories or energy from fat and/or sugar. They can be included as part of a healthy balanced diet, but if eaten too frequently they may dampen the appetite for more nutritious foods. It is a question of moderation.

A word about fibre

Fibre is important to help prevent constipation. The risk of constipation is greater for people who are inactive, do not drink enough or eat a low fibre diet. Certain medications can also aggravate the problem.

Page 9 of 21

A good way of preventing constipation is to include foods that are a good source of fibre in the diet - fruit and vegetables, salads, beans, lentils, wholemeal bread or wholegrain breakfast cereals, for example. However, it is best to introduce high fibre foods gradually if the person is not used to eating them. Too much fibre in the diet can be bulky and uncomfortable; small changes are usually sufficient.It is not advisable to add raw bran to foods as this can cause bloating and discomfort. It can also make it difficult for the body to absorb nutrients such as calcium and iron.

To help prevent constipation also try, if possible, to encourage daily activity for those who are able. A short gentle walk is a good start.

Drink to think

Drinking enough fluid every day is vital for good health. A low intake of fluid is likely to result in dehydration. This can increase the risk of constipation and affect mood, resulting in increased irritability and confusion. Some people with dementia may not recognise that they are thirsty or may simply forget to drink.

Fluids include water, tea and coffee, fruit juice, milk and other soft drinks. Gentle reminders and prompts to drink may help. Offering the person the cup rather than leaving it on the table may prompt a person to drink.

Some supermarkets offer a delivery service, where orders can be placed by phone or through the internet. This is a good way of ensuring a regular stock of fresh food and can help if time is limited or it is difficult to get to the shops. There may be a charge for this service, so it is best to ask first.

Poor appetite

There are several reasons why a person with dementia may have a poor appetite or seem uninterested in eating.

In the early stages of dementia some people lose interest in food because they are depressed. Depression is very common but there are effective drug treatments available. If you suspect this is a problem, consult your GP. When the depression lifts, the person's appetite should return.

A sore mouth, badly fitting dentures or sore gums can make eating uncomfortable. Regular dental care is important, so seek the advice of a dentist.

If the person is inactive during the day, they may not feel hungry. Encourage activity such as walking, if appropriate.

In the later stages of dementia, people may no longer understand that the food in front of them is there to be eaten, even if they are hungry. This is

Page 10 of 21

because the nerve pathways in the brain are damaged and the messages do not get through. Gentle prompts and reminders to eat may be helpful. Eating in company can act as a useful cue, reminding the person what to do and how to eat.

Medication can sometimes affect the appetite. Side-effects such as constipation, changes in taste or a dry mouth can reduce the desire to eat. Constipation can be helped by increasing fibre and fluid intake. Keeping food moist by adding sauces or gravy can help the person to eat more easily if their mouth is dry. Small sips of water taken while eating may also help.

Chewing and swallowing sometimes becomes a problem as dementia progresses. People may find chewing solid food difficult; they may hold food in their mouths rather than swallow it, or you may notice that they cough after swallowing. If you have any concerns about chewing and swallowing food, a speech and language therapist can advise.

Some people with dementia find eating with a knife and fork difficult because they have problems with co-ordination. This can be frustrating and they may feel embarrassed if they drop food or if the task becomes messy. This can be sufficient to put a person off eating at mealtimes. Try offering finger foods to boost confidence and maintain independent eating.

People with dementia often experience changes in food preferences. This is thought to be a result of damage to specific areas in the brain or it may be due to the person simply forgetting which foods or drinks they used to like.

Changes in taste and smell can all impact on the amount and variety of foods eaten. If food preferences become very limited, the person will probably not be getting all the nutrients they need to stay healthy and they may lose weight. A dietician can offer practical advice on how to enrich food and drink to help with a poor appetite and weight loss. Some people with dementia may need food supplements, such as energy- and protein-enriched drinks. These are usually prescribed and should be taken under the guidance of a dietician and GP. Some supplement drinks can be purchased from chemists and supermarkets. These often come in a powdered form and can be made into a drink, usually by adding milk.

Losing weight is not an inevitable part of having dementia. With time, effort and knowledge of the person, food intake can be increased. It is helpful to be aware of some of the changes that can occur as dementia progresses, such as difficulties using cutlery and changes in visual perception: these changes can result in a person eating and drinking less than they need to stay healthy and well nourished.

