Nrs Resource Manual

Identifying and Planning Assistance
for Home-based Adults who are

Nutritionally at Risk: A Resource Manual
1
DEPARTMENT OF HUMAN SERVICES
HOME AND COMMUNITY CARE PROGRAM
Identifying and Planning Assistance for
Home-Based Adults Who Are Nutritionally at Risk:
A Resource Manual
Identifying and Planning Assistance for Home-Based People Who are Nutritionally at Risk: A Resource Manual (2001)
2
ISBN: 0 7311 6122 X
Published by Aged, Community and Mental Health Division
State of Victoria, 2001
Funded by Home and Community Care
Editors for the project:
Beverley Wood
Jenny Bacon
Alison Stewart
Sue Race
for the
Dietitians Association of Australia (Victorian Branch)
1/8 Phipps Close
Deakin ACT 2600
Tel: and Fax: (02) (6282 9798)
e-mail: vic@daa.asn.au
Project Steering Committee:
Ms Sue Race, Project Chairperson, Dietitians Association of Australia (Victorian Branch)
Ms Alison Stewart, Chief Dietitian, Kingston Centre, Southern Health Care Network
Ms Jenny Bacon, Chief Dietitian, Bendigo Health Care Group, Bendigo
Representatives, Aged Community and Mental Health Division, Victorian Department of Human
Services (Ms Jacinta Bleeser, Mr David Stanley, Ms Sally Mayne)
Ms Jill Fraser, Co-ordinator, Food Services Business Unit, Hobsons Bay City Council
Dr Beverley Wood, Senior Project Officer
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PREFACE
This Resource Manual has been designed to demonstrate and advocate for the introduction of
nutritional risk screening and monitoring to the assessment process for adults in the Home and
Community Care (HACC) Program.
The majority of these adult clients are frail older people. Others include the younger adult person
with disability (intellectual, psychiatric, physical), and the adult who is financially disadvantaged
and living in alternative accommodation.
This Manual has been developed through the active leadership and committed work of the
Dietitians Association of Australia (Victorian Branch). Generous informed assistance was
provided by the work of focus groups of assessment officers and local dietitians in the Central
Grampians Region, the Central Wellington Gippsland Region, the Southern Metropolitan Region,
and in the City of Darebin in the Northern Metropolitan Region.
Input on clients with a disability came from a number of assessment officers interested in
disability and dietitians with many years experience working in this area. Anational group of
dietitians developed the initial draft materials and the Victorian Reference Group oversaw the
trial of these materials and their final inclusion in this Manual.
The input on clients who are living in alternative accommodation has been made through the
voluntary work of the project officer with the Royal District Nursing Service Homeless Persons
Program.
Indirect input from clients was made by the trial of a client information booklet Good Food and
Health Advice for Older People Who Want to Help Themselves with the assistance of carers and a large
number of home-based elderly clients receiving community services in the City of Greater
Geelong.
The significant contribution made by all of these people is sincerely acknowledged.
This Resource Manual explains the basis of nutritional risk screening and monitoring and the tool
which has been developed. It also gives many practical suggestions about solving client problems
and information on where further assistance may be sought for them. It has been possible to
combine the materials for nutritional risk screening and monitoring to the frail older person, the
low dependency client with a disability and the homeless adult without sacrificing the integrity
of the needs of these very different population groups. In a few instances, the complex nutritional
needs of high dependency clients have warranted separate sections in the Manual.
This Resource Manual is one of the main outcomes of the project Identifying and Planning Assistance
for Home-Based Adults Who Are Nutritionally at Risk which was commissioned and funded by the
Victorian Department of Human Services Home and Community Care (HACC) Program.
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CONTENTS
Preface
Section 1 Introduction
1.1 Summary of This Manual and Its Use
1.2 Nutritional Risk Screening and Monitoring Tool
Section 2 Nutritional Risk Screening and Monitoring
2.1 Nutritional Risk Screening and Monitoring as Part of the Assessment and
Intervention Process
2.2 The Nutritional Risk Screening and Monitoring Trigger Questions
2.3 The Nutritional Risk Screening and Monitoring Tool for Home-Based Adults
2.4 How Does Nutritional Risk Screening and Monitoring Fit into Assessment
and Planning Assistance for Intervention?
2.5 General Assessment Includes Factors Relevant to Nutritional Risk
2.6 Checklist for Intervention
2.7 Monitoring is Conducted as Required
2.8 Nutritional Risk Screening and Monitoring Case Study form
2.9 Nutritional Risk Screening and Monitoring in Other Settings
2.9.1 Discharge Planning and Temporary Home Care
2.9.2 Retirement Villages, Supported Residential Services, Day Care Centres,
Sheltered Workshops, Shelters
Section 3 Nutrition and Health Issues
3.1 Obvious Underweight-frailty?
3.1.1 Healthy Weight Range for people Over 65 Years
3.1.2 Healthy Weight Range for adults 16 to 64 Years
3.2 Unintentional Weight Loss?
3.3 Reduced Appetite or Reduced Food and Fluid Intake?
3.4 Mouth or Teeth or Swallowing Problem?
3.5 Follows a Special Diet?
3.6 Unable to Shop for Food?
3.7 Unable to Prepare Food?
3.8 Unable to feed self?
3.8.1 Feeding Problems in High Dependency Adults
3.8.2 Nutrition Decision Tree for Adult Referral to a Specialist
3.9 Obvious Overweight Affecting Life Quality?
3.10 Unintentional Weight Gain?
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Section 4 General Needs Assessment of Food and Nutrition Issues
4.1 Summary of General Assessment Factors Affecting Food and Nutrition
4.2 Financial Difficulties
4.3 Social Problems
4.4 Personal Hygiene and Food Hygiene Problems
4.5 Mental Health Problems
4.6 Poly-drugs
4.7 Nausea and Vomiting
4.8 Diarrhoea
4.9 Constipation
4.10 Incontinence
4.11 Breathing Problems in the Older Person
4.12 Outline of Some Medical Problems Affecting Nutrition
4.12.1 Diabetes
4.12.2 Cardiovascular Disease
Section 5 Dietary Principles and Problems
5.1 Food Facts and Fallacies
5.2 Food Habits and Patterns
5.3.1 Good Nutrition for Older People: The 1 3 3 4 5+ Food Plan
5.3.2 Good Nutrition for Adults 16 to 64 years. The 1 2 3 4 5+ plan
5.3.3 Who Needs Extra Foods in Addition to the Daily Food Plan?
5.3.3.1 High Energy Foods and Drinks
5.4 The Importance of Fluid Intake
5.5 Alcohol as Part of a Vulnerable Persons Diet
5.6 Vitamin D
5.7 Use of Vitamin and Mineral Supplements
5.8 How to Be Well-Nourished on Meals on Wheels
5.9 Outline of Some Food and Dietary Problems
5.9.1 Poorly Balanced or Inadequate Food Intake
5.9.2 Difficult Behaviours which Involve the Use of Food
5.9.3 High Dependency Adults with Feeding Problems, who require Foods
and Fluids which are Modified in Texture
5.10 Brief Counselling Methods
Section 6 Ways Dietitians can assist Home-Based Adults and Services
6.1 Summary of Roles and Functions of Dietitians in Home-Based Adults
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Section 7 Case Studies Frail Older People
Number one: Woman, 75 years, Recent Hospital Discharge
Number two: Woman, 75 years, Emphysema, Weight Loss, Referred by
Daughter
Number three: Man, 74 years, Recent Stroke, Referred by Doctor
Number four: Man, 72 years, Alcohol Abuse, Frail, Review Requested by
Home Carer
Number five: Woman, 71 years, Meals on Wheels not used, referred by
Volunteer
Number six: Woman, 85 years, Overweight, Many Medical Problems
Section 8 Case Studies Adults with a Disability
Number one: Woman, 21 years, Severe Weight Loss, Cerebral Palsy,
Referred by Mother
Number two: Woman, 28 years, Overweight, Mild Intellectual Disability,
Referred by Husband
Number six: Man, 33 years, Down syndrome, Referred by Doctor
Section 9 Case Studies Financially Disadvantaged Adults Living in
Alternative Accommodation
Number one: Man, 27 years, Unwell and Underweight, Living in Squat,
Needs Temporary Crisis Care
Number two: Woman, 40 years, Lack of Housing, Homeless,
Needs Temporary Crisis Care
Section 10 Quality Improvement for Nutritional Risk Screening and Monitoring
10.1 Quality Improvement for Nutritional Risk Screening and Monitoring
10.2 Record of Results for Nutritional Risk Screening and Monitoring
10.2.1 Types of nutritional risks in home-based adults
10.2.2 Number of nutritional risks in home-based adults
10.3 Are You Satisfied?
10.4 Register of Client Comments and Complaints and Reasons for
Termination of Service
Appendices
Appendix 1 Definitions
Appendix 2 More Information on Harm Reduction in Alcohol Abuse
Appendix 3 References and Resources
Appendix 4 Project Focus Groups
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SECTION 1
INTRODUCTION
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1.1 SUMMARY OF THIS MANUAL AND ITS USE
This Resource Manual has been designed to demonstrate and advocate for the introduction of
nutritional risk screening and monitoring to the assessment process for all vulnerable adult
clients (frail older people, younger adults with a disability and people living in alternative
accommodation) who require Community Services to remain living independently.
Asimple tool for nutritional risk screening and monitoring has been presented in Section 1 and
described in Section 2 Nutritional Risk Screening and Monitoring. The tool consists of ten trigger
questions to increase awareness as to whether nutritional risk exists for the client. These trigger
questions are expanded further in Section 3 Nutrition and Health Issues.
The general assessment* which is conducted with the client explores the reasons why such
nutritional risk exists. These reasons are discussed in Section 4 General Assessment of Food
and Nutrition Issues. In Sections 3 and 4, outlines have been provided for simple strategies
of intervention, monitoring, and for accessing expert resources for further client assistance.
Section 5 Dietary principles and problems provides further information on this important subject.
Section 6 Ways in which Dietitians Can Assist Home Care Clients and services summarises the roles
and functions of dietitians can take. Sections 7 to 9 provide a range of completed Case Studies
which are self explanatory and Section 10 gives some examples which can be used for Quality
Improvement for Nutritional Risk Screening.
In potential or actual HACC clients receiving community support to remain in their own homes,
malnutrition can lead to an increased risk of falls and infections, poor wound healing, and poor
recovery from surgery. Malnutrition may also lead to decreased appetite, dental problems,
depression, apathy, and even dementia. Poor nutrition (sometimes malnutrition) is one of the
major reasons why people become frail and dependent. Poor nutrition reduces quality of life
and also increases the cost of health care for the individual and the community.
The risk of poor nutrition can be identified by nutritional risk screening, hopefully while
intervention can be effective, so preventing premature frailty, ill health, or increasing dependency,
and temporary or permanent admission to an institution.
This Manual provides alerts to the particular food and nutrition issues which may affect the
vulnerable adult person living independently. While some stereotypes exist, it is important to
target individuals so that the effectiveness of intervention is increased.
As people mature and age, their nutritional requirements change. It is now known that although
activity decreases, nutrient requirements are the same (and sometimes increased) in older people
compared to younger adults. Dietary Guidelines for apparently healthy active adults relate to the
prevention of premature death from cardiovascular disease and cancer. In the frail older person
and the frail person with disability, there is more emphasis on their need for increased support
and nourishment and the prevention of malnutrition.
* For the Home and Community Care (HACC) Program, general assessment includes use of the Client Information
and Services Record and perhaps local assessment forms.
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Overweight is to be avoided in adults but is a protective factor in high dependency adults with
disability and older people with advancing age. Body weight maintenance at an appropriate
level is then desirable to maintain physical strength and activity, resistance to infection and skin
breakdown, and life quality. The ability to take nourishing foods and fluids becomes an essential
approach for maintaining independence in any person. The interested reader is directed to the
References and Resources in the Appendix for further information.
Poor nutritional health in home-based adult clients: Does it matter?
More likely to fall
Need more assistance
Need more complex support and care
More complications such as infections, pressure sores, skin ulcers
Need more frequent and longer stays in hospital
Less likely to be able to live independently
Poor nutrition makes people feel awful, affects their quality of life,
and starts deterioration in a downward cycle.
Poor nutrition is associated with increased morbidity and mortality.
Poor nutrition is much harder and more expensive to treat than to
prevent.
In this Manual, vulnerable people includes frail older
people, younger adults with a disability and financially
disadvantaged adults living in alternative accommodation.
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NUTRITIONAL RISK SCREENING AND MONITORING TOOL
CLIENT: DATE:
INSTRUCTIONS:
Fill in the clients name and the date you use the tool: tick the box when
the answer to your observation is YES
Obvious underweight-frailty?
Unintentional weight loss?
Reduced appetite or reduced food and fluid intake?
Mouth or teeth or swallowing problem?
Follows a special diet?
Unable to shop for food?
Unable to prepare food?
Unable to feed self?
Obvious overweight affecting life quality?
Unintentional weight gain?
SIGNATURE: POSITION:
OUTCOME:
YES to one or more questions means that nutritional risk exists
Nutritional risk increases when the person is affected by an Increasing number of
general needs assessment factors
In particular, deterioration in health and loss of independence can result from under-
nutrition and perhaps malnutrition
ACTION:
Try TWO weeks of simple intervention strategies (less time if severe weight loss);
if no response refer to a specialist
Monitoring at monthly intervals (or more frequently) by a team member is required to
ensure that nutritional risk has decreased through the most effective intervention
GENERAL NEEDS ASSESSMENT FACTORS WHICH ARE RELATED TO
NUTRITIONAL RISK
DATE:
Has food run out in the past week with no $ to buy more?
Less than $30 for food for each adult every week?
Social problems?
Personal and food hygiene problems?
Mental health problems?
More than three different medications?
Nausea and vomiting, gastritis?
Diarrhoea? Constipation?
Rumination? Regurgitation?
Incontinence?
Breathing problems?
Medical problems?
Alcoholism? Substance abuse?
Irregular meals or less than 3 meals a day?
Doesnt take 1 3 3 4 5+ food plan most days (older people)?
Doesnt take 1 2 3 4 5+ food plan most days (adults 16-64 years)?
Omitted to have one or more of the major food groups yesterday?
Excessive use of sweet or savoury foods?
2+ alcoholic drinks daily?
Housebound? No direct skin exposure to sunlight?
Highly dependent person needing food and fluid texture modification?
Tube (enteral) feeding is required?
Eats inedible objects such as dirt, soap (pica)?
Inappropriate and challenging behaviours which involve food?
Unable to access or use secure, clean food storage and preparation area?
Rummaging, foraging, begging or stealing food?
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The underweight adult has little body energy and nutrient reserves for use in times
of emergency such as illness and/or reduced food and fluid intake This is even
more critical to health, if underweight is not usual
Even a short bout of poor food intake and/or increased need for nourishment can
precipitate severe weight loss in the vulnerable person
Prevention of underweight is highly desirable
When a person loses a lot of weight without trying (say 5 kg in less than six
months), it is a serious sign of decline which is more rapid and worse if the person
was underweight before the weight loss began
Severe weight loss is a factor clearly associated with relatively higher rates of
morbidity and mortality-it is not a sign to be ignored
Review food intake and implement simple intervention strategies
Always consider referral to a specialist
In the underweight person, more than one or two days of reduced food and
reduced fluid intake can rapidly lead to severe weight loss
Many medical conditions affect food intake and the need for food and can be risk
factors for malnutrition
Loss of appetite can sometimes be related to a change in medication
It is very difficult to ingest enough nourishing food if teeth or dentures are loose,
broken or missing, if the tongue or gums are sore; if there are any swallowing
difficulties
As a result of these problems, major food groups may be omitted and the person
may avoid socialisation
Severe deficiencies of some of the micro-nutrients can actually cause mouth
problems
People are put at nutritional risk by any acute or chronic illness which causes
change in their usual diet
Nobody should be on a modified or special diet, unless the aim and benefit of the
diet is clearly known to them
If a special diet is required for specific treatment, then it becomes very important
to follow it properly
The vulnerable person may only buy foods which are easy to carry or easy to
prepare and to cook
A person who is unable to shop may not eat enough because of reduced food
choice (no ideas or prompts), and a reduced level of independence
A person may not be physically able to prepare and cook food
This lack of independence can seriously affect enjoyment and intake
There may be problems organising their food into nourishing meals and snacks,
and possibly dislike of the foods and fluids offered
A person who requires feeding may not eat enough
This may be because of embarrassment, insufficient assistance and care, or not
enough time to eat and drink
It might be due to inappropriate presentation and types of items offered, or dislike
of the foods and fluids offered
Obvious overweight affecting life quality? Unintentional weight gain?
A good body weight is a protective factor in the vulnerable person
Body fat is an energy store for stress (infections, trauma) or reduced appetite,
reduced food or fluid intake or unintentional weight loss
An overweight person on a very restricted diet is at risk of muscle wasting, falls,
infection and illness. If weight loss is essential, always refer to a specialist
Nutritional Risk Screening and Monitoring Trigger Questions
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SECTION 2
NUTRITIONAL RISK SCREENING AND
MONITORING
17
2.1 NUTRITIONAL RISK SCREENING AND
MONITORING AS PART OF THE
ASSESSMENT AND INTERVENTION
PROCESS
REFERRAL
Client Information and Referral Process
GENERAL NEEDS ASSESSMENT AND MONITORING
NUTRITIONAL
RISK
SCREENING
AND
MONITORING
CLIENT CARE PLAN
COMMUNITY DEVELOPMENT
Equitable access
Safe quality food
Public transport
Shop locations
User friendly shops
Local cafes and markets
RESOURCES
Policies
Staff
Development
and training
Staff support
Quality
improvement
SIMPLE
INTERVENTIONS
Client and carer
information
Social support
Home carer
Transport
Shopping
Food
preparation
Personal carer
Meals
Food safety
Delivered meals
Respite Care
Referral to
specialisation
assessment and/
or intervention
and care
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2.2 THE NUTRITIONAL RISK SCREENING AND
MONITORING TRIGGER QUESTIONS
Nutritional risk definition: The risk factors of poor nutritional status are characteristics that are
associated with an increased likelihood of poor nutritional status (Nutrition Screening Initiative,
1992).
Nutritional risk screening and monitoring definition: The process of discovering characteristics
known to be associated with dietary or nutritional problems (Nutrition Screening Initiative,
1992).
The purpose of nutritional risk screening and monitoring is to identify:
1) Individuals at high risk of food and nutrition problems
2) Individuals who already have poor nutritional status
Screening then facilitates intervention.
Nutritional risk screening and monitoring:
The first level of nutritional risk screening and monitoring applies to all clients at initial
assessment, and then at each monitoring stage thereafter: YES, to ONE OR MORE of the
following questions means that nutritional risk exists for the client.
1) Obvious underweight-frailty?
This factor is more important if underweight is not the normal situation for the client.
Astable body weight at a low level (say 80-90%) over a period of years can be consistent with
apparent health, but a bout of poor food intake and/or increased energy and nutrient needs
can precipitate severe weight loss. As far as we know, it is unlikely that life can be sustained
when body weight drops below say 60% of the reference weight.
To regain weight more energy must be taken in food and drink than the body requires. This is
particularly difficult for a vulnerable person to achieve on a consistent daily basis for weeks
and perhaps months.
Prevention of underweight is highly desirable in vulnerable people.
2) Unintentional weight loss?
When a person loses a lot of weight without trying (say 5 kg over six months or less), it is a
serious sign of decline into a poor nutritional state and perhaps malnutrition. This decline is
more rapid and worse if the person was underweight before the weight loss began.
Of all the signs and symptoms of malnutrition, severe weight loss is the factor most clearly
associated with relatively higher rates of morbidity and mortality. It is not a sign to be ignored.
Check that fluid retention is not masking weight loss or that dehydration has not contributed
to this weight loss.
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3) Reduced appetite or reduced food and fluid intake?
In the underweight vulnerable person, a short period (more than one or two days) of reduced
appetite and reduced food intake can rapidly lead to severe weight loss.
4) Mouth or teeth or swallowing problem?
It is very difficult for a person to ingest enough nourishing food (with variety) if their teeth or
dentures are loose, broken or missing, or if they have a sore tongue and gums, or swallowing
difficulties.
5) Follows a special diet?
Any acute or chronic illness which causes distortion of the usual diet puts the person at
nutritional risk.
6) Unable to shop for food?
Aperson may not be physically capable of shopping for food. This independence lack may
seriously affect their enjoyment, appetite, choice and intake of food and fluids.
7) Unable to prepare food?
Aperson who is unable to prepare food for themselves may not eat enough because of lack of
choice, a reduced independence level, and possible dislike of foods offered.
8) Unable to feed self?
In this difficult situation, the person may have reduced food and fluid intake because of lack of
independence, embarrassment, possible lack of care and attention to feeding by the Carer, and
possible dislike and monotony of the foods offered.
9) Obvious overweight affecting life quality?
People who are moderately overweight will have more protection from any stress which
reduces food intake (even temporarily).
To lose weight, an older person must follow a very strict diet for a long time. This affects their
life quality and their health may also deteriorate.
Even if life quality is obviously affected by overweight, the decision has to be made as to
whether the harm caused by any strict weight reduction will be too great.
10) Unintentional weight gain?
This factor is only really important in younger disabled people who are already on the brink of
being overweight or who are obese.
In the frail vulnerable person of any age, weight gain may be due to fluid retention.
Unintentional weight gain (unless due to fluid retention) is likely to be useful to vulnerable
people who are underweight or of normal weight.
Unintentional weight gain may be disadvantageous in overweight people with severe heart
disease or lung disease or diabetes or problems with mobility (see above).
When there is YES, to ONE OR MORE of these questions, it means that nutritional risk exists for
the client. The diagram in Section 2.3 shows these trigger questions listed in a way which can be
easily attached to the assessment form. More detailed exploration of these trigger questions can
be found in Section 3.
CONDUCTED
WITH CLIENT
INFORMATION
AND SERVICES
RECORD AND
CLIENT-CARER
INPUT
OPTIONAL
PLACEMENT
ON ASSESSMENT
FORM
OPTIONAL
PLACEMENT IN
CLIENT
INFORMATION
AND SERVICES
RECORD
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2.3 THE NUTRITIONAL RISK SCREENING AND
MONITORING TOOL FOR HOME-BASED ADULTS
CLIENT: DATE:
INSTRUCTIONS:
Fill in the clients name and the date you use the tool: tick the box
when the answer to your observation is YES
OUTCOME:
ACTION:
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2.4 HOW DOES NUTRITIONAL RISK SCREENING
AND MONITORING FIT INTO ASSESSMENT
AND PLANNING ASSISTANCE FOR
INTERVENTION?
The next diagram shows where this simple and quick method of nutritional risk screening and
monitoring can be used in association with the Client Information and Referral process or forms
or any other assessment form or process. The Nutritional Risk Screening and Monitoring Tool
may also be placed in the client Information and Services Record book (refer Section 2.3).
This diagram also shows that further nutritional risk screening is embedded in the General Needs
Assessment and Monitoring conducted with the client, which will probably reveal the reasons
why the client is at nutritional risk.
REFERRAL
Client Information and Referral Process
GENERAL NEEDS ASSESSMENT AND MONITORING
NUTRITIONAL
RISK
SCREENING
AND
MONITORING
CLIENT CARE PLAN
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2.5 GENERAL ASSESSMENT INCLUDES
FACTORS RELEVANT TO NUTRITIONAL RISK
1) Household management problems
a) Financial difficulties?
Has food run out in the past week with no $ to get more?
Less than $30 for food a week?
b) Organisational difficulties?
2) Social problems
a) Bereavement, depression, social isolation (reduced food intake common)?
b) Reduced motivation to eat or drink for known or unknown reasons?
c) Unable to access or use secure, clean food storage and preparation area?
d) Rummaging, foraging, begging or stealing food?
3) Personal and food hygiene problems:
a) Possible food contamination and diarrhoeal illnesses?
4) Dietary problems.
a) Irregular meals or less than 3 meals a day?
b) Doesnt take 1 3 3 4 5+ food plan most days (frail older person)?
c) Doesnt take 1 2 3 4 5+ food plan most days (younger adults)?
d) Did not have one or more of the food groups yesterday?
e) Excessive use of sweet or savoury foods?
f) 2+ alcoholic drinks daily?
g) Housebound? No direct exposure to sunlight?
h) High dependency with food and fluid texture modification?
i) Tube (enteral) feeding is required?
j) Eats inedible objects such as dirt, soap (pica)?
k) Inappropriate and challenging behaviours which involve food?
5) Mental health problems
6) Poly-drugs (more than three types of medications daily)
The more medications taken, the more likely these medications are to interact to produce side
effects such as loss of appetite, taste change, nausea, diarrhoea, constipation, fatigue and
drowsiness (causing reduced food intake).
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7) Gastro-intestinal problems
a) Nausea and vomiting
b) Diarrhoea
c) Constipation
d) Incontinence
e) Regurgitation
f) Rumination
8) Breathing problems
9) Other medical problems
a) Medical problems reducing ability to access enough food and fluids
b) Medical problems increasing the need for nourishment
c) Major medical disorders which change the clients need for nourishment
10) Alcoholism and substance abuse
More detailed explanation can be found in Section 4 for the general needs assessment factors
which are related to nutritional risk.
Nutritional risk increases when the person is affected by an
increasing number of these factors.
Deterioration in health and loss of independence can result from
under-nutrition and perhaps malnutrition.
Nutritional risk can be a client safety issue
Low body weight? Section 3.1
Unintentional weight loss? Section 3.2
Unable to feed self? Section 3.8
Rumination?
Regurgitation?
Choking?
Food contamination? Section 4.4
Unable to recognise food? Section 4.5
Rummaging for food?
Alcohol withdrawal? Appendix 2
27
2.6 CHECKLIST FOR INTERVENTION
Simple intervention strategies have been provided thoughout this Manual and an outline of these
strategies has been given below.
1) Food and nutrition information
a) Client
b) Carer
2) Client care plan with client-carer input
3) The most appropriate INTERVENTION then follows:
a) Family, person responsible, g) Case management
key worker h) Medical care, dental care
b) Home care, personal care, i) Nutritional care
social trainer j) Counselling, information
c) Day care, respite care k) Living skills program
d) Nursing care l) Other allied health resources
e) Social support m) Disability services
f) Volunteer transport
SIMPLE
INTERVENTIONS
Client and carer
information
Social support
Home carer
Transport
Shopping
Food preparation
Personal carer
Meals
Food safety
Delivered meals
Respite care
Referral to
specialisation
assessment and/or
intervention and care
CLIENT CARE PLAN
28
3) Client referral for further assessment and/or intervention
a) Visiting nurse g) Physiotherapist
b) Doctor h) Dentist
c) Dietitian i) Psychologist
d) Occupational therapist j) Delivered meals
e) Speech pathologist k) Diabetic educator
f) Social worker l) Other
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2.7 MONITORING IS CONDUCTED AS REQUIRED
Try TWO weeks of simple intervention strategies (less time if severe weight loss); if no response
refer to a specialist. Monitoring at monthly intervals (or more frequently), by one of the team
members to determine if nutritional risk still exists.
To determine if nutritional risk still exists, this is accomplished by review of outcomes, and best
determined by repeat of Nutritional Risk Screening:
CLIENT: DATE:
INSTRUCTIONS:
OUTCOME:
ACTION:
30
The care process and plan then begins again
On the next page (Section 2.8), a Case Study form has been provided for clients in Nutritional
Risk Screening. Anumber of Case Studies have been shown in Sections 7 to 9, and Section 10 is
about Quality Improvement using Nutritional Risk Screening processes.
3
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Nutritional risk increases when the person is affected by an increasing number of general
needs assessment factors.
Deterioration in health and loss of independence can result from undernutrition and perhaps
malnutrition.
NAME:
ADDRESS:
NUTRITIONAL RISK SCREENING
YES, to one or more of these questions
means that nutritional risk exists
GENERAL NEEDS ASSESSMENT
The factors which are relevant to nutritional
risk for this client
INTERVENTION
Briefly consider what, if any, action you can
take (including referral)
MONITORING*
Repeat nutritional risk screening
How often should this be done?
Who can monitor?
Reduced appetite or
reduced food or fluid intake?
Mouth or teeth or swallowing
problem?
Obvious overweight
affecting life quality?
*Try TWO weeks of simple intervention strategies (less time if sever weight loss); if no response refer to a specialist. Monitoring at monthly intervals (or more frequently) by one of the
team members is recommended to ensure that the most effective intervention has been implemented.
Signature: Position: Date:
2.8 NUTRITIONAL RISK SCREENING CASE STUDY FORM
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Checklist of general needs assessment factors which are related to nutritional risk:
1) Unable to feed self
a) Physical disability
b) Sensory disability
c) Mental/ behavioural problems
4) Social problem affecting food/fluid
intake
a) Bereavement, depression, social
isolation
b) Reduced motivation
7) Medical problems/increased food and
drink needs
a) Elevated body temperature, fever
b) Impaired wound healing
2) Household management problems
a) Financial difficulty
b) Organisational difficulty
5) Medical problems/reduced access
food/fluid.
a) Weight loss, muscle wasting,
reduced mobility
b) Breathing problems
8) Major disorders/changed nourishment
needs
a) Metabolic disorders (diabetes/
renal/liver)
b) Cancer
c) Gastro-intestinal disorders
3) Personal hygiene and food hygiene
problems
6) Medical problems/reduced
intake/absorption
a) Nausea and vomitingb) Diarrhoea
c) Constipation d) Incontinence
e) Regurgitation f) Rumination
9) Poly-drugs (more than three types daily)
Checklist for intervention and referral: the most appropriate supply of client needs may then be provided
1a) Client food and nutrition information
1b) Carers food and nutrition information
2) a) Family, person responsible, key
worker
b) Home care, personal care, social
trainer
c) Day care, respite care
d) Nursing care
e) Social support
f) Volunteer transport
g) Case management
h) Medical care, dental care
i) Nutritional care
j) Counselling, information
k) Living skills program
l) Other allied health resources
m) Disability services
n) Client care plan with client-carer input
3) Client referral for assessment and
intervention
a) Visiting nurse
b) Doctor
c) Dietitian
d) Occupational therapist
e) Speech pathologist
f) Social worker
g) Physiotherapist
h) Dentist
i) Psychologist
h) Delivered meals
i) Diabetic educator
j) Other
33 Identifying and Planning Assistance for Home-Based People Who are Nutritionally at Risk: A Resource Manual (2001)
2.9 NUTRITIONAL RISK SCREENING IN OTHER
SETTINGS
2.9.1 Discharge Planning and Temporary Home Care
Emergency or temporary home care may be required for a person under the following
circumstances:
1) Client discharged from hospital or respite care on a Friday, or just prior to a public holiday,
and/ or
2) No able or responsible person nearby to provide support, shop and prepare food for the client.
CLIENT: DATE:
INSTRUCTIONS:
OUTCOME:
ACTION:
35
2.9.2 Retirement Villages, Supported Residential Services,
and Day Care Centres, Sheltered Workshops, and
Shelters
1) Nutritional Risk Screening
The Nutritional Risk Screening tool can also be used in these settings. It is possible to observe
and monitor the trigger questions, as follows.
Obvious underweight - frailty?
Unexplained weight loss?
Reduced appetite or food and fluid intake?
Always record your observations about different people, and if these observations persist try to
achieve some preventive strategies or intervene in some way.
If you have the opportunity to apply the trigger questions of Nutritional Risk Screening with the
group (either directly, or indirectly by observation), use the forms in Section 10 to create your
report and to look at the group as a whole.
2) Discussion of food and health issues
Opportunities may also be available to discuss food and nutrition issues with the group of people.
On the first occasion, ask them one of the screening questions and use their response to create
some discussion and increase their awareness of the importance of what they eat and drink.
Acreative and colourful wall poster or signboard can also be used to focus attention and act
as a reminder to them. The material in this Resource Manual can be simplified and used for this
purpose. The local dietitian will be able to assist in the development of your program, provide
appropriate brochures and leaflets, and perhaps attend on some occasions.
Amealtime is an ideal time to talk about food, nutrition, and health.
3) Apparently healthy and active older people
If the older group is apparently healthy and active, you may wish to ask them to fill in the ten
trigger questions in Nutritional Risk Screening above. This will increase awareness of food and
nutrition and health issues and promote much discussion.
37
SECTION 3
NUTRITION AND HEALTH ISSUES
In this Manual, vulnerable people include frail elderly
people, adults with disability, and financially
disadvantaged adults living in alternative accommodation
39
3.1 OBVIOUS UNDERWEIGHT FRAILTY?
This factor is important because the underweight adult has so little body energy and nutrient
reserves for use in times of emergency such as illness or reduced food and fluid intake. This is
even more critical to health, if underweight is not the normal situation for the particular person.
Astable body weight at a low level (say 80-90%) over a period of years can be consistent with
apparent health, but a bout of poor food intake or increased needs can precipitate severe weight
loss. As far as we know, it is unlikely that life can be sustained when body weight drops below,
say 60% of the reference weight.
The vulnerable adult is in a difficult position, because to regain weight more energy must be
taken in daily food and drink than the body requires on a daily basis. This is difficult for a
vulnerable person to maintain on a consistent basis for weeks and perhaps months.
Prevention of underweight is highly desirable in the vulnerable person. Those who are
moderately overweight will have more protection from any stress which reduces food intake
(over a day or two). Even temporary reduction in food and fluid intake will have an effect.
Relevant comments:
I am always this weight
I am very tired
I cant go to the letterbox at the moment
I like to be thin, it is natural to be thin when you are old or disabled
Observations:
Is the person obviously underweight or wasted?
Are there any signs of fluid retention (swollen feet, hands) pushing weight up?
Are there any signs of dehydration (decreased back of hand skin elasticity) pushing weight
down?
Try to identify possible reasons for underweight-frailty.
Further questions:
Do you think that you are losing weight?
How long have you been at your present weight?
Assessment of body weight status (a global indicator of nutritional status)
If you have the persons weight and height, look up their best weight range in Section 3.1.1
(adults over 65 years), 3.1.2 (adults 16 to 64 years).
40
Simple interventions:
Address any identified problems
Increase the awareness of the person and carer
Statement you can make to the person:
You can help yourself by starting to eat little and often
Review medications
Update food preferences
Suggest three small meals and three small snacks every day
Give most food when the person is most alert
Allow adequate time for meals and snacks
Provide substitutes for meals refused
Recommend use of extra milk (to ensure tolerance to milk, increase milk gradually)
Increase energy intake with extra sugar, milk, margarine, thick soups, cream
Suggest fortified drinks between meals (particularly at night), for example-milk with skim
milk powder and topping for a high energy milk shake, milo (refer Section 5.3.3.1)
Ask a dietitian about nourishing snacks for the person to take between meals
Amulti-vitamin and mineral supplement may be recommended two to three times weekly
(Refer Section 5.7)
Encourage slight increase in activity
Monitor weight
Monitoring:
Low body weight may be a client safety issue
Weekly support and check of food and fluid intake and weight is important
Check outcome: Obvious underweight-frailty?
Consider referral: doctor dietitian, if no improvement in two weeks (less time if severe weight
loss as well)
41
3.1.1 Healthy Weight Range for People Over 65 Years
Height Ideal weight range
centimetres feet and kilograms stone (st) and pounds (lb)
inches
142 4 8 44.4 to 54.4 6 st 13 lb to 8 st 5 lb
145 4 9 46.3 to 56.8 7 st 3 lb to 8 st 12 lb
147 4 10 47.5 to 58.3 7 st 6 lb to 9 st 1 lb
150 4 11 49.5 to 60.8 7 st 10 lb to 9 st 7 lb
152 5 0 50.8 to 62.4 7 st 13 lb to 9 st 10 lb
155 5 1 52.9 to 64.9 8 st 4 lb to 10 st 2 lb
158 5 2 54.9 to 67.4 8 st 8 lb to 10 st 8 lb
160 5 3 56.3 to 69.1 8 st 11 lb to 10 st 11 lb
163 5 4 58.5 to 71.7 9 st 2 lb to 11 st 2 lb
165 5 5 59.9 to 73.5 9 st 5 lb to 11 st 7 lb
168 5 6 62.1 to 76.2 9 st 10 lb to 11 st 13 lb
170 5 7 63.6 to 78.0 9 st 13 lb to 12 st 5 lb
173 5 8 65.8 to 80.8 10 st 4 lb to 12 st 9 lb
175 5 9 67.4 to 82.7 10 st 7 lb to 12 st 13 lb
178 5 10 69.7 to 85.5 10 st 12 lb to 13 st 5 lb
180 5 11 71.3 to 87.5 11 st 2 lb to 13 st 9 lb
183 6 0 73.7 to 90.4 11 st 7 lb to 14 st 2 lb
185 6 1 75.3 to 92.4 11 st 11 lb to 14 st 6 lb
188 6 2 77.8 to 95.4 12 st 2 lb to 14 st 12 lb
This table shows the best and most protective weight range for height, in older people over 65
years. This range is higher than that for other people, and approximates a body mass index of 22-
27.
43
3.1.2 Healthy Weight Range for Adults 16 to 64 Years
It is difficult to provide one simple healthy weight range for younger adults. These clients range
from those who are active and ambulant and independently living-to those who are vulnerable,
perhaps non-ambulant and highly dependent.
Significant recent weight change particularly unintentional weight loss (refer Section 3.2) is more
important for morbidity and mortality than actual body weight.
Active adults 16 to 64 years
The healthy weight range for active younger adults 16 to 64 years is shown on the next page, and
is always applied with common sense.
Vulnerable, and highly dependent people
It is difficult to set body weight standards for these people as a group. For the individual,
difficulties may include retarded growth and development, immobility, distorted body shape,
limb contractures, spinal deformity, and skeleton abnormalities.
In most cases, low body weight is NOT due to the particular disability, but due to low food intake
and perhaps a higher need for nourishment.
An arbitrary choice of body weight standard can be made and considerable care needs to be
taken in deciding what is the persons best weight. For practical reasons this may be on the low
side (say no more than 5 kg less than that for more ambulant clients).
In essence, the choice of an appropriate body weight is usually a practical decision, based on the
body weight when the person has the best health and life quality. It may come back to
maintenance of the clients usual weight.
44
Height Ideal weight range
centimetres feet and kilograms stone (st) and pounds (lb)
inches
142 4 8 40.3 to 50.4 kg 6 st 5 lb to 7 st 13 lb
145 4 9 42.1 to 52.6 kg 6 st 9 lb to 8 st 4 lb
147 4 10 43.2 to 54.0 kg 6 st 11 lb to 8 st 7 lb
150 4 11 45.0 to 56.3 kg 7 st 1 lb to 8 st 12 lb
152 5 0 46.2 to 57.8 kg 7 st 4 lb to 9 st 1 lb
155 5 1 48.1 to 60.1 kg 7 st 8 lb to 9 st 6 lb
158 5 2 49.9 to 62.4 kg 7 st 12 lb to 9 st 11 lb
160 5 3 51.2 to 64.0 kg 8 st 0 lb to 10 st 1 lb
163 5 4 53.1 to 66.4 kg 8 st 5 lb to 10 st 6 lb
165 5 5 54.5 to 68.1 kg 8 st 8 lb to 10 st 10 lb
168 5 6 56.4 to 70.6 kg 8 st 12 lb to 11 st 1 lb
170 5 7 57.8 to 72.3 kg 9 st 1 lb to 11 st 5 lb
173 5 8 59.9 to 74.8 kg 9 st 6 lb to 11 st 11 lb
175 5 9 61.3 to 76.6 kg 9 st 9 lb to 12 st 0 lb
178 5 10 63.4 to 79.3 kg 9 st 14 lb to 12 st 6 lb
180 5 11 64.8 to 81.0 kg 10 st 3 lb to 12 st 10 lb
83 6 0 67.0 to 83.7 kg 10 st 7 lb to 13 st 2 lb
185 6 1 68.5 to 85.6 kg 10 st 11 lb to 13 st 6 lb
188 6 2 70.7 to 88.4 kg 11 st 2 lb to 13 st 12 lb
This table shows the best and most protective weight range for height, in adults 16 to 64 years.
This range approximates a body mass index of 20 to 25.
Healthy Weight Range for Adults 16 to 64 Years
45
3.2 UNINTENTIONAL WEIGHT LOSS?
When a vulnerable person loses a lot of weight without trying (say 5 kg over six months or less),
it is a serious sign of decline into a poor nutritional state and perhaps malnutrition. This decline is
more rapid and worse if the person was underweight before the weight loss began.
Of all the signs and symptoms of malnutrition, severe weight loss is the factor most clearly
associated with relatively higher rates of morbidity and mortality. It is not a sign to be ignored.
Ask the visiting nurse to check that dehydration has not contributed to this weight loss.
Loss of weight can occur for the following reasons:
Reduced food intake (refer Section 3.3)
Mouth or teeth or swallowing problem (refer Section 3.4)
Feeding problems (refer Section 3.8)
Nausea and vomiting (refer Section 4.7)
Diarrhoea or constipation (refer Sections 4.8 and 4.9)
Increased need for energy (such as illness and/ or increased activity) (Refer Section 5.3.3)
Clients who have lost weight unintentionally may not be getting enough food for their needs.
Less food may be eaten or there may be an increased need for food due to disease. If medication
is taken, this may require review.
Relevant comments:
I think that I am losing weight
My clothes dont fit me
My dentures are loose
I feel weak
Observations:
Try to identify possible reasons for unintentional weight loss
Severity of body weight loss (note that it may be masked by fluid retention)
Time Significant From 70 kg From 60 kg From 50 kg From 40 kg
weight loss
Over 1-month 5 3.5 kg 3 kg 2.5 kg 2 kg
Over 1-3 months 7.5 5.3 kg 4.5 kg 3.8 kg 3 kg
Over 3-6 months 10 7 kg 6 kg 5 kg 4 kg
Time Severe From 70 kg From 60 kg From 50 kg From 40 kg
weight loss
Over 1month More than 5 % More than More than More than More than
3.5 kg 3 kg 2.5 kg 2 kg
Over 1-3 months More than 7.5 % More than More than More than More than
5.3 kg 4.5 kg 3.8 kg 3 kg
Over 3-6 months More than 10 % More than More than More than More than
7 kg 6 kg 5 kg 4 kg
46
Further questions:
How much weight have you lost overall?
How long did it take to lose that weight?
What is your usual weight?
How has this weight loss affected you?
Always review medications
Provide motivational counselling through statements such as:
You will feel much better when you eat much better
Your leg ulcer will heal up when you are back to your best weight
You will feel better when you eat food to give you energy
Suggest three small meals and three small snacks every day (3+3)
Increase energy intake with extra sugar, milk, margarine, thick soups, cream
Suggest fortified drinks between meals (particularly at night), for example-milk with skim
milk powder and topping for a high energy milk shake, Actavite, Milo. Improve tolerance by
not giving large amounts at first (refer Section 5.3.3.1)
Ask a dietitian about nourishing snacks to take between meals
Amulti-vitamin and mineral supplement may be recommended two to three times weekly
(Refer Section 5.7)
Monitoring:
Unintentional weight loss is a client safety issue
Monitor weekly until weight loss has ceased, and improvement begun
Check outcome: Unintentional weight loss?