Measuring a person’s weight each week can help to indicate any changes that need attention. This is part of what is called ‘nutritional screening’, a process of identifying people who are malnourished or at risk of becoming so.

How and when to eat

Page 11 of 21

This depends on the individual and how they prefer to eat. A person with a good appetite may have no problem eating sufficient food at regular mealtimes.

However, a person with a small appetite may not respond well to generous servings of food three times a day. Too much food on the plate can be off-putting to someone whose appetite is poor. In this case, try serving smaller portions at mealtimes and offer nourishing snacks in between mealtimes to supplement food intake. Offer dessert as a separate course an hour or so after the main meal, rather than presenting both courses at the same time, as this may also help.

Alternatively, you may find the person prefers to eat 'little and often' - five smaller meals spread over the day instead of the usual three, for example. It is a matter of finding out what works best for the individual.

Drinks

Encourage milky drinks, hot or cold. Make malted milk drinks or hot chocolate with milk.

Snacks

Sandwiches with fillings such as egg, tinned fish, meat, cheese or peanut butter

Cheese and biscuits Toast with cheese, pâté, peanut butter or yeast extract Buttered scones, toasted teacakes, buttered crumpets or muffins Fruit loaf or malt loaf Milk pudding, breakfast cereals and milk, yoghurt Fruit cake or gingerbread.

Avoiding over eating

Some people with dementia may eat too much food. They may forget they have just eaten or they may have a persistent desire for certain foods, such as sweet biscuits or confectionery, and snack on these throughout the day. Overeating can become a problem if the person gains too much weight. Carrying extra weight will make it more difficult to get around and the person will start to feel uncomfortable.Snacking frequently on foods such as confectionery or biscuits can reduce a person's appetite for more nutritious food at mealtimes, which means they may not be getting all the nutrients they need to keep them healthy.

Try to limit the availability of these snack foods if they are being eaten too often and the person is gaining excess weight. Provide healthier alternatives, such as pieces of

Page 12 of 21

fresh fruit and vegetable. Some people may eat out of boredom or loneliness, or they may not be active during the day

Getting help

If you have concerns about a person's eating or drinking, help is available. Key healthcare professionals who can offer advice and guidance include:

Dieticians, who can provide advice on issues such as poor appetite, weight loss or weight gain, food enrichment and vitamin and food supplements.

Speech and language therapists, who can give advice and guidance on swallowing difficulties. It is important that changes to the texture of food are only made as necessary and with their professional advice.

Occupational therapists, who can advise on adapted eating aids, such as cutlery, cups and plate mats, which help to maintain independent eating.

These professionals can be contacted through their GP or consultant, who will be able to arrange for a referral. Some professionals may be able to offer a domiciliary visit to people who are housebound. Others may be based at a local health centre, GP practice or hospital. Services vary from area to area.

Assessment Criteria 2.1: how mealtime cultures and environments can be a barrier to meeting the nutritional needs of an individual with dementiaAssessment Criteria 2.2: how mealtime environments and food presentation can be designed to help an individual to eat and drinkAssessment Criteria 2.3: how a person centred approach can support an individual, with dementia at different levels of ability, to eat and drink

2The environment in which a person with dementia eats will have an effect on how they eat. People with dementia will not want to stay and eat in an environment in which they feel uncomfortable. Understanding the impact of the mealtime environment can help us to improve the eating experience for people with dementia.

Imagine you are in a restaurant with a group of friends and there is loud music playing or a live band playing close to your table. The restaurant is busy and the conversations around your table are loud. You are trying to make a choice from a long list of options on the menu as well as keep up with the conversation among the friends you are with.

The waiter is hovering and you are feeling pressure to choose your meal. It may be a challenge for you to concentrate on the conversation around you while choosing from the menu, but you will manage to make this choice and continue to converse with your friends despite everything else going on around you.2 www.scie.org.uk

Page 13 of 21

For a person with dementia a noisy environment can be confusing: it can make it difficult to concentrate and focus. So if you had dementia and you were in that noisy restaurant you may have just got up from the table and walked out as the music, conversation and waiter were all competing for your attention.

We need to be aware that people with dementia may struggle to concentrate at mealtimes if there are other distractions. The eating environment needs to be calm and relaxed. Switch off the television or turn down loud music to avoid distractions.

A person with dementia may not be comfortable eating with other people or in an unfamiliar environment. They may have difficulty eating food and this can only make feelings of embarrassment worse if they are sitting with others. As a result, they may leave food uneaten.