Always refer for specialist advice: doctor, dietitian, if weight loss continues for one or two weeks
(depending on severity and time)
47
3.3 REDUCED APPETITE OR REDUCED FOOD
AND FLUID INTAKE?
In the underweight person, a short period (more than one or two days) of reduced appetite and
reduced food and fluid intake can rapidly lead to severe weight loss.
Many vulnerable people miss meals and so dont get enough energy and nutrients from their
food. Some reasons for skipping meals include loss of appetite, poor memory, loneliness,
difficulties in preparing food, access to food, and lack of money.
Adults who receive Meals on Wheels may divide the one delivered meal into lunch and tea, and
not eat any other food that day.
Some people follow special diets that were prescribed many years ago that may no longer be
appropriate or needed (refer Section 3.5).
Illness can cause poor appetite, and treatment may even include diets which limit the foods
which can be eaten and reduce enjoyment of food. Loss of appetite can sometimes be related to a
change in medication. Taste and smell sensations are reduced in vulnerable people, and these can
be further reduced by some medications (refer Section 4.6).
Illness can also increase the need for food. Common diseases such as Alzheimers, dementia,
Parkinsons disease, infections, fractures and hyperactivity all increase the need for additional
energy from food (Section 4.5). Adults who are not taking 6 to 8 cups of fluid every day are
probably missing out on nourishment as well as fluid intake (refer Section 5.4)
Relevant comments:
I only eat two meals a day
I have (or have had) an illness or condition that made me change the kind and/or amount of food I eat
I never eat a proper meal
Observations:
If not eating because of a diet (refer to Section 3.5)
Is the problem due to social isolation, poverty, or a functional dependency or disability?
If an adult spends less than $ 30 on food each week, it is unlikely that s/he can buy enough
food to supply them with adequate nutrients (refer Section 4.2)
Does the person live alone or have limited social support? Is the person housebound?
Does s/he need assistance to walk, travel, shop, prepare and cook food, etc?
Does s/he have access and use of a secure, clean food storage and preparation area?
Is there any evidence of mental problems?
Further questions:
Try and identify the reason for reduced appetite or reduced food and fluid intake
Do you miss meals because they are difficult to prepare or cost too much?
Do you keep some of your Meals on Wheels for later?
If appetite is poor: How long have you had a poor appetite?
48
Address reasons for reduced food intake
Review medications such as digoxin toxicity
Suggest small frequent meals or snacks (3+3)
The person should eat most when their appetite is best-even if not at a usual mealtime
Consider a special nutritional supplement if food intake is very small
Suggest home care services assist with meal preparation or assistance with shopping
Check if assistance is required with finances
Can Meals on Wheels provide an evening meal?
For people who forget meals:
-Can someone visit around meal times to remind them?
-Can they attend group meals where they will be encouraged to eat with others?
What to do when people say they just dont want to eat:
Emphasise that improved eating will make them feel better; they could feel stronger, have less
constipation or have their wounds heal more quickly
Avoid setting goals related to weight; the desired outcome is eating and feeling better
Better nutrition helps to maintain independence
Set small (or even smaller) goals and gradually build on them
Even a small glass of milk, a banana, sandwiches, a couple of biscuits with cheese, or sugar in
cups of tea can make a difference if repeated day after day
Be patient: their food intake may be low but each improvement brings them closer to their goal
Encourage social contact at mealtimes with family or neighbours, or arrange transport to
group meals or distant friends; look to include them in other social activities which include
some food
Monitoring:
At least monthly
Check outcome: Reduced appetite or reduced food and fluid intake?
Consider referral: doctor (for any sudden change in appetite), dietitian (for problems with a diet
or when supplements might be needed to make up for a poor intake); bereavement counsellor,
Aged Care Packages Team, Aged Care Recreation Officer
Others may be relevant-Social worker, Local Government Community Services (including Meals
on Wheels), day care, occupational therapy, physiotherapy.
49
3.4 MOUTH OR TEETH OR SWALLOWING
PROBLEM?
It is very difficult for people to ingest enough nourishing food (with variety) if their teeth or
dentures are loose, broken or missing, or if they have a sore tongue and gums, or any swallowing
difficulties. Oral health involves teeth, gums, dentures, swallowing and dryness or pain in the
mouth.
Problems include missing teeth, ill-fitting dentures, teeth grinding, chewing and swallowing
difficulties, cracked or sore lips, dry mouth, sore tongue, gingivitis, and pain or sensitivity to hot
or cold.
As a result of mouth or teeth problems, many people may omit some foods or an entire food
group from their diet. These problems may affect food and fluid intake, nutritional quality of the
diet and socialisation.
Severe deficiencies of micro-nutrients (iron, folate, riboflavin, ascorbic acid) can actually cause
mouth problems.
Meat (a valuable source of protein, iron, zinc and energy, and other micro-nutrients) is the most
common food which will be avoided because of mouth, teeth or swallowing problems.
Poor oral health leading to weight loss is an important risk factor for malnutrition, and
intervention in this area of health may be very important for some clients. Specific medical
problems can also occur (dysphagia, cancer) which cause even more complex problems.
Aswallowing problem is a physical symptom of an underlying disorder.
Relevant comments:
I have a teeth, mouth, or swallowing problem that makes it hard for me to eat
This medicine makes my mouth dry
Further questions:
Try to investigate the reasons for mouth, teeth or swallowing problems
Does the person have one or more of the following:
-Loose teeth or ill-fitting dentures? Teeth grinding?
-Dry mouth? Pain, soreness in tongue?
-Soreness/cracks in corner of mouth?
-Mouth sores that dont heal?
-Bleeding, swollen gums?
-Toothache or sensitivity to hot and cold?
-Pain, clicking in jaw?
How long is it since your client visited the dentist?
-If the person has visited the dentist recently, what was the reason for this visit (checkup,
dentures fitted)?
50
Are there any other causes of the swallowing problem?
-Is food consistency and texture an issue?
-Is the temperature of food and fluids an issue?
-Is food quantity an issue?
-Is there a problem swallowing liquids or solids or both?
-Is gagging and/or choking a problem?
-Is the throat sore?
-Is the person drowsy at the mealtime?
-Is food found in the mouth some time after a meal?
Plan intervention to correct or limit signs and symptoms, and if possible the causative factors
Ill fitting dentures should be adjusted or replaced
Suggest use of lip balm to keep the lips moist
Use soft and minced meats
Use soft and wet foods instead of liquid and dry foods
Avoid irritants such as peppers and spices
Encourage small frequent meals and snacks (say 3+3)
Encourage concentrated high energy items such as sugars, and perhaps fats
If chewing meat is a problem suggest casseroles and minced meat dishes. If the client is on
Meals on Wheels, arrange for the meat to be soft (not always minced)
Include concentrated high energy items such as sugars, and perhaps fats
Increased presence of mucus or phlegm is NOT improved by avoiding milk; if this is a
problem (in the absence of disease), then encourage extra fluid of any kind, including milk
For a dry mouth and/or cracked lips-encourage adequate fluid intake and sipping of water to
keep the mouth moist, and suggest gravies and sauces with meals to make the food moist
Review the effect of medication over the mealtime
Monitoring:
Weekly review of mouth, teeth and swallowing difficulties, body weight
Check outcome: Mouth, teeth or swallowing problem?
Consider referral: visiting nurse, dentist, chemist, doctor, dietitian, speech pathologist (Difficulty
in swallowing should always be investigated by a doctor, with possible referral to a speech
pathologist and dietitian)
51
3.5 FOLLOWS A SPECIAL DIET?
Vulnerable people are put at nutritional risk by any acute or chronic illness which causes change
in their usual diet.
Modified and special diets can affect quality of life, be a nuisance and may cost clients more.
Modified/special diets are not always required for a lifetime and clients nutritional needs will
change over time.
Individuals often get mixed messages about food and diet from doctors, dietitians, and well
meaning relatives and friends; a coordinated approach is always required in the client care plan.
Clients can develop other health problems if the usual amounts and types of foods that they take
are restricted or altered to follow a modified or special diet; careful supervision is required.
No person should be on a modified or special diet unless the aim and benefit of the diet is clearly
known to them. Always assess the relevance of following a special diet at frequent intervals
(at least 6 to 12 months).
If a special diet is required for a specific therapeutic reason then it is important to follow it
properly. This will ensure that the clients health and well being improves, which makes it worth
the effort.
Relevant comments:
I am sick of this diet
I only follow it when I am sick
My doctor says that I shouldnt eat any food beginning with p
Observations:
Try to find out why the special diet is required and if the aim and benefit of the diet is clearly
known to the person
Further questions:
1) Why are you following this diet?
What is your diet doing for you?
Is it working for you? Do you still need it?
2) What do you think about this diet?
Does your diet suit you?
3) When did you start this diet?
How long have you been following this diet?
4) Who suggested/recommended/asked you to follow this diet?
Who gave you the details about this diet?
When did you last get your diet reviewed by a doctor and a dietitian?
52
Address the identified problem
Avoid adding to the mixed messages about the diet
Try to achieve a co-ordinated approach in the client care plan
If the modified or special diet appears to conflict with the health goals most appropriate for
the person now or if the person/carer does not know the reason why a modified diet is being
followed, or if the aim of the diet is not clear, always refer the person to the doctor and/or
dietitian
After firm encouragement and a trial period with a modified or special diet, consider cessation
after discussion with the person and carer, doctor and/or dietitian if compliance is poor
Monitoring:
Preferably monthly
Regular monitoring is essential if an adult is following a modified or special diet, in order to
make sure that the (treatment) goals of the diet are being achieved
Approach your local dietitian for assistance if required
Check outcome: Follows a special diet?
Always refer for specialist advice: doctor, dietitian.
53
3.6 UNABLE TO SHOP FOR FOOD?
Vulnerable people may only buy foods which are easy to carry or easy to prepare and cook.
Difficulty with shopping may be due to a decreased mobility or physical disability, or (if they
have not been shopping for some time) people may not know or remember what foods are
available. Aperson who is unable to shop may not eat enough because of reduced food choice
(no ideas, no prompts), a reduced level of independence, or reduced life quality.
Relevant comments:
I dont know what to eat when I dont go shopping; I like other people helping me
I am not always able to go shopping
Observations:
Try to identify possible reasons for inability to shop
Does your client have any other resources available to help them (family, neighbours)?
Further questions:
What is the main problem when you go shopping?
Address causes of the problem if possible
Assess food skills
Support maintenance of independence as long as possible
Arrange assistance from family and neighbours if possible
Help the person with shopping lists (basic items and extras)
Provide the client with information about food delivery from local shops and markets
Help to arrange food orders by telephone
Contact family or neighbour support for assistance with shopping
If you provide a shopping service, take the person with you when you can
Monitoring:
As often as possible
Check outcome: Unable to shop for food?
Consider referral: local government services, occupational therapist (for assessment and aids),
dietitian (for assessment and information), social worker (such as finance for utensils)
55
3.7 UNABLE TO PREPARE FOOD?
Vulnerable clients may not be physically or mentally capable of preparing and cooking food. This
lack of independence can have serious effects on their enjoyment of it, and their intake of food
and fluids. There may also be problems organising their food into nourishing meals and snacks.
Adults who are unable to prepare food for themselves may not eat enough because of lack of
choice (no ideas, no prompts), a reduced level of independence, possible dislike of the foods
offered, or reduced life quality.
Relevant comments:
I am not always able to cook for myself
I dont like the way she cooks the food
I dont like Meals on Wheels
My daughter cooks with too many spices
Observations:
Try to identify possible reasons for inability to prepare food
Does the person have any other resources available to help them (family, neighbours, friends)?
Would the person be helped by special utensils or Meals on Wheels?
Could the person assemble meals if the preparation was already done?
Assess food skills
Contact family or neighbour or friend for assistance with food preparation
Check if more prepared foods can be purchased
Check if prepared foods can be assembled and heated by the client
Check if packages can be opened, divided and stored cleanly and safely by the client
Would the person be helped by special utensils and devices, or by Meals on Wheels?
Provide simpler recipes
Monitoring:
Check outcome: Unable to prepare food?
Consider referral: occupational therapist (for assessment and aids), dietitian (for assessment and
information), social worker (such as finance for utensils), local government services.
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3.8 UNABLE TO FEED SELF?
Aperson with a physical, mental or intellectual problem may require feeding. Then a number
of reasons may give rise to reduced food and fluid intake such as embarrassment, loss of
independence, possible lack of time and care and attention by the carer, possible dislike of
the food and fluids offered.
Quality of life can be reduced by poor social and eating skills which reduce socialisation and
limit outings away from home.
Relevant comments:
I dont like the way she cooks the food
I dont like Meals on Wheels
The food hurts me
The food is cold
I am hungry
I want more
Observations:
Try to identify possible reasons for inability to feed self
Does the person have any other resources available to help them (family, neighbours, friends)
Would the person be helped by special utensils or Meals on Wheels?
Arrange assistance from family, neighbours and friends if possible
Provide special utensils and devices, or Meals on Wheels
Provide simpler recipes
Avoid actually feeding a person unless this is absolutely necessary
Monitoring:
Check outcome: Unable to feed self?
Always consider referral: dietitian (for assessment and information), occupational therapist
(for assessment and aids), social worker (finance for utensils etc.), Local Government Services.
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3.8.1 Feeding Problems in High Dependency Adults
Feeding high dependency adults is often time consuming and difficult. If it isnt done with
sufficient time, care and attention then the person often does not get enough food and fluid.
In this situation, clients often experiences increased feeding problems as their health deteriorates.
Complex feeding and swallowing problems most often improve as the persons nutritional health
improves towards the best weight for their best health.
Factors which need to be considered to reduce feeding problems and poor nutrition in high
dependency adults can include the following:
Low palatability of diet (appearance, smell, taste, texture)
Low nourishment value of foods and fluids offered
Inappropriate posture while feeding (sagging body when sitting up, unsupported chin)
Inappropriate timing of meals, insufficient time allowed to the client for meals
Low body weight, which is incorrectly perceived to be acceptable by client and/or carer
High energy and nourishment needs, hyper-activity, hyper-flexion of muscles
Embarrassment, discomfort and possibly pain and fear of eating and drinking
Chewing and swallowing problems, constipation
Dependency, inability to ask for more food or fluid, chronic underfeeding
Types of physical feeding problems:
Feeding dependency, drinking dependency
Food refusal, drink refusal
Drooling
Coughing while eating or drinking, or immediately afterwards
Swallowing air while feeding
Choking episodes (choking risk)
Gurgly wet voice during or after meals (aspiration risk from entry of food or fluid into the
lungs); food aspiration may also occur without any noise, when the person with silent
aspiration does not cough or blink
Vomiting
Regurgitation of food (unpleasant and unexpected return of previously swallowed food to
the mouth)
Rumination of food (previously swallowed food is deliberately returned to the mouth for
re-chewing, and then is re-swallowed)
THERE MAY BE RISK OF FOOD AND FLUID LUNG ASPIRATION SO:
DO NO HARM
DO NOT FORCE FEED
DO NOT CHANGE CLIENTS FEEDING ROUTINE IN ANY WAY
ALWAYS REFER FOR SPECIALIST ADVICE (DOCTOR, DIETITIAN)
60
Simple and safe interventions:
Sitting up support and chin support
Peaceful calm mealtimes, good hygiene displayed, no distractions
Appropriate time spacing of fluids and foods, and enough time to eat and drink
Attention to individuals food and fluid preferences
Consider taste, smell and appearance of the plated food, and the temperature of the food and
drink
Does the person know the name of the food and drink that they are having?
Refer Section 5.9.3 for advice about high dependency adults with feeding problems who require foods
and fluids which are modified in texture (thinned or thickened)
Adult safety issues:
Food and fluid aspiration into the lungs is a safety issue for all vulnerable persons with
feeding problems
Safety is an even more critical issue for frail adults who have lost a lot of weight and are
underweight and who aspirate into their lungs and are at risk of pneumonia
Concern is expressed that for individuals with aspiration swallowing problems the carer must
DO NO HARM and make no changes whatsoever to the persons feeding routine without
expert assistance and advice
DO NOT CHANGE the texture and thickness of foods and fluids without specialist advice
The person MUST be referred immediately to a specialist
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3.8.2 Nutrition Decision Tree for Adult Referral to a
Specialist
Feeding problem Referral
Consistent refusal of food and/or fluids? Dietitian, doctor, pharmacist, social
worker, psychologist
Gum or tooth disease? Visiting nurse, dentist
Cant reach meal and feed self? Carer
Cant sit in chair comfortably to feed? Occupational therapist, physiotherapist
Is a feeding program required? Dietitian, speech pathologist
Food or fluid dribbles out of mouth? Speech pathologist
Coughs, gags or chokes while feeding or Speech pathologist, dietitian
immediately afterwards?
A meal takes more than 40 minutes to eat? Doctor, dietitian, speech pathologist,
physiotherapist
A physiological problem with swallowing Speech pathologist, doctor
or silent aspiration?
Gurgly wet voice during or after meals?
Gut not functioning? Doctor
Will texture modification be sufficient to Doctor, dietitian, speech pathologist
make feeding safe?
Continue to monitor at regular intervals by
Nutritional Risk Screening and Monitoring
* Modified from the Nutrition Decision Tree (Dear & Webb, 1996).
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3.9 OBVIOUS OVERWEIGHT AFFECTING LIFE
QUALITY?
Normal to moderate overweight is a protective factor in the vulnerable person. Body fat provides
a readily available energy store and is a safeguard in times of stress (infections, trauma) or
reduced appetite and reduced food or fluid intake or unintentional weight loss.
To lose even small amounts of weight (say 0.5 kg a month), an overweight inactive person has to
follow a very strict diet which cannot provide enough nourishment for them to maintain their
physical activity and life quality. An overweight person who goes on a very restricted diet is at
risk of muscle wasting, infections and associated morbidity and mortality.
In making a decision about whether a weight loss program should be commenced in a vulnerable
overweight person, life quality should be considered. The answer lies in the balance between any
expected improvement in life quality with a small slow weight loss, versus any expected
deterioration in life quality due to a very restricted diet, muscle wasting and associated health
risks.
Abetter option for older adults may be omission of high energy refined foods and a goal of
weight maintenance. This is also the best option for people with a disability who have disorders
which are associated with obesity (Prader Willi syndrome, Down syndrome).
Relevant comments:
It doesnt hurt me to go without food; I am too fat anyway
I am having difficulty walking; I have always been tubby
The doctor says I have to lose weight
I havent eaten anything since yesterday because I am trying to lose weight
Observations:
Try to identify the possible effects on the person of overweight and obesity or of dieting
Further questions:
Do your legs feel weak?
Why are you trying to lose weight?
Adults who are concerned about their weight can safely avoid sugars, fats and alcohol
If the person is determined to follow a diet to lose weight, suggest a nourishing diet of the
1 3 3 4 5+ food plan for older people (refer Section 5.3.1) or the 1 2 3 4 5+ food plan for
younger adults (refer Section 5.3.2), without any extra foods
Also suggest a low dose vitamin and mineral supplement (three or four times a week)
Always consider referral to a dietitian if weight loss is essential
64
Monitoring:
As frequently as possible, for food intake, well being and weight
Check outcomes: Support weight maintenance or slow weight loss
(no more than 0.5 kg/month)
Consider referral: doctor, dietitian if weight loss is definitely needed.
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3.10 UNINTENTIONAL WEIGHT GAIN?
Unintentional weight gain can occur for the following reasons:
Change in medication
Constipation
Increased food intake
Change in food behaviour or feeding situation
Decreased activity
Fluid retention
In vulnerable adults, unintentional weight gain is not usually as
important as weight loss (refer Section 3.2), however-
If unintentional weight gain-occurs due to fluid retention, the adult may need medical care
and a medical check-up may be required
If weight gain occurs due to constipation, this is usually small and temporary and only
accounts for 1-2 kg; it can be corrected over time by change in food and bowel habits
(refer Section 4.9)
In overweight vulnerable people with severe heart disease (or lung disease, diabetes, or
problems with mobility), unintentional weight gain may be disadvantageous; in this case it
may be important to try to assist the person to prevent further weight gain (refer Section 3.9)
Relevant comments:
I am having difficulty walking
Can you get me some clothes that fit me?
I cant stop eating
I want fried foods, sweets, chocolates
Further questions:
Are you hungry?
Have you had any activity today?
Are you lonely?
Who are concerned about their weight can safely avoid sugars and fats and alcohol
If the person is determined to follow a diet to lose weight, suggest they follow a nourishing
diet of the 1 3 3 4 5+ food plan (for older people) or the 1 2 3 4 5+ food plan (for younger
adults), without any extra foods (refer Section 3.9)
Also suggest a low dose vitamin and mineral supplement (three or four times a week)
Always consider referral to a dietitian if weight loss is essential
66
Monitoring:
As frequently as possible, for food intake, well-being and weight
Check outcomes: Support weight maintenance or slow weight loss
(no more than 0.5 kg/month)
Consider referral: doctor, dietitian if weight loss is definitely needed
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SECTION 4
GENERAL ASSESSMENT OF FOOD AND
NUTRITION ISSUES
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4.1 Summary of General Assessment Factors Affecting
Food and Nutrition
1) Financial difficulties?
a) Has food run out in the past week with no $ to buy more?
b) Less than $30 for food for each adult person every week?
2) Social problems.
a) Bereavement, depression, social isolation (reduced food intake common)?
b) Reduced motivation to eat or drink for known or unknown reasons?
c) Unable to access or use secure, clean food storage and preparation area?
d) Rummaging, foraging, begging or stealing food?
3) Personal hygiene and food hygiene problems.
a) Possible food contamination, diarrhoeal illnesses
4) Food and dietary problems (refer Section 5.9)
a) Irregular meals or less than 3 meals a day?
b) Doesnt take 1 3 3 4 5+ food plan most days (older person)?
c) Doesnt take 1 2 3 4 5+ food plan most days (younger adults)?
d) Did not have one or more of the food groups yesterday?
e) Excessive use of sweet or savoury foods?
f) 2+ alcoholic drinks daily?
g) Housebound? No direct skin exposure to sunlight?
h) Eats inedible objects such as dirt, soap (pica)?
i) Inappropriate and challenging behaviours which involve food?
5) Mental health problems.
6) Poly-drugs (more than three types of medications daily)
The more medications taken, the more likely these medications are to interact to produce side
drowsiness (causing reduced food intake).
7) Gastro-intestinal problems
a) Nausea and vomiting
b) Diarrhoea
c) Constipation
d) Incontinence
e) Rumination
f) Regurgitation
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8) Breathing problems
9) Other medical problems
a) Medical problems reducing ability to access enough food and fluids
b) Medical problems increasing the need for nourishment
c) Major medical disorders which change the clients need for nourishment
d) Medical problems which are effectively treated by specific modified/special diets
10) Alcoholism and substance abuse
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4.2 FINANCIAL DIFFICULTIES
The amount of money that an adult has to spend on food each week may restrict the variety and
amount of food bought (see weekly food budget below). More expensive foods such as meat
contain many important nutrients. Adequate diets can be purchased on limited income but it
needs care and knowledge to do so.
Some people may not spend enough on food even when they have sufficient money to buy an
adequate diet. Their meals may become very limited and boring; they may lose interest in eating.
If less than $30 is spent on food for each adult every week ($22 in 1995), it is likely that the person
is not getting enough nourishment. People suffering economic hardship on a low income can find
it difficult to buy enough food, and to buy food which supplies them with adequate nourishment
(energy and nutrients). Aconsequence can be the effect of poor nutrition on quality of life and
health, which can progress into malnutrition.
Relevant comments:
I dont always have enough money to buy food
Cat food is so expensive now
Observations:
Try to identify possible reasons for financial difficulty
Further questions:
How much money do you spend on food each week?
Are you getting all of the financial assistance you are entitled to?
Weekly food budget
The minimum amount of foods needed for an adult to obtain adequate nourishment (but not total
energy) each day can be described in the food plan for each group as follows:
Adults over 65 years Adults from 16 to 64 years
1 serve Meat, fish, poultry 1 serve Meat, fish, poultry
3 serves Dairy foods 2 serves Dairy foods
3 pieces Fruit 3 pieces Fruit
4 serves Vegetables 4 serves Vegetables
5+ serves Breads and cereals 5+ serves Breads and cereals
20 g Margarine, butter, oil 20 g Margarine, butter, or oil
When these (minimum) food group items alone are costed as actual purchases in a competitive
supermarket, the total bill comes to about $30 a week. So it costs even more than this to buy
enough food to satisfy energy needs and appetite.
72
This is a theoretical exercise because people do not eat in such a prescribed and fixed way.
However it demonstrates the reasons why about $30 a week is the smallest amount of money that
an adult needs each week to purchase food which will meet their own basic need for
nourishment.
Ayounger active adult will need to spend even more than $30 a week on food for adequate
nourishment.
Monitoring:
Monthly-weight, physical appearance and life quality.
Check outcome: Financial difficulties?
Consider referral for particular advice: welfare worker, financial counsellor, social worker
(such as advice on finances), dietitian (for advice on buying adequate food on limited income)
- a dietitian can provide carers with education sessions on the most appropriate ways to assist
people on low incomes, and can also conduct supermarket tours
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4.3 SOCIAL PROBLEMS
Eating is usually a social activity and meals eaten with others are often more enjoyable; eating
alone can lead to reduced interest in food. Reliance may also be placed on ready prepared or
snack foods rather than on maintenance of cooking skills.
Reduced food intake is common when people are experiencing social isolation, bereavement or
depression. Vulnerable people may have even less motivation to eat or drink, for known or
unknown reasons.
Relevant comments:
I eat alone most of the time
I used to cook for ten people every night
It is awful cooking for one person
Observations:
Try to identify possible reasons for social problems
Further questions:
Would you like to eat with other people sometimes?
Do you need suggestions for easily prepared meals for one?
Address reasons for social problems if possible
Encourage the person to consider ways of making meals a positive experience
Encourage the person to eat with others when possible, for example, by arranging to have
meals with family and neighbours on a regular basis
Encourage social activities where meals are provided-Adult Day Care, Craft Groups, Adult
Day Training Centres, etc.
Consider ways for vulnerable adults to meet and eat together, and with other people
Monitoring:
Quality of life factors
Check outcome: I eat alone most of the time.
Consider referral: local government services, dietitian (for recipes, suggestions for meals for one
person, resources), doctor (for management of depression)
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4.4 PERSONAL HYGIENE AND FOOD HYGIENE
PROBLEMS
Personal hygiene problems and ingestion of contaminated food and fluids can cause nausea,
vomiting, and diarrhoeal illnesses.
Relevant comments:
I have a stomach ache
I have diarrhoea
I am going to the toilet a lot today-I must hurry
Observations:
Try to identify possible reasons for personal and food hygiene problems
Check the condition of food on the tables and in the cupboards and refrigerator
Check the food wrappings and discarded food in the rubbish bin
Check the diarrhoea (colour and consistency)
If a number of people have diarrhoeal illnesses, report it
Further questions:
Are you taking fluids?
What did you eat yesterday?
Where did you get this food?
Attention to personal hygiene-washing of hands before food handling
Recommend hot food is kept hot, cold food is kept cold until a short time before eating
(especially in summer)
Always recommend washing all dishes and cutlery in hot soapy water (not under the tap)
Throw out all old foods and fluids regularly
ALWAYS throw food out if it smells odd, looks watery, dull and listless, or is growing bacteria
ALWAYS heat soup to a rolling boil for a few minutes and THOROUGHLY heat stews and
casseroles
Dont refreeze food after thawing (package in small quantities instead)
Dont freeze the following items: eggs, raw sausages, and foods which are not fresh
All eggs should be cooked before eating
Always use a clean tea-towel
Follow instructions for the storage and heating of Meals on Wheels
Keep the kitchen clean
Keep pets away from food and kitchen tables
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Monitoring:
As often as possible, as this is a personal safety issue
If a number of people have this problem, always report it as it may be due to food
contamination
Check outcome: No tummy aches, diarrhoea etc ?
Consider referral: visiting nurse, doctor, dietitian
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4.5 MENTAL HEALTH PROBLEMS
Poor mental health (sadness, grief, confusion, depression, memory loss, anxiety, nervousness)
affects motivation to eat, the ability to meet nutritional needs and general health. It is therefore
important to address these problems to achieve the best possible health and nutrition for the
person.
Poor mental health may include depression and acquired brain injury. Other common problems
affecting cognition include dementia, Parkinsons disease, Alzheimers disease, intellectual
and/or psychiatric disability. Change in mental state can result from the use of alcohol or
sedatives when taking particular types of medication, or the chronic use of alcohol.
Severe micro-nutrient deficiencies (folate, vitamin B-12, thiamin, niacin), and dehydration can
also cause mental problems.
Relevant comments:
I have three or more glasses of beer, wine or spirits almost every day
I eat alone most of the time
I have lost or gained 5 kg in the last six months
I cant remember where my bed is
Observations:
Try to identify possible reasons for mental health problems
Further questions:
Does the person exhibit memory problems or confusion, depression, anxiety, nervousness?
Does the person have loss of appetite or recent weight loss?
Is the person underweight?
Does the person drink alcohol?
-How much alcohol is taken on an average day?
-How long has the person been drinking at this level?
-Has the person ever had any treatment for alcohol abuse?
What is the persons living situation and conditions?
Are all medical problems under control?
Are medications having side effects?
General:
Review medications and alcohol intake
Seek support from family, neighbours, friends, or provide home care or personal care
Refer to day care centres and adult day training centres
Provide Meals on Wheels or group meals
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Adults with confusion and/or dementia:
Avoid burns by not serving very hot foods
Reduce confusion by presenting a limited number of food choices
Serve finger foods if the person has poor balance and coordination, and reduced mobility
Adults with Alzheimers disease (symptoms: agitation, confusion, loss of memory,
depression, loss of skills, medication effects, weight loss):
Reduce distractions (sound, sight, smells and other activities
Serve meals at regular times
Orient the client to food
Provide relaxing quiet music
Serve one course at a time
Make sure the client has enough time to eat
Provide nourishing supplements
Follow food preferences
Monitoring:
Safety and nourishment
Check outcome: No accidents, stable weight?
Possible referrals: case manager, doctor, dietitian, alcoholics anonymous, social worker,
psychologist, local council services (Meals on Wheels, group meals)
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4.6 POLY-DRUGS (MORE THAN THREE TYPES OF
MEDICATION DAILY)
The more medications taken, the more likely these medications are to interact and produce side
drowsiness, with reduced food intake.
Medications can also affect nutrient needs and may alter the bodys response to nutrients and
medications (drug-nutrient and drug-drug interactions). Drug-nutrient interactions are
exacerbated by poly-pharmacy, ageing, and marginal food intakes or existing nutritional
deficiencies.
Taking more than three medications can increase the chance of these effects, and can lead to
weight loss. Some drugs also affect taste (Allopurinol, Atromid, Diabex, Prednisolone,
Salazopyrin, Valium). These effects increase with increasing age and reduced body weight.
It is important that an adult gets all of their medications from the same pharmacy so that the
pharmacist can inform them of any possible interactions. If the effectiveness of drug therapy
changes without known reasons, always review whether there has been a recent diet change.
Food itself can alter the action of a drug or drugs that are taken.
An example of inappropriate poly-drugs for one person for one day:
Captopril (bd) Anginine (prn) Prednisolone (mane)
Prazosin (bd) Mianserin (nocte) Pulmicort (bd)
Diltiazen (tds) Coloxyl (nocte) Atrovent (bd)
Lasix (mane) Panadol (prn) Aspirin (mane)
Slow K (mane) Eye drops (qid) Nilstat (qid)
Sherry
Relevant comments:
These pills upset me
I have stopped taking my pills
I love a sherry before tea
I have less than 6 to 8 cups of fluid most days
I have lost (or gained) 5 kg in the last six months
Observations:
Try to identify any possible poly-drug effects
Does the person go to more than one pharmacy to get prescriptions filled?
Is the person able to read the labels on medications and does the client understand the
instructions?
Is the person aware when medications should be taken such as before or after eating?
Has the person gained or lost more than 5 kg since taking any new medication?
Has the effectiveness of the drug therapy declined since the persons diet changed?
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Has the persons nutrition and weight declined since drug therapy began?
Is the person taking other medications bought over the counter or in the supermarket?
If possible, base interventions on correcting the causative factor
Use a dosette box-supervise the filling of the box and the taking of medication
Check that the person gets all prescribed medications from one pharmacy
Check the person can read the labels and follow instructions about taking the drugs
Review the possibility of unprescribed medications and alcohol intake
Review fluid intake
Monitoring:
Always check at the commencement of a new regime, or a new drug
Check outcome: No side effects of medication
Consider referral: pharmacist, doctor, dietitian
Note about Warfarin and diet: This drug is an anti-coagulant and is prescribed according to the
clients level of blood vitamin K (another anti-coagulant). If the person does not have a change of
diet, then the food that the client eats will not affect the dose of Warfarin required.
The foods which contain the most vitamin K include lettuce, cooked cabbage, liver, cooked
broccoli and spinach. If a person begins to take large amounts of these foods or omits their usual
large intake of these foods, it may affect their Warfarin requirement. An effect may also occur if
the person suddenly and drastically increases or reduces their intake of other foods which contain
lower amounts of vitamin K (peas, ham, bacon, green beans, cheese, egg, beef, milk, peaches,
butter, tomatoes and bananas).
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4.7 NAUSEA AND VOMITING
Reduced fluid and food intake can result from nausea and vomiting, and lead to dehydration and
weight loss.
Nausea and vomiting can be caused by poor personal hygiene, poor food hygiene, food
contamination, medication side effects illness and disease.
Relevant comments:
I am feeling a bit sick
I am getting very thirsty
I dont want to eat anything in case I am sick
Observations:
Try to identify any possible reasons for nausea and vomiting
Further questions:
Are you taking any medication which can cause these side effects?
If you take your medication after meals will that help?
Refer to doctor immediately if you suspect that medication is causing nausea or vomiting
Address any other identified problems
Encourage 1/2 cup of fluid every hour or so
Best tolerance is initially achieved by cold clear sweet fluids, and then anything the client feels
like
Best tolerance is initially achieved by small quantities of plain dry or sweet biscuits, dry bread,
progressing through plain foods according to appetite
Recommend small frequent snacks throughout the day, building up to the clients usual food
pattern
Anti-nausea tablets (such as Maxalon) may be used before food
Recommend medication is taken at the right times, perhaps after meals
Monitoring:
Until nausea and vomiting cease
Check outcome: No further episodes?
After 24 hours, consider referral: doctor, visiting nurse, dietitian
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4.8 DIARRHOEA
Diarrhoea results from malabsorption of fluid or food (wasted fluid or food). It can cause
abdominal discomfort, pain and distress, which in turn leads to reduced fluid and food intake.
Diarrhoea may be due to one or more possible reasons:
1) Eating contaminated food
9) Laxative abuse
2) Lactose intolerance
3) As a side effect of medication
4) As a side effect of constipation (faecal overflow)
5) Use of some sugarless/diabetic foods containing sorbitol and/or fructose as sugar substitutes
6) Stress
7) Gastro-intestinal disease
8) Kidney disease
9) Pica (eating dirt or other inedible substances)
Relevant comments:
I feel bloated
I am spending all the time in the toilet
Observations:
Try to identify any possible reasons for diarrhoea
Further questions:
How often do you have diarrhoea in a day?
What is it like (colour and smell)?
1) Acute diarrhoea
Recommend clear sweet or other clear fluids (not fruit juices or milk) for 24 hours
Then introduce other fluids and foods (avoid rough fibrous foods and fatty foods)
Continue until usual food pattern restored
2) Chronic diarrhoea
Seek advice (doctor, visiting nurse, dietitian)
Ensure a nourishing diet is taken
84
Monitor:
Until diarrhoea has ceased and client is recovered
Check outcome: No further episodes of diarrhoea?
Consider referral: visiting nurse, doctor, dietitian, psychologist (for pica)
85
4.9 CONSTIPATION
Constipation can cause abdominal bloating, discomfort and reduced food intake, and may be due
to one or more of the following reasons:
1) Dehydration
2) Low fluid intake
3) Low food intake
4) Low intake of dietary fibre (over-refined diet)
5) Side-effect of medication
6) Low activity level
7) Laxative abuse
Relevant comments:
I feel bloated
I have to spend hours on the toilet
Going to the toilet is painful for me
I need to strain to use my bowels
Observations:
Try to identify the possible reasons for constipation
Check use of laxatives
Further questions:
Do you think that your medication has something to do with it?
How many cups of fluid are you drinking in a day?
Do you eat cereal (high fibre) in the mornings?
Are you eating brown bread, fruit and vegetables?
Address cause of constipation if known
Review medication
Recommend at least 6 to 8 cups of fluid every day
Recommend slow but steady increase in dietary fibre (over weeks and months):
wholegrain cereals (All-bran, Fibre Plus, Just Right, Sultana Bran, porridge, muesli),
wholemeal breads (or high fibre white bread), fruits (pineapple, apricots, pineapple,
fresh fruit), fibrous vegetables, legumes
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Recommend mobility and activity as tolerated
Recommend regular toileting to achieve soft bowel motions without straining
Offer hot tea and coffee (caffeine)
Monitoring:
Check outcome: Gradual improvement in regularity and ease of
bowel actions (over months)?
Consider referral: visiting nurse, doctor, dietitian
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4.10 INCONTINENCE
Always seek expert advice from a continence adviser, doctor, registered nurse, dietitian.
Incontinence is very distressing and can lead to reduced fluid and food intake. It can be caused
by one or more of the following:
1) Constipation (refer Section 4.9); faecal impaction leads to lack of awareness of the fullness
of the bladder; the bowel is full and presses on the bladder causing discomfort and perhaps
urine flow
2) Weak anal sphincter
3) Poor mobility
4) Use of medications:
a) Bowel hydrating agents eg. lactulose, sorbilax
a) Diuretics
b) Sedatives, anti-cholinergic agents
c) Sleeping tablets
5) Too much alcohol
6) Medical problems:
a) Diabetes
b) Urinary tract infection
c) Obesity
d) Stroke
e) Parkinsons disease
f) Multiple sclerosis
7) Insufficient dietary fibre (causing constipation)
8) Insufficient fluid intake (causing constipation and/or decreased potential bladder capacity).
Relevant comments:
It is painful to pass water
I had an accident in the hallway
I wet the bed
I have to get up three times every night
I am always washing my clothes
Observations:
Try to identify the possible reasons for incontinence
Check possible causative factors
88
Intervention is based on identifying and correcting the causative factors and providing
assistance with the development of a toileting strategy
Assist in the development of a toileting strategy, take time with toileting
Urinary incontinence:
-Pelvic exercises for bladder control
-Maintain fluid intake at 6 to 8 cups of fluid daily (increases potential bladder capacity)
-Delay all toileting until it is really necessary
Faecal incontinence:
-Encourage time with toileting
-Encourage gradual increase in intake of dietary fibre
Always refer for expert advice: continence adviser, doctor, visiting nurse, dietitian-incontinence
is very distressing and can lead to reduced fluid and food intake
Monitoring:
Whenever possible
Check outcome: Continence achieved?
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4.11 BREATHING PROBLEMS IN THE OLDER
PERSON
Asthma, chest infections and emphysema are conditions which cause difficulty with breathing
and cause the body to work much harder. Thus more energy is used and it is difficult to take
sufficient dietary energy to maintain a good body weight. This may also cause meal disruption by
coughing and spluttering.
People with breathing problems need one and a half times more energy in their diet due to the
extra effort required for breathing. More energy is used and it is difficult to take sufficient dietary
energy to maintain a good body weight when people experience breathing problems.
Adiet high in carbohydrate results in even more carbon dioxide being produced by the body for
expiration through the lungs.
As less carbon dioxide (for expiration) is produced from the metabolism of fat, fat intake is a
better source of some of a persons energy than carbohydrates for the older person with breathing
problems. In younger adults increase in fat intake may need to be balanced with the prevention of
cardiovascular disease.
Relevant comments:
I cant get enough air when Im eating
Observations:
Try to identify the possible reasons for the breathing problem
Further questions:
Is it worse at any particular time of day?
Is it worse after particular foods and fluids?
Use whole milk products
Suggest the addition of margarine, oil or butter to vegetables
Include cheese as a snack between meals, or grate some into soup or on vegetables
Suggest the addition of cream to cereals, soups and desserts
Add mayonnaise to sandwiches or vegetables
Fry meats to add extra fat
Monitoring:
Check outcome: Some ease of eating, maintenance of body weight ?
Consider specialist referral: dietitian
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4.12 OUTLINE OF SOME MEDICAL PROBLEMS
AFFECTING NUTRITION
1) Medical problems which reduce ability to access enough food and fluids
a) Weight loss, muscle wasting and decreased mobility (reduced access to food and fluids)
(refer Section 3.1)
b) Difficulty with breathing and eating at the same time (refer Section 4.11)
c) High dependency, feeding problems (refer Section 3.8.1)
2) Medical problems which increase the need for energy and nutrients
a) Elevated body temperature, fever (wasted heat, marked increase in need for energy)
b) Impaired wound healing, infections, recent surgery, fractured bones (increased energy
and nutrient requirements, particularly protein and the micro-nutrients)
c) Cancer, AIDS, recent surgery
d) Hyperactivity, Alzheimers disease (refer Section 4.5)
3) Major medical disorders which change the clients need for nourishment
a) Metabolic disorders such as diabetes (Section 4.12.1), renal and liver disease
b) Cancer
c) Gastro-intestinal disorders such as ulcerative colitis, coeliac disease and other small
and large bowel disorders
4) Medical disorders which are effectively treated by a specific modified/special diet
(refer Section 3.5).
a) Underweight (refer Section 3.1)
b) Indigestion and oesophageal reflux syndrome, hernias
c) Colostomies and ileostomies, diverticulitis
d) Diabetes (refer Section 4.12.1)
e) Cardiovascular disease (refer Section 4.12.2)
f) Parkinsons disease, other neurological diseases
g) Some kidney and liver disorders
h) Stroke, head injury
i) Osteoporosis, fractures, trauma
j) Respiratory disease
If a client does not want to follow their special diet, refer Section 3.5.
92
Relevant comments:
I have too much pain to eat
I feel much better on my diet
Observations:
Try to identify the possible effects of other medical problems on food and nutrition
Further questions:
Is your illness affecting the way you eat?
Has your weight changed lately?
Address causative factors if possible
Seek advice and support from other health professionals
Try to achieve a coordinated approach in the client care plan
Monitoring:
Activities of daily living, life quality, body weight
Check outcome: Signs and symptoms of illness, body weight,
well being ?