Allow a person to sit and eat in a place where they feel comfortable, either at a table or perhaps sitting with a tray on their lap on a comfortable chair.

It is important to be aware that some people with dementia may experience visual impairments that make it difficult to see the food in front of them.

Describe the food you are offering and ensure that the food is presented colourfully and attractively. It should look good enough for anyone to eat.

Ensure the area in which a person with dementia eats is bright and well lit so they can see the food easily

Food and images of food can also be used for reminiscing or part of reminiscence activities. This can help stimulate discussion and interest in food and mealtimes by helping the person to reconnect with familiar food from their past.

It is not uncommon to notice a person’s likes and dislikes for food and drinks change as dementia progresses. These may be quite dramatic and very different to the preferences a person may have held for many years. It is wise to expect change and not make assumptions that everything will stay the same.

A flexible approach to providing food and supporting the person at mealtimes is vital. As with any one of us, the appetite of a person with dementia may vary from day to day.

We all have likes and dislikes and eating habits that are particular to us as individuals. People with dementia are no different. We need to know what type of food a person likes to eat, where they like to eat it and when they like to eat.

Page 14 of 21

For example, a person with dementia may be used to eating their main meal in the early evening by themselves, sitting in a comfortable chair listening to the radio.

If this person is suddenly offered their main meal at lunch time and expected to sit at a dining table with others it would be no surprise if they refuse to eat the meal or leave it uneaten. This new situation may be confusing and unfamiliar to the person or they may just not be hungry at that time of the day.

Asking people with dementia about their mealtime preferences, when and where they like to eat and what foods they enjoy is vital to ensure we provide food and options at mealtimes that are familiar to them. Families and carers can be a valuable source of information if the person with dementia is struggling to communicate their eating habits and preferences for food and drinks.

People with dementia may struggle to ask for food if they have difficulty finding the words to express themselves. Food and drinks need to be visible and available throughout the day so that people can eat and drink whenever they feel hungry or thirsty.

Ensure that snacks and drinks are easy to access and see so that people with dementia can take a drink or eat without having to wait for it to be offered.

Look at this website and view the video clip about nutritional care for older peoplehttp://www.scie.org.uk/socialcaretv/video-player.asp?guid=3e55885f-2190-4d6e-8c15-090cf5c7e68e

Assessment Criteria 1.1: Explain how cognitive, functional and emotional changes associated with dementia can affect eating, drinking and nutrition

Think about an individual you support who has dementia and complete the chart below

How it affects their eating

How it affects their drinking

How it affects their overall nutrition

Page 15 of 21

Cognitive changes

3Functional changes

Emotional changes

Assessment Criteria 1.2: Explain how poor nutrition can contribute to an individual’s experience of dementia. (Minimum 50 words)

3 What they can do

Page 16 of 21

Assessment Criteria 1.3: Describe how other health and emotional conditions may affect the nutritional needs of an individual with dementia (Minimum 50 words)

Assessment Criteria 1.4: Describe the importance of recognising and meeting an individual’s personal and cultural preferences for food and drink (Minimum 50 words)

Page 17 of 21

Assessment Criteria 1.5: Explain why it is important to include a variety of food and drink in the diet of an individual with dementia(Minimum 50 words)

Assessment Criteria 2.1: Explain how mealtime cultures and environments can be a barrier to meeting the nutritional needs of an individual with dementia – describe at least three for each that are common to the type of work you do

Page 18 of 21

What environmental barriers there may be to good nutrition

How I can reduce these barriers

What cultural barriers there may be to good nutrition, including organisational cultures as well as the individuals

How I can reduce these barriers

Assessment Criteria 2.2: how mealtime environments and food presentation can be designed to help an individual to eat and drinkAssessment Criteria 2.3: how a person centred approach can support an individual, with dementia at different levels of ability, to eat and drinkLook at this website and view the video clip about nutritional care for older people

Page 19 of 21

http://www.scie.org.uk/socialcaretv/video-player.asp?guid=3e55885f-2190-4d6e-8c15-090cf5c7e68e

Think about an individual you support who has dementia. Describe how you support that person to eat and drink that demonstrates a person centred approach and ensuring all factors of this approach are taken into account. (Minimum 200 words)

Once complete please make sure that your details are on the front of the workbook and then return it to your assessor:

Oxfordshire Skills and Learning ServiceUnipart House

Page 20 of 21

Garsington LaneCowleyOX4 2GQ

Page 21 of 21