Consider referral for particular advice: doctor, dietitian
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4.12.1 Diabetes
Diabetes may be simple (treated with diet only), moderate (treated with diet and tablets) or more
complex (treated with diet and insulin injections). Complications are common and can be severe
(poor eyesight, poor wound healing, difficult mobility).
Younger adults need as much information as they can take in, to assist them to prevent the long
term complications of diabetes.
Many older people have had this problem a long time, often without the benefit of enough
information to look after themselves in the best way.
Assist the person to keep a good weight
Assist the person to be as active as possible, without overdoing it
Assist the person to take regular meals and snacks, and nourishing foods
Seek assistance from the visiting nurse
Provide the person with the best and latest information to keep well
Monitoring:
Regular medical check with doctor, with a thorough yearly medical review
Full information about diabetes and the treatment diet with an expert dietitian; thorough
yearly reviews
Referral to a diabetic educator if appropriate
Check outcome: Signs and symptoms of thirst, illness, body weight,
well being?
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4.12.2 Cardiovascular disease
When cardiovascular disease affects the blood vessels to the major organs-perhaps the heart,
the brain, the legs-a major medical problem develops.
This happens over a lifetime and many risk factors contribute to it, such as smoking, inactivity,
high blood fats, overweight and so on.
Younger adults need information to reduce these risk factors to prevent the long term
development of medical problems.
Some older people have avoided the premature development of major problems with
cardiovascular disease. Such problems may be even less important when an older person is
at risk of losing weight, becoming frail, and perhaps developing malnutrition and losing their
quality of life and independence. Depending on the individual the balance of their dietary needs
starts to change to support weight maintenance, independence and quality of life.
Check the persons blood fat or blood cholesterol level
Check if the special diet is still required and if it assists the individual in any way
(refer Section 3.5)
Adults who start to lose weight, become underweight, or feel weak, may need to change to
more nourishing foods
Consult an expert dietitian for the best advice on food for health
Monitoring:
Yearly review of blood cholesterol and blood fats (if the person is on a modified fat diet)
Full information about treatment diet with an expert dietitian; thorough yearly reviews
Check outcome: Signs and symptoms of illness, body weight,
well being ?
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SECTION 5
DIETARY PRINCIPLES AND PROBLEMS
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5.1 FOOD FACTS AND FALLACIES
Food facts
Vulnerable people need more nourishing foods than other adults
Painful constipation can usually be corrected by increasing dietary
fibre
One of the best tips for vulnerable people is to eat more frequently
(3+3)
If you have good teeth you can eat more
People usually eat more when they are with other people
It is good to feed a fever as well as a cold
Food fallacies
When you are older or have a disability, being thin is good for you
Milk is mucous forming
Fried foods are no good for vulnerable people
Milk is for babies not for vulnerable people
Sugar is no good for vulnerable people
Pasta and bread are fattening
Feed a cold and starve a fever
AND MANY MORE!
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5.2 FOOD HABITS AND PATTERNS
Adults have a lifetime of eating and drinking experiences, and they often have established a fairly
set daily food pattern which suits them. This pattern takes into account their food preferences
and dislikes, and meets their ethnic, social and cultural needs.
Such food patterns are often central to the existence of an elderly or disabled person, providing
structure for the day and giving them control over something in their difficult lives. Their food
behaviour is probably linked to preservation of their identity and personality, and the nurturing
and comforting aspects of food are often very important to them.
The person with a disability who is dependent on others for feeding usually has reduced or
no control over these important matters, which can contribute to serious feeding problems
(refer Section 3.8.1, 5.3.3.1).
Disturbance of a persons preferred food habits should be minimal. If the need exists to change
a food pattern for health reasons, then advocacy for a small change will often increase their
awareness and allow response in the required direction.
Provision of choice in taking action is usually helpful to people and they will often welcome
assistance with food budgeting. The assessment officer, service provider and the carers must
always consider the food life experiences of their client, and respect their food habits and
patterns.
Only when there is substantial and known benefit to a person, should consideration be given to
changing their basic food habits and pattern of eating. On these occasions, modification of their
usual pattern of eating is the best approach for them.
It is important not to stereotype your clients, who are likely to have been raised in and lived
in a wide range of cultural and environmental settings, all of which affect food and health.
Gender issues
People of different genders have different attitudes, knowledge and roles for many matters,
including the following:
Shopping
Food preparation
Financial management
Relationships with dependents
Awareness of health and body needs
Use of drugs (particularly sedatives)
Self medication and treatment
Expectations of their carers
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Ethnic, cultural and religious issues
Ethnic, cultural and religious groups have different attitudes, knowledge and roles for many
matters, including the following:
Fear of the unknown
Fear of death in an unknown environment
Need for interpreter services, advocacy
Need for visual and audio learning and modelling by known and respected people, preferably
of their own background
Need for additional reassurance and information, preferably from someone of their own
background
Different levels of directness in conversation
Different attitudes to written records and legal issues
Need for confidence in, and respect by their carers
Degree of involvement of the carer in their support
Variation in sharing of personal matters with strangers
Different approaches to issues of privacy and personal shyness about their bodies
Possible complex relationships between men and women which involve avoidance of eye
contact, speech, body language for example in the Koori community
Need for carer to be of the same gender
Frustration and possible anger at the loss of personal autonomy and freedom
Relationships to dependents, relatives and friends
Family responsibilities and level of concern about filling them (may be barriers to effective
care)
Attitude to medication-fear of loss of control and lack of knowledge and understanding of
how the medicine works (always give full explanation)
Use of different foods and fluids for different cultural and other reasons
Strategies:
Respect all food taboos and beliefs
Offer fresh or plain foods, to which familiar and favourite flavours can be added
Provide food choice
Respect food habits and patterns
Minimal disturbance of preferred food habits
Consider referral: To a respected person, to find out if any particular problems exist, and to a
dietitian, if food habits and patterns are complex.
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5.3.1 Good Nutrition for Older People: The 1 3 3 4 5+
Food Plan
In the healthy older person, energy requirements may be reduced due to decreased basal
metabolic rate and activity level.
Although the basic energy requirement is less than for younger adults, the requirement for
protein, vitamins and minerals remains the same. Requirements for some nutrients may even
increase (such as calcium).
Hence, the nutrient density of the older persons diet must be greater in order to maintain
nourishment and optimal nutritional health. It is therefore more difficult for older people to meet
their nutrient requirements, as they require the same amount of nutrients from a smaller amount
of food.
In addition, in the presence of disease or trauma, both energy and nutrient requirements in older
people may increase, thus increasing their need for food at a time when their appetite may be
reduced.
In summary:
Energy needs generally decrease as people grow older
Energy needs are increased by illness, stress, infection, surgery
Protein, mineral and vitamin needs remain the same or increase with age
Protein, mineral and vitamin needs are increased by illness, stress, infection, surgery
More dietary vitamin D is required by housebound people
More calcium is required by post-menopausal women
Less iron is lost by post-menopausal women
Sufficient fluid and fibre intake is always important
All of the Dietary Guidelines for older people may not be
appropriate for frail older people who have difficulty obtaining
sufficient energy from their food due to increased requirements or
reduced appetite.
In these circumstances extra nourishment and more sugar and fat
may be required as useful sources of energy.
What foods should older people eat?
The 1 3 3 4 5+ food plan is based on the 1 2 3 4 5+ food and nutrition plan for younger adults,
(Baghurst, Hertzler et al, 1992), with an additional serve of the milk and milk products group to
better meet the nutritional needs of frail older people. Some frail older people require an even
larger amount of food to maintain their weight.
104
The following will provide sufficient nutrients for older people who are not underweight and/or
do not have any special nutritional problems:
1 One small serve of meat, fish, poultry or eggs (60g cooked)
3 Three serves of dairy foods (+/- fat)
one serve = 250 ml milk, or 30g cheese, or 200g yoghurt
3 Three serves fruit (fresh, canned or stewed)
4 Four serves vegetables (including one serve potato)
5+ Five or more serves wholegrain bread and cereals
one serve = 1 slice bread, or 1/2 cup rice or pasta, or 3/4 cup breakfast cereal (preferably
high fibre)
And extra foods from these five groups according to appetite and level of activity
Indulgences
Unless weight reduction is essential, one or two extras such as a piece of cake, a scone, a few
lollies or a glass of wine can be enjoyed. Asmall appetite means that taking the most nourishing
foods first is the best thing to do, followed by the less nourishing foods (indulgences).
Salt
Salt and salty foods can be used sparingly, and according to taste, except when a special low salt
diet is required for medical reasons (high blood pressure, fluid retention).
Fluids
6-8 cups of fluid are needed each day, and may include water, tea, coffee, milk and juice.
Soft drink and cordial can also be taken.
Important notes about the need for even more food by some older people:
1) More food than is outlined in the 1 3 3 4 5+ food plan is required by some older people
to maintain their body weight at a reasonable level.
2) Older people with this higher requirement for energy and nutrients, and often for long
periods, need extra foods in addition to the 1 3 3 4 5+ food plan to:
Correct underweight
Reverse weight loss
Fight an infection
Heal a wound
Recover from recent surgery
Rebuild a fracture
Meet increased needs in hyperactivity or head injury
Promote recovery in rehabilitation
Older people must eat better ...not less!
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5.3.2 Good Nutrition for People 16-64 years: The 1 2 3 4 5+
Food Plan
It is difficult to provide one simple guide for good nutrition in vulnerable people over the
wide range of ages from 16 to 64 years.. These adults range from being active, ambulant and
independently living to being vulnerable, perhaps non-ambulant and highly dependent.
Some dietary principles have been given below.
Dietary guidelines for people 16-64 years
1) Ambulant individuals
a) Enjoy a wide variety of nutritious foods
b) Eat plenty of breads and cereals (preferably wholegrain), vegetables (including
dried peas and beans) and fruits
c) Eat a diet without too many fried foods, and one in which fats are reduced and modified
d) Unless weight reduction is essential, a few extras such as a piece of fruit cake, a scone,
a few lollies (and perhaps a glass of beer or wine) can be enjoyed
e) Maintain a healthy body weight by balancing food intake and having regular physical
activity
2) Non-ambulant people who are vulnerable and highly dependent
a) Enjoy a wide variety of nutritious foods
b) Eat plenty of high fibre foods, particularly cereals and fruits
c) It is best not to limit fats and fried foods (unless weight reduction is essential)
d) Extras such as a piece of fruit cake, a scone, a few lollies (and perhaps a glass of beer
or wine) can be enjoyed (unless weight reduction is essential)
e) Maintain a healthy body weight
f) Drink plenty of fluids
The 1 2 3 4 5+ food plan:
1 One small serve of meat, fish, poultry or eggs (60g cooked)
2 Two serves of dairy foods
one serve = 250 ml milk or 30g cheese or 200g yoghurt
3 Three serves fruit (fresh, canned or stewed)
4 Four serves vegetables (including one serve potato)
5+ Five or more serves wholegrain bread and cereals
one serve = 1 slice bread or 1/2 cup rice or pasta or 3/4 cup breakfast cereal
(preferably high fibre).
And extra foods from these five groups according to appetite and level of activity
106
Indulgences
Unless weight reduction is essential, one or two extras such as a piece of cake, a scone,
a few lollies or a glass of soft drink (or perhaps wine) can be enjoyed.
Salt
Salt and salty foods may be used sparingly. Most vulnerable people enjoy tasty food.
They may be in the habit of using some salt in cooking and at the table, and have favourite
salty foods such as bacon, olives, sausage. The contra-indications to this use of salt follow:
High blood pressure
Fluid retention
The management of specific illnesses with a low salt (sodium) diet
Fluids
6-8 cups of fluid are needed each day, and may include water, tea, coffee, milk and juice.
Sugary drinks such as soft drink and cordial can also be taken.
Important notes about the need for even more food by some younger
adults:
1) More food than this is required by many clients to maintain their body weight at a reasonable
and healthy level.
2) Adults with a high requirement for energy and nutrients, and often for months and years,
need extra foods in addition to the 1 2 3 4 5+ food plan to:
Correct underweight
Reverse weight loss
Fight an infection
Heal a wound
Rebuild a fracture
107
5.3.3 Who Needs Extra Foods in Addition to the Daily
Food Plan?
Vulnerable people with a high need for energy and nutrients need extra foods in addition to the
daily food plan, and often for months and years to:
Correct underweight
Reverse weight loss
Fight an infection
Heal a wound
Rebuild a fracture
When clients need increased nourishment the best thing for them to do is to eat slightly smaller
meals and include between meal snacks, say three small meals and three small snacks daily.
The problem for vulnerable people is to take more food than their appetite dictates, which means
taking foods of higher value rather than increased quantities which would be the other way
round of doing it.
Ways of encouraging and planning for foods and drinks:
Provide encouraging comments
You can help yourself by starting to eat little and often; nurture and comfort yourself with food
Update food preferences
Suggest three small meals and three small snacks every day (3+3)
Give most food when the person is most alert, or when their appetite is best-even if not at a
usual mealtime (overnight may be a good time in the long break between the evening meal
and breakfast)
Allow adequate time for meals and snacks
Provide substitutes for meals refused (such as a sandwich, cereal and milk, a glass of milk)
Recommend use of extra milk (to ensure tolerance to milk, increase milk gradually)
Increase energy intake with extra sugar, milk, margarine, thick soups, cream, special drinks
(refer Section 5.3.3.1)
Ask a dietitian about nourishing snacks for the person to take between meals
Amulti-vitamin and mineral supplement may be recommended (two to three times weekly)
Encourage slight increase in activity
Provide motivational counselling (you will feel much better when you eat much better your leg ulcer
will heal up when you are back to your best weight)
Always monitor weight if possible
108
Monitoring:
Weekly support and check of intake and weight
Check outcome: Obvious underweight-frailty?
Consider referral: to doctor, dietitian, if no improvement in two weeks (less time if severe weight
loss as well)
Some vulnerable people need extra nourishment to achieve their
best weight
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5.3.3.1 High Energy Foods and Drinks
Solid foods and thicker foods and fluids with the least water in them are usually high in energy
value.
The food group which is the highest in energy value by weight is fat, then alcohol. Starchy foods
and foods containing sugar often have high energy value (by weight) also.
At the bottom of the list with little or no energy value is fibre and water.
Foods with the most water in them are usually low in energy value, such as broths, watery fruits
and vegetables.
High energy foods
To increase the energy value of a food:
Add extra milk (to ensure tolerance to milk, increase milk gradually)
Increase the value of foods by adding extra sugar, and perhaps margarine and cream
Ask a dietitian about nourishing snacks for people to take between meals
Always monitor weight if possible
High energy drinks
Special drinks can add extra food energy (kilojoules) and nutrients to the daily diet. Consider
serving small amounts of these drinks if food intake is very small. These drinks are not a meal
replacement and are best taken in small amounts as between meal snacks. They are best served
cold
Points to remember about high energy drinks:
When suggesting fortified drinks between meals, do not give large amounts at first (to avoid
tummy upsets)
The best drinks are those familiar to the client such as milkshakes, malted milks, Milo, Activite,
and fruit smoothies; others include milk with skim milk powder and topping for a high energy
milk shake, or an icecream soda
Soups are useful providing they are not too watery and providing extra ingredients are added
such as minced meat, a beaten egg, a tablespoon of yoghurt or cream
The recipe measurements must be accurate to achieve the correct nourishment
It is important for each person to receive the prescribed quantity of special drinks each day
As milk is readily contaminated, all mixing and storing utensils must be scrupulously clean
The drink must be stored in a covered container in the refrigerator at all times and any mixture
not drunk within 24 hours must be thrown out to avoid possible bacterial growth.
110
IN A PERSON WITH SWALLOWING DIFFICULTIES
THERE MAY BE RISK OF FOOD AND FLUID LUNG ASPIRATION
SO:
DO NO HARM
DO NOT FORCE FEED
Some vulnerable people need extra nourishment to achieve their
best weight
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5.4 THE IMPORTANCE OF FLUID INTAKE
Many vulnerable people (particularly frail older people and people with a disability) do not drink
enough fluids.
This may be because of fear of incontinence or accidents or because their toilet is difficult for
them to use, particularly at night. Insufficient fluid intake will usually make incontinence worse
in the long run.
Drinking too little fluid can lead to constipation and dehydration, raised body temperature and
perhaps stroke. We should all drink 6-8 cups of fluid daily. This can be water, tea, coffee, fruit
juice, cordial, soup or milk. Some people also take alcoholic beverages.
Factors affecting fluid intake:
Use of diuretics
Fear of incontinence
Alcohol intake
Hot weather
Reduced thirst
Lower total body water reserves
Swallowing problem (refer Section 3.4)
Conditions which affect fluid balance:
Excessive sweating
Fever
Diarrhoea, vomiting
Fluid retention
Infection
Heart failure
Diabetes
Kidney disease
Head injury
Burns
Constant drooling and dribbling
Regurgitation and rumination (refer Section 3.8.1)
Relevant comments:
I dont have anything to drink after 4 pm
I dont have the soup-it is too much fluid
I dont have 6 to 8 cups of fluid most days
My mouth is dry
I do not drink in case I have to go to the toilet
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Observations:
Try to identify the possible reasons why the person is not drinking enough fluid
Why does your client not drink enough?
Are there any other factors affecting their fluid needs?
Would a night light help them find the toilet safely at night?
Address the problem of why the person does not drink enough
If incontinence is a problem, encourage them to seek expert help
Suggest small frequent drinks through the day
Suggest they take a variety of fluids-it doesnt have to be all water
Ask the home carer to leave poured fluids handy to the client
IMPORTANT NOTE:
To prevent serious fluid aspiration into the lungs, some vulnerable disabled people with severe
feeding problems may require the addition of thickeners to their fluids. This thickness MUST
NOT be changed or introduced except under expert supervision from a specialist.
Monitoring:
Is enough fluid taken every day ?
Check outcome: Normal urine volume, weight constant?
Possible referrals: doctor, dietitian, speech pathologist (drinking problems), continence adviser
113
5.5 ALCOHOL AS PART OF A VULNERABLE
PERSONS DIET
Vulnerable people may drink alcohol daily because they have always done it or to ease loneliness,
depression or poverty. Frail older people and people with a disability are often more sensitive to
alcohol at lower doses than other people.
Points to remember about alcohol as part of a vulnerable persons diet:
As older people often have lower body weight than younger people, they have reduced
tolerance to alcohol
They are also at risk of alcohol withdrawal at much lower doses of alcohol (for example, as
little as the daily use of 1-2 standard drinks of an alcoholic beverage in a small frail older
person)
Any person who is affected by alcohol should not stop taking it without medical supervision
Withdrawal of alcohol for any reason (such as no money, or admission to hospital) can result
in alcohol withdrawal symptoms (such as confusion and disorientation)
Alcohol interacts with many medications, and the combined effect may make the client feel
worse. It can also affect the financial and social situation of your client. Excessive intake of
alcohol is also a risk factor for poor nutrition as it may replace food in the diet.
Relevant comments:
I need a drink
Mary forgot to get my bottle of sherry
I have two or more glasses of beer, wine, or spirits almost every day
Observations:
Try to identify if a person may be drinking alcohol inappropriately
How long has the person been drinking this amount of alcohol?
Has the person ever sought help to change their drinking behaviour (such as attending
Alcoholics Anonymous)?
Other important issues (refer Appendix 2):
Sudden alcohol withdrawal can be unsafe (always check with a doctor)
Unusual confusion in a person who has stopped drinking alcohol suddenly
Reduced tolerance to alcohol in vulnerable people and its possible interaction with drugs
114
Simple interventions (harm reduction strategies):
Address the reasons for any problems
Take a gentle harm reduction approach when making suggestions to an adult
Do not cease daily alcohol intake except under medical supervision
Counsel about reduced tolerance for alcohol and its possible interaction with drugs
Advise the person to avoid drinking alone, or between meals if possible (to lessen the risk of
falls)
Encourage the person to limit alcohol intake to one to two standard drinks a day and to have
at least two alcohol free days weekly
Encourage the use of diluents such as soda water and lemonade
Encourage the use of light alcoholic beverages
Monitoring:
Safety
Check outcome: Safety, no adverse effects?
Possible referral for particular advice: pharmacist, doctor, dietitian, alcohol counsellor, Alcoholics
Anonymous, alcohol and drugs 24 hour professional advisory services (refer Appendix 2)
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5.6 VITAMIN D
Vitamin D is important in maintaining the integrity and strength of the muscle and skeleton and
teeth.
Regular exposure of the skin to sun, say 1-2 hours direct sunlight per week in Summer), allows
the clients body to make enough vitamin D for itself.
The housebound person also needs to regularly take foods which supply vitamin D.
The only foods in the Australian diet which supply enough vitamin D are:
Vitamin D enriched table margarine
herrings
mackerel
sardines and tuna
The most useful vitamin D recommendation for housebound
people is the daily intake of vitamin D enriched table margarine
(read the label to make sure that the margarine is vitamin D
enriched).
Housebound people or people who are always fully covered up and have little or no exposure to
direct sunlight are at risk of vitamin D deficiency, and should also take vitamin D (5-190 mcg
vitamin D daily) supplements.
117
5.7 USE OF VITAMIN AND MINERAL
SUPPLEMENTS
If a frail older person, person with a disability or homeless client has not been eating properly for
more than four days, recommend a low dose vitamin and mineral supplement with food, three or
four times weekly until the person is eating normally.
In frailty and/or serious gastric disturbance, intramuscular injection of vitamins and mineral
supplements should be considered once weekly for a few weeks.
Frail older people have a similar/increased need for vitamin and mineral supplements compared
to young adults. Their need for vitamin and mineral supplements may be even higher in the
presence of disease.
Points to remember about vitamin and mineral supplements:
Vitamin and mineral supplements are taken best in doses corresponding to the RDIs
(recommended dietary intakes)
Liquid form vitamin and mineral supplements taken with food may be better tolerated in
underweight people
Much higher doses of vitamin and mineral supplements are not required
Vitamin and mineral supplements are yet another expensive medication and may not be
tolerated- they may cause gastric upset.
Refer to Section 5.6 for more information about vitamin D.
119
5.8 HOW TO BE WELL-NOURISHED ON MEALS
ON WHEELS (MOW)
Guidelines for Meals on Wheels (MOW) have been planned around the needs of older people
(NOT younger adults). For older persons these guidelines specify that the four food items,
(soup, main course, desert, fruit/juice together supply approximately:
1/3 daily need* for energy
1/2 daily need* for protein
1/2 daily need* for thiamin, riboflavin, niacin and other vitamins
1/2 daily need* for vitamin A
1/2 daily need* for calcium, iron, zinc and other minerals
2/3 daily need* for vitamin C
* Need = Recommended Dietary Intake (RDI)
This can be achieved by including the following food servings (as a minimum) in each delivered
meal (weight in grams is for cooked food) to an older person:
1) Meat or substitute-1 serving daily:
75-90 gm meat, poultry, fish
1 cup dried peas, beans, lentils
2) Potato or substitute-1 serving daily:
90 gm potato
1/2-1 cup rice or pasta (occasionally)
3) Green Vegetable-1 serving daily:
60 gm green vegetable
4) Yellow vegetable-1 serving daily:
90 gm yellow, orange, red vegetable
5) Fruit-1 serving daily:
120 gm cooked or prepared fruit
1 medium apple, banana, pear (or substitute)
6) Bread or cereal or substitute-1 serving daily:
1 slice bread
1 serving bread roll, pancake, dumpling
1/2 muffin
1/2 cup breakfast cereal
1/2-1 cup rice or pasta (when not counted as potato substitute)
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7) Milk or substitute-1 serving daily
200 ml milk (or 20 gm skim milk powder)
30 gm cheese (or 250 gm cottage cheese)
150 gm yoghurt
8) Vitamin C supplement-1 serving daily
1 small orange juice
90-120 gm fresh fruit (mandarin, tomato, grapefruit, pineapple, cantaloupe)
70 gm strawberries
75 ml orange juice, apple juice or blackcurrant juice
150 ml other juices
To achieve an adequate daily diet, two other meals are added in the diet so that
it looks something like this:
MORNING AFTERNOON NIGHT
Cereal + milk + sugar Main course (MOW) Soup (MOW)
Toast + spread + jam Dessert (MOW) Sandwiches
Tea + milk + sugar Coffee + milk + sugar Fruit, yoghurt
Tea + milk + sugar
Fruit juice (MOW) Tea + cake Milk + biscuits
If a frail older person with a disability or homeless person does not take such extra foods
(particularly more of the milk group, cereals and breads), they will not be getting sufficient
energy and nourishment. This is particularly the case for younger active adults.
Good snacks for people to take between meals are the ones that they know and like best.
These will include fruits, cake, biscuits, milk drinks, desserts, cereals with milk, bread and butter,
icecream, fruit juice, yoghurt, lollies, chocolates, crisps, cheese, dried fruits, and so on.
As most vulnerable people like tasty food, they may refuse food which is not cooked with some
salt.
Meals on Wheels is ONLY PART of the daily diet for any person. For more detail, refer Section 5.3.1
for older people and Section 5.3.2 for people 16 to 64 years.
At least three meals every day are recommended for all vulnerable
adults
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5.9 OUTLINE OF SOME FOOD AND DIETARY
PROBLEMS
Food and dietary problems vary enormously in their variety and complexity. If the client is
motivated many of these simple problems can be easily resolved through simple intervention.
Other clients may require assistance from specialists.
1) Poorly balanced or inadequate food intake (refer Section 5.9.1)
a) Irregular meals or less than three meals a day
b) Takes a diet with a low level of nourishment
c) Takes a diet with a low level of fibre
d) Excessive use of sweet or savoury foods
2) Does not have enough fluid: 6-8 cups of fluid most days (refer Section 5.4)
3) Unable to access or use a secure, clean food storage and preparation area
Some people do not have a permanent home. Many shelters and temporary lodgings,
boarding houses, private hotels and most squats do not have secure, clean food storage
and preparation areas.
4) Rummages, forages, begs and steals food
This is an important sign that the person has serious food and other needs which are not being
met. Seek advice from an experienced team leader or expert.
5) Eats inedible substances (pica) such as dirt, grass, paper, soap, toothpaste etc.
Seek help from a psychologist.
6) High dependency clients with feeding problems who require foods and fluids which are
modified in texture for example semi-solid food, thickened fluids
These complex clients are at high nutritional risk for many reasons. They are at high risk of
food and fluid aspiration into the lungs and usually require expert assessment,
information and support (refer Section 5.9.3). DO NO HARM
7) Difficult behaviours which involve the use of food (refer Section 5.9.2)
8) Tube feeding (enteral feeding) is required through the nose, or the stomach or the intestine
These complex clients require expert assessment, information and support refer doctor and
dietitian
Possible referral for particular advice: dietitian
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5.9.1 Poorly Balanced or Inadequate Food Intake?
Use the following simple checklist to identify an adult with poor food intake:
1) Irregular meals or less than three meals a day?
2) Takes a diet with a low level of nourishment?
-Omits to have one or more of the five food groups most days?
-Takes less than the 1 3 3 4 5+ food plan plus extra foods (older person)?
-Takes less than the 1 2 3 4 5+ food plan plus extra foods (younger adult)?
3) Takes a diet with a low level of fibre?
-Does not take wholegrain or high fibre breads and cereals?
-Does not take the skins, seeds and fibres of fruits and vegetables?
4) Takes a diet lacking in enough energy?
-Does not take enough high energy foods when they need them (when underweight, ill or
hyperactive)?
5) Excessive use of sweet or savoury foods?
- Takes too many high energy foods when they do not need them (overweight)?
- Clients may enjoy the taste of these foods and seek them out. They may also be forced to eat
them through poor cooking skills, inadequate food preparation facilities, and lack of
information about food availability and how to make better choices.
If you need more information on a persons food or fluid intake, the
following questions may be useful:
1) Start at the beginning of a usual day
Do you eat anything when you first get up in the morning?
What do you have mid-morning? etc.
Have you had anything to eat and drink just now? (then work backwards)
What do you eat at each meal, and between meals?
Do you eat differently on Saturdays or Sundays?
2) Do you ever run out of food?
Do you have enough money to get the foods and drinks that you want?
3) Do you have difficulty eating or drinking? Hot/cold items? Soft/textured items?
Small/large mouthfuls?
4) Do you have any difficulty chewing or swallowing?
Do you ever get a stomach ache?
5) Do any foods and drinks upset you?
6) Social, cultural, religious, and habitual food patterns and preferences?
7) What sort of food do you give your pets? Do you cook any food for your pets?
8) Which food products are purchased regularly? Checklist of common foods?
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9) How are Meals on Wheels used (when, how, how much)?
10) Meals supplied by family, friends, and significant other people?
11) Have you a clean safe place to store, prepare and eat your food?
Questions in italics can be asked of a person directly-other questions are to guide your
observations.
If the person is a poor historian, use a checklist of food groups. This list can also be used to check
food and fluid preferences and intolerances:
Meat and meat substitutes Cakes, biscuits, pastries
Milk and milk substitutes Sugar, soft drinks, cordials, jams, honey
Fruits and vegetables Water
Cereals and breads Tea, coffee
Fats, margarines, oils Other drinks
Soups (thick, thin) Alcoholic beverages
Salt, pepper
If the person is not cooperative, give up and perhaps try another day.
NOTE: Some adults will be willing to keep a food record and write down everything that they eat
and drink over a couple of days.
Possible referral for particular advice: dietitian
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5.9.2 Difficult Behaviours Which Involve the Use of Food
People who have socially unacceptable and abnormal eating and drinking behaviour may be
exercising their control over their environment and relationships in the only way in which they
can demonstrate it. It is important to try and separate such behaviour from genuine physical or
mental ill health.
Afrail older person may not recognise new foods and a person with an intellectual disability who
has limited experience with food behaviour may refuse to eat new or different foods. Refusal to
eat and drink may also be a sign of depression or withdrawal.
The mealtime can become very difficult unless there is some resolution to the problem that the
person with a disability is experiencing or is presenting to their carer.
If the vulnerable person finds that the mealtime is an enjoyable and pleasant experience, they will
make more effort to overcome any mental or physical difficulty encountered while eating and
drinking. They will be more likely to avoid the consequences of underweight and malnutrition,
which in turn makes the feeding problems worse.
Feeding problems improve when the person is well nourished because there is improved strength
in the feeding and breathing functions as well as improvement in appetite.
The setting in which eating and drinking takes place should be supportive, peaceful and
pleasant, without distractions such as television, pets and other people who are not eating and
drinking
Good lighting, an attractive table and crockery all assist
Conversation about the mealtime and the food should always include the actual names of the
foods and the drinks
Attractive and recognisable food, with plenty of time to chew and swallow each mouthful is
very important
If a person has difficulty talking and eating, conversation may need to be adjusted accordingly
Clients with a disability who experience eating and drinking as an unpleasant activity, can be
assisted by the provision of a positive, peaceful and pleasant ambience and atmosphere
If a behaviour problem is identified, behaviour modification techniques can be utilised. If an anti-
social behaviour occurs while eating or drinking, consideration can be given to removing the food
or fluid for an interval of time, or alternatively the person can be temporarily removed from the
setting in which the problem is occurring. Success in resolving or reducing the abnormal
behaviour will only result if consistent action is taken. Positive reinforcement should be
encouraged. The same sequence of events must occur every time the inappropriate behaviour
occurs.
Possible referral for particular advice: always consult a psychologist or dietitian if problems
persist
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5.9.3 High Dependency Adults with Feeding Problems Who
Require Foods and Fluids Which are Modified in
Texture
Adults with high food-related dependency are more likely to be underweight. Such
underweight can affect the musculature of the body SO MUCH that it weakens the muscles
which operate chewing and swallowing food (and breathing). Improvement in body weight
towards the normal range can provide great benefits to the individual with improvement in
chewing swallowing (and breathing). After gaining sufficient weight, some people even begin to
achieve feeding themselves!
When high dependency people require foods and fluids which are modified in texture (thickened
or thinned):
Always give the person the opportunity to enjoy a wide range of foods served in an
appropriate manner
Serve each food item separately on the plate (avoid mixing foods) so that individual flavours,
textures, aromas and colours of the foods can be experienced and enjoyed
Make sure that the client knows the names of the foods and fluids which are being served
Most foods can be blended (pureed, vitamised) so that they are as thick as possible and look
attractive; hot foods may require reheating after blending
Avoid using water to soften foods because it reduces the nourishment and taste value of the
food; use sauces, gravies, soup, broth or milk with savoury foods, and milk, juices or syrups
with sweeter foods
Blended foods should be thick enough to sit up on the plate without spreading
Margarine or cream or oil may be added to food to increase food energy intake
Use sauces and gravies to improve taste and ease of eating
Any foods to be cut up should be cut up at the table in front of the client
Eating skills need to be encouraged all of the time
The muscles of the head, neck and chest are weak in a frail underweight person. This person
has much more difficulty chewing and swallowing and is more difficult to feed than a person
of more normal body weight.
FOOD AND FLUID LUNG ASPIRATION RISK:
DO NO HARM
DO NOT FORCE FEED
Adequate nourishment and fibre value is most important.
The daily food and fluid intake should provide sufficient energy
to achieve or maintain a desirable body weight.
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5.10 BRIEF COUNSELLING METHODS
Some people are very resistant to health information and other information that you might give
them. It is challenging to find a way to motivate clients who are reluctant to change what they
are doing.
The best approach is to find something small in their area of motivation or interest which is
practical for them to achieve and which will give them the outcome they want.
Ask them if anything is bothering them, and then work through this background to useful
activities.
The ability to change is restricted by poor quality of life and ill health. Conversely, small changes
in life quality and well-being will improve the ability to change.
An effective motivational approach* has been summarised below:
Giving. . . . . . . . . . . . ADVICE
Removing. . . . . . . . . BARRIERS
Providing . . . . . . . . . CHOICE
Decreasing . . . . . . . . DESIRABILITY
Practising . . . . . . . . . EMPATHY
Providing . . . . . . . . . FEEDBACK
Clarifying . . . . . . . . . GOALS
Active . . . . . . . . . . . . HELPING
An outline for brief counselling or FRAMES* follows:
FEEDBACK . . . . . . .Provide feedback on results of assessment and progress
RESPONSIBILITY . .Emphasise the clients responsibility for change
ADVICE . . . . . . . . . .Give the client very clear advice about best options
MENU . . . . . . . . . . .Give the client a number of options for change
EMPATHY . . . . . . . .Interact empathically with the client to enhance effectiveness
SELF EFFICACY . . .Reinforce the clients hope, optimism, and ability
*Miller, W.R. & Rollnick, S. (eds) 1991, Motivational interviewing, The Guildford Press, New York
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SECTION 6
WAYS DIETITIANS CAN ASSIST HOME CARE
CLIENTS AND SERVICES
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6.1 SUMMARY OF ROLES AND FUNCTIONS OF
DIETITIANS IN HOME-BASED CARE
Actual and potential ways dietitians can assist home care clients and services with food and
nutrition issues include:
1) Consultancy, training and provision of resources to services providers:
All food, nutrition and health problems in frail older people, people with disabilities and people
who are financially disadvantaged living in alternative accommodation:
a) Policy development
b) Consultancy to service providers on how they can resolve simple food and nutrition
issues for individual clients and groups of clients
c) Provision of in-service sessions for all levels of home care service providers (co-ordinators,
case managers, assessment officers, home carers, trained nurses, allied health teams,
doctors)
d Advocacy and specialist liaison on food and nutrition issues with other services
e) Information about available local dietitians such as their geographical location and general
or particular interests
2) Development of community resources to support home care:
a) General information on food and nutrition issues
b) Service provider information on food and nutrition issues
c) Local shopping and transport services
d) Local food supply (commercial) and other food-related activities
e) Meals on Wheels recipients
f) Community food services
g) Delivered meals from other food services
h) Consultation and liaison with service providers
3) Policy development:
a) Food and health issues
b) Nutrition and health issues
c) Community food supply and food service issues
4) Community food services:
Consultation and information about some or all of the following aspects of Community Food
Services:
a) Relationship to local commercial and other food-related activities
b) Community food service review
c) Food service training
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d) Food service menus
e) Food service management
f) Modified/special diets
g) Enteral feeding
h) Nutritional supplements
5) Direct client services:
When a person is unable to respond to simple types of intervention, the dietitian has the
knowledge and skill to investigate the problem in some detail, and provide information which
has been geared to be of use to the particular person.
a) Assessment of dietary patterns and intake.
b) Assessment of nutritional status:
Identify complications of poor nutrition and malnutrition, nutritional care
Review food - medication interactions
Problem solving - weight loss, poor appetite, eating and digesting difficulties
Identify factors which decrease/increase food and fluid intake, which if acted upon
could improve health
c) Assess the appropriateness of a modified or special diet:
Does the person need it?
What does the diet involve?
How can it be best supplied?
d) Intervention:
Assist in change of attitude from prevention of premature health problems (heart
disease etc.) to prevention of frailty and supportive nourishment.
Assist high dependency clients with feeding problems
Counsel and educate adults and carers about ways in which a person can make
minimal changes to their food and fluid intake, and so improve their enjoyment of
food and quality of life and retain their independence
Suggest removal of unnecessary food restrictions for a person, introducing food
variety
Solve person problems relating to lack of food access, and food adequacy with respect
to budgetary constraints
Provide information on cost-effective shopping, simple ways of shopping, how to
read food labels
Conduct supermarket tours
Provide information on household management-food hygiene, menu plans, recipes,
food and drink preparation, and the use of kitchen equipment
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Provide of additional nutritional support when an individual is unable to meet their own
needs; This involves supplementing energy or nutrients, changing the timing, size or
composition of meals, and texture modification
Liaise with other service providers
e) Adult support and monitoring
Some indications for client referral to a dietitian
I have gained or lost 5 kg (10 lb) or more without trying in the
last six months*
My appetite is poor and food doesnt taste good to me
I have trouble chewing and swallowing*
My pills are upsetting me and I cant eat
I treat illness with vitamin supplements
I have many nutrition questions or need advice about what to eat
I spend less than $30 a week on food
I usually need help shopping for food
I have an illness that the doctor told me needs a special diet*
I am supposed to be on a special diet, but I have trouble
following it
* Personal safety issues
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SECTION 7
CASE STUDIES
FRAIL OLDER PEOPLE
List of Case Studies: Frail Older People
Number One: Woman, 75 years, Recent Hospital Discharge
Number Two: Woman, 75 years, Emphysaema, Weight Loss, Referred by Daughter
Number Three: Man, 74 years, Recent Stroke, Referred by his Doctor
Number Four: Man, 72 years, Alcohol Abuse, Frailty, Review Requested by Home Carer
Number Five: Woman, 71 years, Meals on Wheels not Used, Referred by Volunteer
Number Six: Woman, 85 years, Overweight, Many Medical Problems
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7.1 CASE STUDY NUMBER ONE: WOMAN, 75 YEARS,
RECENT HOSPITAL DISCHARGE
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During her stay in hospital she developed pressure sores on her heels and sacrum, which did not heal before she returned home.
She was widowed about 12 months ago and has been very depressed, particularly since she fell.
She states she only has a small appetite, only has bottom dentures, and is a little constipated.
She feels she has lost some weight but is not sure how much. Her usual weight is 60 kg, you weigh her on her bathroom scales
which read 48 kg.
She tells you she is five feet four inches (163 cm) tall.
Her daughter brings in lunches for her at weekends, and she gets Meals on Wheels (MOW) delivered during the week.
She tells you that her diet is as follows:
Breakfast: 2 slices of white toast, half a glass of orange juice (MOW)
Lunch: Meat, vegetables and dessert (MOW)
Tea: Soup (MOW), vegemite sandwich
Drinks: 4 to 5 cups white tea, no sugar
Snacks: Occasionally has a sweet biscuit for supper
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Nutritional Risk Screening and Monitoring Case Study Form
malnutrition.
NAME: Case study number one: woman, 75 years
ADDRESS:
YES to one or more of these questions means
that nutritional risk exists
INTERVENTION
MONITORING*
Who can monitor?
Reduced appetite or reduced
food or fluid intake?
?? Mouth or teeth or swallowing
problem?
?? Unable to prepare food?
Obvious overweight affecting
life quality?
Post fractured hip
Pressure sores
Impaired mobility
Depression, grief, social isolation
Severe weight loss
(approximately 20%)
Bottom dentures only
Eats alone
Constipation
Small food intake
No sugar or much milk
Visiting nursing service
(pressure sores)
Home care?
Community meals program
Grief counselling
Refer to dentist
Occupational therapist
(assessment of mobility)
Provide information to client and
daughter re small frequent meals and
high energy snacks, high fibre intake,
more fluid, milk
Can she use sugar in cups of tea?
Monitor nutritional risks
Visiting nurse to monitor depression
and weight for two weeks
Home carer and daughter to monitor
food intake
Refer to dietitian after two weeks if no
improvement in nutritional risk (weight)
* Try TWO weeks of simple intervention strategies (less time if severe weight loss); if no response refer to a specialist. Monitoring at monthly intervals (or more frequently) by a team member is
recommended to ensure that nutritional risk has been decreased through the most effective intervention.
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7.2 CASE STUDY NUMBER TWO: WOMAN, 75 YEARS,
SEVERE EMPHYSEMA, WEIGHT LOSS, REFERRED BY DAUGHTER
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A75 year old woman has severe emphysema and uses a ventolin pump daily.
She lives in a one bedroom flat, is on a pension, and doesnt have a telephone at home because of the cost.
She manages to go shopping in an electric wheelchair but is unable to cook as a rule.
Her daughter cooks a meal for her on most weekends, otherwise she buys a take-away chicken dinner, and she has a meal delivered by
Meals on Wheels (MOW) during the week.
She has lost a lot of weight over the past few years, and states she was normally around 10 stone. She is now 45 kg.
She has a small appetite and often goes without breakfast (otherwise a bowl of porridge), especially if she is not up before 9 am, because
she says she couldnt manage to eat her lunch if she ate breakfast after 9 am.
She feels she must be getting enough to eat since she has a good meal at lunchtime.
She saves the soup from MOW for tea, and usually has nothing else to eat. Black tea is her usual drink, about four cups a day.
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NAME: Case study number two: woman, 75 years
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor?
problem?
life quality?
Reduced mobility
Shortness of breath
Severe weight loss (30%)
At risk (no phone)?
Social isolation
Depression?
Finances?
Personal care decreasing
Poor knowledge of food needs?
Misses breakfast
Small evening meal
No sugar
Refer for case management
Home care daily?
Day care attendance?
Refer to doctor for shortness of breath
Refer to visiting nurse for medication
and personal care
Occupational therapist (kitchen safety)
Financial counselling?
Talk with daughter
Encourage small frequent meals, milk
and increased sugar intake
Monitor nutritional risk
Case manager as required
Visiting nurse to monitor every two
weeks until weight much improved
Service If no improvement,
refer to aged care assessment
Refer to dietitian if necessary
* Try TWO weeks trial of simple intervention strategies (less time if severe weight); if no response refer to specialist. Monitoring at monthly intervals (or more frequently by a team member ) is
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7.3 CASE STUDY NUMBER THREE: MAN, 74 YEARS, RECENT STROKE,
REFERRED BY DOCTOR
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A74 year old man has had a recent stroke, which has left him with right sided paralysis.
He also has trouble swallowing, often choking on some foods.
His dentures are loose, so he tends to leave them out. He has lost 3 kg in one month.
Most of the time his wife has to feed him; recently this is taking longer as he is very drowsy.
He is also constipated and has problems with his bladder (often needing to go to the toilet every one or two hours).
His wife has osteoarthritis, so cannot shower him-the visiting nurse comes in to do this.
His diet history is shown below:
Breakfast: Cereal and milk, 1/2 glass orange juice
Lunch: Pumpkin soup or a mornay dish
Tea: Mince meat and vegetables
Drinks: 1/2 cup tea (morning and afternoon)
1 brandy, lime and soda before tea
His wife says that she tries to avoid high fat foods to avoid the risk of her husband having another stroke.
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NAME: Case study number three: man, 74 years
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Identify the factors which are relevant to
nutritional risk for this client
INTERVENTION
MONITORING*
Who can monitor?
problem?
life quality?
Recent stroke, drowsy
Psychological issues (concerned about
wife); reduced mobility
Bladder problems, constipation
Severe weight loss (3 kg in one month)
Decreased fluid intake
(500 ml per day)?
Fear of choking
Dentures not used?
Wife feeds him
Wife inappropriately avoids high fat
foods for him
Low bread, milk intake
Refer to doctor (prostate, constipation,
medication, drowsiness)
Visiting nurse support
Refer to speech pathologist
Refer to dentist
Carer support
Refer to dietitian for client/carer
education
Small frequent meals
Information to client and wife re food
and fluid needs, use of sugar, milk and
bread
Visiting nurse daily supervision of
rehydration and intervention, then
weekly, then two weekly
Wife to monitor food intake
Dietitian to monitor food intake
* Try weeks trial of simple intervention strategies (less time if severe weight loss); if no response refer to specialist. Monitoring at monthly intervals (or more frequently) by a team member is
recommended to ensure that nutritional risk has been decreased through effective intervention.
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7.4 CASE STUDY NUMBER FOUR: MAN, 72 YEARS, ALCOHOL ABUSE,
FRAIL, REVIEW REQUESTED BY HOME CARER
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Avery personable and beguiling down and out man aged 72 years was admitted to the local hospital for crisis management, then
discharged home.
The home carer is concerned about his increasing frailty. He is living alone in squalor and chaos in his own home.
He has a long history of alcohol abuse, alcohol being part of his earlier lifestyle in the rock and roll music scene.
He is an aged pensioner and manages his own affairs, paying his own bills, but does not appear to have any household management
skills.
He has been on Meals on Wheels for five years but does not eat them. The fridge is full of mouldy meals, and discarded food and bottles
are all over the house. He has a poor food intake.
The Home Carer can get him to agree to take certain actions but he never carries them out. He appears to be full of good intentions,
totally resistant to Community Services, and does not have any insight. He is not good at learning new things.
Alcohol intake is daily (1 dozen stubbies), with a small bottle of rum twice weekly and one bottle of wine twice weekly.
No other fluids are taken.
He is afflicted by dermatitis, with swelling and redness of the lower legs, particularly the left leg where there are ulcers.
Occasionally incontinent of urine, he has no medical care.
His wife left him many years ago. The family is in contact but do not know what to do.
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Nutritional Risk Screening and Monitoring Study Form
malnutrition.
NAME: Case study number four: man, 72 years
ADDRESS:
Identify the factors which are relevant to
nutritional risk for this client
INTERVENTION
MONITORING*
Who can monitor?
?? Unintentional weight loss?
problem?
?? Unable to shop for food?
life quality?
High alcohol intake
Unwell (leg ulcers)
Social isolation
Dehydration?
Occasional incontinence
Decreased mobility
Unsafe environment
No housekeeping skills
Not eating Meals on Wheels
Poor irregular food intake
Visiting nurse (leg ulcers, dermatitis)
Family conference
Doctor review (alcohol, legs,
incontinence)
Vitamin supplements?
Home care with specific tasks and
external support
Personal care?
Improve socialisation? music? meals?
Family?
Occupational therapist (safety)
Establish relationship, take dietary
history, find out food preferences, plate
Meals on Wheels, supervise regular
meals
Visiting nurse leg ulcers, incontinence,
monitor nutritional risk
Home carer monitor food intake
Long term: harm reduction for alcohol
intake, medical review, family support
Consider vitamin supplements
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7.5 CASE STUDY NUMBER FIVE: WOMAN, 71 YEARS,
MEALS ON WHEELS NOT USED, REFERRED BY VOLUNTEER
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Concern is held for a professional woman aged 71 years who has shown rapid deterioration recently.
She is very articulate but of variable clarity and lacking in insight.
Her personal care is declining, but she is very resistant to assistance.
She lives alone, having been divorced from a wealthy man. She does not qualify for the Aged Pension.
Her son lives 100 km away, supports her (emotionally) and stays with her occasionally.
He appears to keep deferring the arrangement of financial assistance for her. He holds Power of Attorney.
She often doesnt have enough money to buy food.
She prepares her own food, but does not manage it well and there is mouldy food in the house.
She doesnt recognise the packet containing Meals on Wheels.
She is losing weight.
Acouple of times she has suffered from dehydration and urinary tract infections with associated acute brain syndrome.
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Nutritional Risk Screening Case Study Form
malnutrition.
NAME: Case study number five: woman, 71 years
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor?
problem?
life quality?
Limited socialisation
Sons behaviour and insight?
Lacks insight
Deteriorating personal care
Resistant to support
Deterioration-urinary tract infection?
Financial access
Lack of food recognition
Irregular meals
Refer to social group
Arrange meeting with son
Medical review (confusion, urinary
tract infection)
Test urine frequently
Supervise regular meals
Plate food (Meals on Wheels)
Increase fluids
Monitor nutritional risk at two week
intervals
Weigh if possible
Consider psychological-geriatric
assessment in context of shift in social
status
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7.6 CASE STUDY NUMBER SIX: WOMAN, 85 YEARS, OVERWEIGHT,
MANY MEDICAL PROBLEMS
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An 85 year old woman is to be discharged from hospital to her home alone, after a replacement knee operation.
She weighs 90 kg (she is obese).
There are a number of other medical problems including diabetes, congestive cardiac failure, diverticulitis and hypertension.
Ablood transfusion was required after her surgery, and she has needed many weeks rehabilitation while she recovered.
At least 12 prescribed medications are taken daily.
She has been unable to walk outside for about a year and in this time has gained 12-15 kg in weight.
She was having trouble shopping and preparing food because of her decreased mobility and had begun to buy ready prepared foods
(pies, fish and chips).
Asugar free diet has been taken and her daughter was making her an apple pie each week without sugar for Sunday dinner.
On discharge, the hospital orders reduction Meals on Wheels, but she cancels them one week later as she says that she can manage as
she did before.
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NAME: Case study number six: woman, 85 years
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor?
problem?
life quality?
Knee replacement, long hospital stay;
many medical problems; decreased
mobility
Poly-drugs
Lack of knowledge (client and
daughter)?
May need assistance with shopping,
meal planning and food preparation
Visiting nurse assist with showering
Occupational therapist home
assessment
Physiotherapist assessment-
hydrotherapy if possible?
Friendly visiting
Medication review
Home care-shop, home duties
Arrange assistance if required
Suggest regular meals and low fat low
sugar intake
Case management to monitor
independence
Monitor at two week to monthly
intervals for ability to manage at home
alone
Refer to dietitian-diabetes, overweight,
diverticulitis?
151
SECTION 8
CASE STUDIES
ADULTS WITH A DISABILITY
List of Case Studies: Adults with a Disability
Number One: Woman, 21 years, Severe Weight Loss, Cerebral Palsy, Referred by Mother
Number Two: Woman, 28 years, Overweight, Mild Intellectual Disability, Referred by
Husband
Number Three: Man, 33 years, Down syndrome, Referred by Doctor
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8.1 CASE STUDY NUMBER ONE: WOMAN, 21 YEARS,
SEVERE WEIGHT LOSS, CEREBRAL PALSY, REFERRED BY MOTHER
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Awoman, 21 years of age, lives at home with her mother and two younger siblings.
She has been referred with severe weight loss and is obviously underweight (weight is 32 kg).
She has shown recent frailty, requiring increased need for assistance from her mother, who is feeling taxed by this.
She is non-ambulant and non-verbal and has a day placement at a special school.
She has cerebral palsy, epilepsy (anti-convulsant medication) and microcephaly and is prone to bronchitis and constipation.
She has poor appetite, all fluids are thickened and food is vitamised.
She does not aspirate and is given naturopathic nutrition supplements.
Her height is 1.6 metres after 7% deduction for curvature of the spine.
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NAME: Case study number one: woman, 21 years
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor these risks?
Obvious underweight-
frailty?
Reduced appetite or
reduced food or fluid
intake?
?? Mouth or teeth or
swallowing problem?
?? Unable to feed self?
Obvious overweight
Sick (bronchitis)?
Fibre, fluid intake?
Quality of vitamised food and thickened
fluids
Reliant on mother
Anti-convulsant medication?
Refer to doctor
Consult schoolteacher
Take dietary history
Refer to speech pathologist and
dietitian?
Support for mother
Seek more information on drugs
Add in sugar and fat
High energy thickened drinks
1-2 weeks
Refer to dietitian, especially if no
improvement in weight
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8.2 CASE STUDY NUMBER TWO: WOMAN, 28 YEARS, OVERWEIGHT,
MILD INTELLECTUAL DISABILITY, REFERRED BY HUSBAND
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Awoman, 28 years of age, lives with her husband in a house and works part-time. Husband works full-time.
Both have mild intellectual disability.
Her husband is worried about her overweight (70 kg). Weight has increased 12 kg in the past five years.
Medication: Oroxin 50 mg daily.
Reasonably active with walking 2-3 times weekly and tenpin bowling once weekly.
Husband and wife shop together (husband has most understanding).
Dietary history:
Three meals and three snacks
Low intake of dairy foods and cereals
Enjoys butter, biscuits, wants fried foods
Limited cooking skills, home help assists two hours weekly when she prepares meals in advance and freezes them
Poor nutrition knowledge
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malnutrition.
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor these risks? How often
should this be done?
Obvious underweight-
frailty?
Reduced appetite or
reduced food or fluid
intake?
Mouth or teeth or
swallowing problem?
Obvious overweight
5 years
Medication and regularity of dose?
Dependent on home care for main
meals
Frequency of eating
Poor knowledge and skills
Use of fried foods
Review doctor re medication/ thyroid?
Check medication
Increase home care
Educate home carer and husband re
shopping/cooking
Seek advice from dietitian about
control of weight gain
Simple interventions
One month
If no weight control, refer to dietitian
recommended to ensure that nutritional risk has decreased through the most effective intervention.
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8.3 CASE STUDY NUMBER THREE: MAN, 33 YEARS, OVERWEIGHT,
DOWN SYNDROME, REFERRED BY DOCTOR
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Aman, 33 years of age with Down syndrome lives with his parents at home.
He is overweight, as is his father.
He attends an Adult Training Centre on weekdays and has easy access to a Milk Bar on the way to and from the centre.
His mother is a good cook and bakes his favourite cakes for him. His loving siblings provide him with chocolates and sweets.
Diet history:
Three meals daily
Takes cut lunch from home to the centre, which he helps to prepare
The local doctor has expressed concern about his overweight, which is affecting his ability to care for himself.
Consideration is being given as to whether the family need assistance with his personal care, or respite care, or whether he requires
admission to a Community Residential Unit.
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malnutrition.
NAME: Case study number three: man, 33 years
ADDRESS:
The factors relevant to nutritional risk for this
client
INTERVENTION
MONITORING*
Who can monitor these risks? How often
should this be done?
problem?
life quality?
?? Unintentional weight gain?
5 years
Medication and regularity of dose?
Dependent on home care for main
meals
Frequency of eating
Poor knowledge and skills
Use of fried foods
Review doctor re medication/ thyroid?
Check medication
Increase home care
Educate home carer and husband re
shopping/cooking
Seek advice from dietitian about
control of weight gain
Simple interventions
One month
If no weight control, refer to dietitian
* Try TWO weeks of simple intervention strategies (less time if severe weight loss); if no response refer to a specialist. Monitoring at monthly intervals
(or more frequently) by a team member to ensure that nutritional risk has decreased through the most effective intervention.
159
SECTION 9
CASE STUDIES
FINANCIALLY DISADVANTAGED ADULTS
LIVING IN ALTERNATIVE ACCOMMODATION
List of Case Studies: Financially Disadvantaged Adults
Living in Alternative Accommodation
Number One: Man, 25 years, Unwell and Underweight, in Squat, Needs Temporary Crisis
Care
Number Two: Woman, 40 years, Lack of Housing, Homeless, Needs Temporary Crisis Care
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9.1 CASE STUDY NUMBER ONE: MAN, 27 YEARS, UNWELL AND
UNDERWEIGHT, LIVING IN SQUAT, NEEDS TEMPORARY CRISIS CARE
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Young man, aged 27 years, needs two weeks of temporary crisis care with his partner who is five months pregnant with their third child.
They have been living in a local squat. The children have been with them for short periods before being taken into other care.
He begs for food, and also shares a food parcel given to his partner weekly by a welfare agency.
Once or more weekly he also obtains food from the nightly soup van (soup, sandwich, coffee).
He lacks information and life skills and can probably buy ready to eat food but not organise or cook food.
He may have an intellectual disability and may have suffered traumatic head injury.
He also has a past history of gastritis or diarrhoea, ulcers, gallstones, and pneumothorax.
There is a past history (seven years ago) of substance abuse (three years use of heroin and speed).
It is six months since he left prison. He presents unwell to the clinic nurse with intermittent vomiting of blood and diarrhoea, and is
unable to eat very much. He also has dental decay, rotting teeth, and infected gums.
He has no medication and is reluctant to attend the clinic doctor.
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Nutritional Risk Screening and Monitoring Form
Nutritional risk increases when the person is affected by an
increasing number of general needs assessment factors.
malnutrition.
NAME: Case study number one: man, 27 years
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor?
problem?
life quality?
Social problems
Personal and food hygiene problems
Mental health problem?
Gastritis, vomiting, diarrhoea
Medical problems
Past history of substance abuse
(heroin, speed)
Irregular meals
Doesnt take 1 2 3 4 5+ food plan
Omitted to have one or more of the food
groups yesterday
Low food skills
Unable to access or use secure, clean
food storage and preparation area
Begging for food
Refer to visiting nurse (assessment,
care, advocacy, support)
Doctor (review medical problems,
vitamin supplements)
Social worker referral (income
stablisation, social problems and
accommodation)
Family conference
Refer to dental service
Assessment of possible brain injury
Refer to Food Aid
Consider long term food and nutrition
support
Visiting nurse (health status, substance
abuse, dental problems, and nutritional
risk)
Consider referral to HACC services for
Meals on Wheels or for supervision of
quality and quantity of food intake
Long term: when accommodation
stabilises, promote increased skills in
food access, food budgeting, food
preparation and storage
* Try TWO weeks of simple intervention strategies (less time if severe weight loss); if no response refer to specialist. Monitoring at monthly intervals (or more frequently) by a team member is
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9.2 CASE STUDY NUMBER TWO: WOMAN, 40 YEARS, LACK OF
HOUSING, HOMELESS, NEEDS TEMPORARY CRISIS CARE
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Avery bright woman, 40 years of age, is admitted to crisis care for four to six weeks because of lack of housing and inability to cope.
She has a history of crisis care admissions once yearly.
As an adult she has lived in a variety of accommodation (low cost hotels, rooming houses). She has been in and out of institutional care
since the age of eight years.
She has a past history of psychiatric disability, personality problems and substance abuse (alcohol and drugs), gastritis, diarrhoea and
constipation.
Most of her Social Benefit payments are spent on lodgings and a variety of medications.
She tries to send things to her three children who are in care.
She is overweight, her teeth are decaying and she has gum infections and poor oral hygiene.
Always hungry and eating on the run, she scrounges and begs for food.
When she has enough money she purchases junk food (to satisfy hunger) such as a hamburger, a bucket of chips and coffee.
She has a poor diet, omitting one or more food groups most days.
She probably doesnt have any food management skills.
In crisis care she tried to get hold of the cooking pots and pans and was hassled by the other residents.
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Nutritional Risk Screening and Monitoring Form
malnutrition.
ADDRESS:
INTERVENTION
MONITORING*
Who can monitor?
?? Reduced appetite or reduced
problem?
life quality?
Mental health problems
Poly-drugs
Medical problems
Gastritis, diarrhoea, constipation
Past history of substance abuse
(alcohol and drugs)
Social problems
Personal and food hygiene problems
Food has run out in the past week
Irregular meals or less than 3 meals a
day
Doesnt take 1 2 3 4 5+ food plan
Omitted to have one or more of the food
groups yesterday
Low food skills
Unable to access secure, clean food
storage and preparation area
Begging and scrounging food
Refer to visiting nurse
(assessment, care, referral, advocacy,
support)
Doctor (review of medical problems,
vitamin supplements)
Social worker (income support,
accommodation, social problems)
Refer to alcohol and drug agency
(management of substance abuse)
Refer to dental services
Refer to food aid
Consider long term food and nutrition
support
Visiting nurse to monitor medical
problems, alcohol and drugs, dental
problems and nutritional risk
Consider financial counselling and
issues about access to children
Consider referral to HACC Services for
Meals on Wheels or supervision of
quality and quantity of food intake
Long term: when accommodation
stabilises, promote increased food
access skills, budgeting, shopping
skills, food information, food
preparation, food storage
* Try TWO weeks trial of simple intervention strategies (less time if severe weight loss); if no response refer to specialist. Monitoring at monthly intervals (or more frequently) by a team member to
ensure that nutritional risk has been decreased through the most effective intervention.
165
SECTION 10
QUALITY IMPROVEMENT FOR NUTRITIONAL
RISK SCREENING AND MONITORING
167
10.1 QUALITY IMPROVEMENT FOR NUTRITIONAL
RISK SCREENING AND MONITORING
The usefulness of nutritional risk screening and monitoring to staff and clients will be evaluated
from time to time. What will you achieve by nutritional risk screening and monitoring and how
will you measure this?
Evaluation of the value of nutritional risk screening and monitoring will be carried out by
yourself.
It is even better if your team is able to pool their results; it shares the work involved and
produces more meaningful results which can then form the basis of team discussion and decision
making.
Some desired outcomes could be:
Adults and their carers believe that their health and quality of life has been maintained or
improved by intervention
The interventions put in place deliver an acceptable and equitable level of care
All who should be screened have this done in a timely fashion and at any time there is a
change in their functioning or health status
Nutritional risk screening and monitoring has resulted in a reduced rate of hospital admission
Identification of individuals whose need for services has changed
Gathering of data to support client advocacy for improved services and community facilities
Some ways of measuring these outlines could include:
Audit of client nutritional risk screening results (refer Section 10.2.1-10.2.2)
Regular case management and peer review with records of meetings kept
Number of re-admissions to hospital in adults before and after screening introduced by the
hospital discharge planner
Client and carer questionnaires (refer Section 10.2, 10.3)
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10.2 RECORD OF RESULTS FOR NUTRITIONAL RISK SCREENING AND
MONITORING
10.2.1 Types of nutritional risks in the home-based adults
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It is easy to keep records of the results of nutritional risk screening and monitoring on this form. The results can
then be used to review the client group and plan better services for them, or to advocate on their behalf about
matters which affect them in their local community.
DATE Client record
number
No risk
identified
Underweight-
frailty?
Unintentional
weight loss?
Reduced
appetite or
reduced food
and fluid
intake?
Mouth or
teeth or
swallowing
problem?
Follows a
special diet?
Unable to
shop for food?
Unable to
prepare food?
Unable to
feed self?
Obvious
overweight
affecting life
quality?
Unintentional
weight gain?
TOTAL
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10.2.2 Number of nutritional risk factors in the home-based adults
Transfer the information from the form on the previous page to this one, in terms of the number of risks identified
for each person.
The results can then be used to review the client group and plan better services for them.
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Date Client record
number
NO RISKS ONE RISK TWO RISKS THREE RISKS FOUR RISKS FIVE RISKS SIX RISKS SEVEN RISKS EIGHT RISKS NINE RISKS TEN RISKS
TOTAL
171
10.3 ARE YOU SATISFIED?
We are interested in knowing whether your community services are useful to you and how you
feel about them.
If you have the time today, please fill in your answers to the questions below.
Your name is not on this piece of paper, and you can give it back to us in the envelope.
Do we provide you with useful assistance?
None of the time Some of the time All of the time
Do we provide you with enjoyable meals?
Do we provide you with meals at the right temperature?
Do we provide you with meals of the right size?
Do we provide you with meals at a reasonable cost?
Do we deliver your meals at the best time for you?
Thank you for spending this time to help us. We can improve our community
services if we know whether they are useful and what our clients think about
them. You can always reach us in the office on telephone...............................
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10.4 REGISTER OF CLIENT COMMENTS AND COMPLAINTS AND
REASONS FOR TERMINATION OF SERVICE
DATE TYPE OF SERVICE CLIENT COMMENT STAFF ACTION SIGNATURE
HC = Home Care; PC = Personal Care; MOW = Meals on Wheels; DN = District Nurse; D = Doctor
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175
APPENDICES
177
APPENDIX 1: DEFINITIONS
ACAT is the Aged Care Assessment Team. This is a Commonwealth Department of Health and
Aged Care funded program which provides comprehensive assessment of a persons ability to
perform their daily living activities, and information on residential options and in-home
assistance available to the older person. These responsibilities include assessment for admission
to government subsidised hostels, and nursing homes.
Assessment is defined by the HACC Program as Aprocess by which consumers need for
formal HSACC Services is evaluated. Assessment considers all the consumer needs and may
involve an evaluation of other factors, such as the availability of informal care and the
consumers ability to pay where fees are charged for a service. Assessment is conducted in close
consultation with the consumer (Commonwealth of Australia, 1991).
Assessment officers assess the needs of individuals in the HACC target group for community
services, prepare individual care plans with them, and continue to advocate for the client as
required.
Community dietitians are usually employed by community health centres. They may work
across all phases of the life cycle from infants to the older person, or they may be employed to
provide food, nutrition and dietetic services to particular population groups.
Community services officers are assessment officers for Aged Services. These officers assess the
needs of individuals in the target group for community services and prepare individual care
plans with the client.
DAA (Vic) is the Dietitians Association of Australia (Victorian Branch). The Dietitians Association
of Australia (DAA) is the national body representing dietitians throughout Australia, with
branches in all States and Territories.
DAA (Vic) Rehabilitation and Aged Care Special Interest Group This group is committed to
excellence of practice in food, nutrition and dietetics in the areas of rehabilitation, aged care and
disability.
Food issues are defined as client characteristics and problems which are related to client food
needs.
Food needs include those affected by client health and nutritional needs, their social needs
(food range and variety, cultural and social factors, and location of meals).
HACC is the Home and Community Care Program funded by the Commonwealth Department
of Health and Aged Care and the Victorian Department of Human Services.
HACC Dietitians are employed by a variety of organisations and are funded by HACC to
provide food, nutrition and dietetic services in the HACC Program.
HACC service providers provide HACC Services with HACC funding, and include home carers,
personal carers, district nurses, allied health professionals in teams which are home-based,
Linkages (case management), and social support Adult Day Activities (Services) (ADASS).
HACC Subsidised Food Services are partly funded by the HACC program. Service providers
receive $1.10 subsidy per meal and include local governments, hospitals and also non-
government public and private organisations.
178
The HACC target population is defined in the Victorian HACC Program Manual (May 1998) as
being: frail older people, people with physical, functional, sensory, intellectual or psychiatric disabilities,
people with aquired brain damage, carers and families living at home or in the community. (p 10)
Local dietitians may work with home based clients who are aged or who have a disability,
without knowing that they are registered HACC clients. These dietitians may work in health
and Community Care Agencies, hospitals, and/or in private practice.
Nutrition issues are defined as client characteristics and problems which are related to their
nutritional health needs.
Nutritional needs of a client means the need for fluid, energy, and the macro- and micro-nutrients
which are required by the client to support life itself and its daily phases of activity (sleeping,
rest, and movement). These physiological needs increase during fever, illness and trauma, and are
best provided in excess to correct for one or two days of poor or no food intake. Nutritional needs
may be altered to treat and/or correct specific medical problems such as diabetes, and chronic
obstructive airways disease.
Nutrition counselling provides individualised guidance on appropriate food and nutrient
intakes, taking into consideration health, cultural, socioeconomic, functional and psychological
factors. Nutrition counselling may include advice to increase or decrease nutrients in the diet,
to change the timing, size or composition of meals, to modify food textures, and, in extreme
instances, to change the route of administration (Nutrition Screening Initiative, 1992).
Nutrition education imparts information about foods and nutrients, diets, lifestyle factors,
community nutrition resources and services to people to improve their nutritional status
(Nutrition Screening Initiative, 1992).
Nutritional intervention is an action taken to decrease the risk of or to treat poor nutritional status.
(These actions) address the multi-factorial causes of nutritional problems and therefore include actions that
may be taken by many different health and social service professionals as well as family and community
members. A wide range of intervention actions, from utilisation of...meal programs and home care services,
to dental services and pharmacist advice, to nutrition education and nutrition counselling, to specialised
medical and/or dietary treatment,... are all examples of nutritional interventions (Nutrition Screening
Initiative, 1992).
Nutritional risk can be simply defined as the risk of poor health for nutritional reasons.
Amore complex and accurate definition has been provided: The risk factors of poor nutritional
status are characteristics that are associated with an increased likelihood of poor nutritional
status. They include the presence of various acute or chronic conditions or diseases, inadequate
or inappropriate food intake, poverty, dependency or disability and chronic medication use.
Indicators are generally quantitative and provide evidence that poor nutritional status is present
(Nutrition Screening Initiative, 1992).
Nutritional screening is the process of identifying characteristics known to be associated with
dietary or nutritional problems. Its purpose is to differentiate individuals who are at high risk of
nutritional problems or who have poor nutritional status. For those with poor nutritional status,
screening reveals the need for an in-depth nutrition assessment which may require medical
diagnosis and treatment as well as nutrition counselling, as a specific component in a
comprehensive health care plan (Nutrition Screening Initiative, 1992).
179
APPENDIX 2: MORE INFORMATION ON HARM
REDUCTION IN ALCOHOL ABUSE
Practical guidelines
1) Does the client use alcohol, tobacco, or drugs/sedatives (refer Section 5.5)?
2) Identify the clients who are likely to incidentally withdraw from alcohol and seek advice.
3) Expert advice is available through a 24 hour a day advisory service on alcohol and drugs
(refer next page).
Prevention of incidental alcohol withdrawal
Alcohol withdrawal becomes apparent in the first 24-72 hours after cessation of continuous drug
use or excessive recent use of the drug. It is during this period that incidental alcohol withdrawal
can occur. Older adults most at risk include:
1) Those who drink every day and have done so recently
2) Those who undergo procedures, tests or operations within a few days, the effects of which
can mask alcohol withdrawal, and
3) Those who are treated with opiates (for example. pethidine) and other pain killers and
sedatives (for example. benzodiazepines) which can mask alcohol withdrawal and delay its
appearance.
In a few individuals, alcohol withdrawal is so severe that it can cause difficult behaviour and
perhaps result in serious injury to the person and bystanders or death from withdrawal
complications.
The prevention of incidental alcohol or drug withdrawal (in particular, alcohol withdrawal) is an
important feature of good health care in all persons, regardless of their reason for presentation.
Cessation of heavy drinking should not occur without medical supervision.
Care of intoxicated adults
*** NOTE: intoxication and alcohol/drug withdrawal can occur at the same time
1) Overdose, intoxication identified
a) Move the person into a safe, quiet and supportive environment
b) Consult a medical practitioner or expert (refer next page)
2) Aggressive individuals
a) Adopt a calm and quiet approach immediately
b) Inform other staff
3) Very violent individuals (rare)
a) Inform nearby people
b) Call the police immediately
180
ALCOHOL AND DRUG 24 HOUR ADVISORY SERVICES
(VICTORIA)
DACAS. Victorian Drug and Alcohol Clinical Advisory Service.
Metropolitan areas Telephone: (03) (9416 3611).
Country areas Telephone: (1800) (81 2804) (toll free).
DACAS is a 24-hour telephone service which provides health professionals with advice on the clinical
management of drug and alcohol issues.
DIRECT LINE.
Metropolitan areas Telephone: (03) (9416 1818).
Country areas Telephone: (1800) (13 6385) (toll free).
Direct Line is a telephone service which provides anyone in the community (users and health
professionals) with access to services, counselling and information on drugs and alcohol.
ALCOHOL AND DRUG ORGANISATIONS
ADF (Australian Drug Foundation), Victoria
409 King Street, WEST MELBOURNE 3003
Telephone 03 9278 8100
The ADF has an extensive library which provides resource and reference material to anyone, particularly
health workers. There is a lengthy publication list of printed material, posters and videos. Call the Librarian
to arrange access.
ARBIAS (Alcohol Related Brain Injury Advisory Service)
226 Gertrude Street (PO Box 213). FITZROY 3065
Tel 03 9417 7071
The aim of ARBIAS is to assist people disabled through alcohol or other substance related brain injury to
live and function to their full potential in the community. ARBIAS provides assessment, accommodation
and support.
TURNING POINT ALCOHOL AND DRUG CENTRE INC.
54-62 Gertrude Street, FITZROY 3065
Telephone 03 9254 8061; Fax 03 9416 3420
Turning Point is a non-government organisation established to provide leadership in therapeutic
innovation, research and evaluation, and education and training in the alcohol and drug sector in Victoria.
It is affiliated with St Vincents Hospital and the University of Melbourne.
VAADA (Victorian Alcohol and Drug Association)
3 Alexander Parade, COLLINGWOOD 3066
Telephone 03 9416 0899; Fax 03 9416 2085
VAADA is the peak body for Victorian organisations and individuals with an interest in reducing the
health economic and social consequences of the use of alcohol and other drugs. VAADA runs an annual
conference.
181
APPENDIX 3: REFERENCES AND RESOURCES
Nutritional Risk Screening and Monitoring Project
Publications and Materials
Wood, B. 1996, Identifying and assisting people who are nutritionally at risk: Part I: Report, Dietitians
Association of Australia (Victorian Branch), Melbourne.
Wood, B. 1996, Identifying and assisting people who are nutritionally at risk Part II: Appendices,
Dietitians Association of Australia (Victorian Branch), Melbourne.
Wood, B. 1997 Identifying and assisting people who are nutritionally at risk. Second Report, Dietitians
Wood, B. 1997, Identifying and assisting people who are nutritionally at risk. Proceedings of the Dietitians
Focus Group on Disability, 30th April and 1st May, 1997, Dietitians Association of Australia
(Victorian Branch), Melbourne.
Wood, B. 1997, Identifying and assisting people who are nutritionally at risk. Third Report, Dietitians
Wood, B., Bacon, J., Stewart, A. & Race, S. 2000, Identifying and Planning Assistance for Home-Based
Adults who are Nutritionally at Risk: A Resource Manual, Aged Care and Mental Health Division,
Victorian Government Department of Human Services, Melbourne.
Wood, B., Bacon, J., Stewart, A. & Race, S. 2000, Identifying and Planning Assistance for Home-Based
Adults who are Nutritionally at Risk: A Training Manual, Aged Care and Mental Health Division,
Victorian Government Department of Human Services, Melbourne.
Good Food and Health Advice for Older People Who Want to Help Themselves: An Information Booklet for
Older People, Family and Carers 2000, Aged Care and Mental Health Division, Victorian
Government Department of Human Services, Melbourne.
General References
American Dietetic Association 1993, Dining skills. Practical interventions for the caregivers of the
eating-disabled older adult: American Dietetic Association, Chicago.
Anon 1996, Development of the Australian nutrition screening initiative, Australian Journal on
Ageing, vol. 15, no. 15.
Bacon, J. 1995, Famine in the midst of plenty: Nutritional status of the frail elderly, Proceedings
Nutrition Society, vol. 19, pp. 152-156.
Baghurst, K., Hertzler, A., Record, S.J. & Spurr, C.1992, The development of a simple dietary
assessment and education tool, Journal of Nutrition Education vol. 24, pp. 65-72.
Bryan, F., Jones, J.M., Russell, L.1998, Reliability and validity of a nutrition screening tool to be used
with clients with learning difficulties, Journal Human Nutrition and Dietetics vol. 11, pp. 41-50.
Commonwealth Department of Human Services and Health 1995, A world of food: A manual to
assist in the provision of culturally appropriate meals for older people, AGPS, Canberra.
182
Commonwealth of Australia 1992, HACC Program. National Guidelines, AGPS, Canberra.
Commonwealth of Australia, Department of Human Services and Health, Aged and Community
Care Division 1995, The efficiency and effectiveness review of the home and community care program.
Final report, AGPS, Canberra.
Community Services Commission 1997, Report on nutritional and mealtime practices for people
with developmental disabilities in Residential Care, Community Services Commission, Sydney.
Dear, W. & Webb, Y. 1996, The Nutrition Decision Tree, Dear and Webb, PO Box 52, Newcastle.
Haralambous, B. 1992, Being elderly, being disabled and home care issues for people from non-English
speaking backgrounds, Inner West Migrant Resource Centre, Melbourne.
Haralambous, B. 1992, Caring for people from non-English speaking backgrounds, issues for carers,
Inner West Migrant Resource Centre, Melbourne.
Hughes, A. & Alexander, L. 1995, The HACC Program: Improving access for homeless people,
Royal District Nursing Service Homeless Persons Program, Melbourne.
Hunwick, H. & Dear, W. 1997, The Nutrition Project: A case study for screening, assessment and
intervention, West Sydney Intellectual Disability Support Group Inc, Epping, Sydney.
Madden, R. & Hogan, T 1997, The definition of disability in Australia: Moving towards national
consistency, AIHW, Canberra.
Migrant Resource Centre 1992, Ethnic meals project and feasibility study, Migrant Resource Centre,
Melbourne.
Nutrition Screening Initiative 1992, The nutritional intervention manual for professionals caring
for older Americans, Nutrition Screening Initiative, Washington DC.
Pargeter, K. & Flint-Richter, D. 1991, Home and Community Care Food Services Information Kit,
Department of Health and Community Services, Melbourne.
Reynolds, A. McVicar, G. Rijneveld, L. & Macnaught, A-A. 1994, Review of HACC Subsidised
Food Services in Victoria. Report 1: HACC Subsidised Food Services: Key issues and options for future
development, McVicar & Reynolds Pty Ltd, Melbourne.
Reynolds, A. McVicar, G. Rijneveld, L. & Macnaught, A-A. 1994, Review of HACC Subsidised
Food Services in Victoria. Report 2: Background Papers, McVicar & Reynolds Pty Ltd, Melbourne.
Stewart, A. 1993, Nutrition for the elderly in the 1990s, Nutridate, vol 4., pp1-5.
West, R. & Tang, A. 1997, Report on nutritional and mealtime practices for people with developmental
disabilities in Residential Care, Community Services Commission, Strawberry Hills, NSW.
What is happening in ANSI. The Australian nutrition screening initiative, 1995 DAANewsletter,
May.
Wood, B. Morrison, M. & Atkinson, M. 1998, A Training Manual for Carers, Ballarat Health
Services, Ballarat.
Wood, B. Morrison, M. & Atkinson, M. 1998, A Resource Manual for Carers, Ballarat Health
Services, Ballarat.
183
Resources
COOKING FOR ONE OR TWO
Home Economics Institute of Australia (Vic) Inc.
PO Box 143,
CARLTON SOUTH 3053
A small paperback recipe book.
COOKING SMALL EATING WELL
Hawthorn Community Education Project
24 Wakefield Street
HAWTHORN 3122
Telephone: 03 9818 7371
A practical program for community workers to assist older people to eat well.
This program takes community workers through a one day demonstration and information package.
The workers can then use this package in turn, to assist individuals and groups to improve their
information and cooking skills. The emphasis is on preparing dishes and meals for one or two people.
COST CUT WITH CANNED FOODS
Australian Nutrition Foundation (Victorian Division)
c/- Caulfield General Medical Centre
260 Kooyong Road,
CAULFIELD 3162
Telephone/Fax: 03 9528 2453
A VHS video tape with recipes for economical meals using canned foods.
FOOD CENT$ PROJECT
Heal Promotions Services Branch
Health Department of Western Australia
189 Royal Street, EAST PERTH, 6004
A program which targets people on low to moderate incomes. This program takes community workers
through training to enable them to conduct Food Cent$ supermarket tours for adults and schoolchildren,
and to train members of the community to become a Food Cent$ adviser.
IN THE THICK OF IT
Speech Pathology Department
Royal Melbourne Hospital
Chester St
MOONEE PONDS 3039
An innovative video that aims to demonstrate the need for and preparation of thickened fluids for people
with particular swallowing difficulties.
184
A WORLD OF FOOD: A MANUAL TO ASSIST IN THE PROVISION OF CULTURALLY
APPROPRIATE MEALS FOR OLDER PEOPLE
Commonwealth Department of Human Services and Health.
Australian Government Publishing Service
GPO Box 84
CANBERRA2601
A manual designed to assist facilities to meet the food-related needs of older non-English speaking
background people in a culturally appropriate way. It shows how simple it can be to make mealtimes
enjoyable for older people from non-English speaking backgrounds and how to adapt existing menus
to accommodate cultural and individual preferences.
SWALLOWING DIFFICULTIES
Motor Neurone Disease Association of Victoria
PO Box 262
CAULFIELD SOUTH 3162
Telephone: 03 9596 4761
Freecall 1800 80 6632
A 22 minute video guide for carers of people with swallowing problems of any kind (not specific to
motor neurone disease).
THE PROOF OF THE PUDDING: OLDER PEOPLE TALK ABOUT EATING WELL
Australian Pensioners and Superannuation Federation
Suite 62
8-24 Kippax Street
SURRY HILLS 2010
Fax 02 281 5951
A 20 minute video and resource kit.
THERES MORE TO QUITTING THAN QUITTING
Centre for Education and Training in Addiction Studies Melbourne
Royal Melbourne Institute of Technology
Department of Social Work
MELBOURNE 3000
The stages of change in giving up addictive behaviours. A 15minute video training resource for counsellors
working with substance users.
THE MANAGEMENT OF AGGRESSION IN DRUG AND ALCOHOL AFFECTED PERSONS
NSW Nurses Association
43 Australia Street
CAMPERDOWN 2050
Professionally produced 50 minute record of an actual one hour lecture with self-teaching booklet.
185
APPENDIX 4: PROJECT FOCUS GROUPS
Central Grampians Region
Ms Alex Tascas (Regional Aged Care Manager), Ms Robin Reeves, Ms Faye McLeod, Ms Lynne
Hyett (Coordinators), Ms Jane Allen, Ms Meredith Atkinson, Ms Amanda Collins, Ms Lee-Anne
Dolon, Ms Ethne Farrell, Ms Dawn Gilbert, Ms Sally Greenall, Ms Lynden Hayes, Ms Ellen Johnson,
Ms Linda Jones, Ms June Lugg, Ms Shelagh Meates, Ms Megan Morrison, Ms Margaret Patrick,
Ms Margaret Pedrioli, Ms Judy Prendergast, Ms Alice Read, Mr Glen Rowbothom, Ms Rosalie
Sheehan, Ms Val Stevens
Central Wellington Gippsland Region (Central Wellington Health Service, Wellington
Community Care)
Ms Leona Mann (Director), Ms Belinda Greening (Domiciliary Care Coordinator), Ms Julia
Churches, Ms Brenda Clewley, Ms Hana Emms, Ms Gaylee Humphries, Ms Christine Kardash,
Ms Brigitte Jones, Ms Lauren Neilsen, Ms Wendy Newcommen, Ms Jill Quirk, Ms Betty Robinson,
Ms Chris Ronalds, Ms Val Scott, Ms Gaynor Small, Ms Maureen Wilson
Northern Metropolitan Region
City of Darebin: Ms Viki Perre (Manager of Community Care), Ms Adele Carmady
(Coordinator of Support Services), Ms Jenny Bacon, Ms Linda Bennets, Ms Tania Ciotti-Lin,
Ms Lisa Drayton, Ms Fran Harper, Ms Betty Kalambokis, Ms Anna Marino, Ms Pam Newton,
Ms Kathy Vlahakis, Ms Isabella Silveri
City of Knox: Ms Wanda Mitka March
Southern Region (Cardinia Shire, City of Glen Eira, and City of Bayside)
Ms Judy Beaumont (Regional Aged Care Adviser), Ms Tracel Devereux (Cardinia Shire Council
Aged Care Coordinator), Ms Margo Anderson, Ms Vimala Beaucasin, Ms Marion Coughlin,
Ms Margaret Cox, Ms Rachel Davies, Ms Roisin Kelly, Ms Cathy Toyas, Ms Alison Stewart
Regional Dietitians
Ms Simone Austin, Ms Meredith Atkinson, Ms Jenny Bacon, Ms Katherine Bathgate, Ms Rhonda
Gilbert, Ms Helen Gray, Mr Milton Jacob, Ms Mandy John, Ms Amanda Jones, Ms Mary Lawry,
Ms Claire Martin, Ms Pauline Maunsell, Ms Megan Morrison, Ms Sue Race, Ms Alison Stewart,
Ms Cathy Toyas, Ms Barbara Villani, Ms Maureen Wilson, Ms Debbie Wynd
National Focus Group of Dietitians in Disability
Dr Sandra Capra (Queensland University of Technology), Ms Wendy Dear (Stockton Centre,
New South Wales), Ms Jeanette Delatycki (Department of Human Services, Victoria), Ms Sue Gebert
(Kew Residential Services, Melbourne), Ms Michelle Lane (Disability Commission, West Perth),
Ms Sue Race (Austin Repatriation Hospital, Victoria), Ms Alison Stewart (Kingston Centre,
Victoria), Ms Lyn Stewart (Consultant, North Ryde, New South Wales), Ms Barbara Villani
(Dandenong Day Care Centre, Victoria), Ms Bridget Wallace (Manly Hospital, New South Wales),
Ms Robin Wood-Bradley (East Bentleigh Community Health Centre, Victoria), Ms Judith Wright
(Peter Macallum Clinic, Melbourne), Ms Lynden Hayes (Assessment Officer, City of Ballarat)
Victorian Reference Group of Dietitians in Disability
Ms Jenny Bacon (Bendigo Health Care Group), Ms Margaret Cox (Caulfield Community Health
Centre), Ms Jeanette Delatycki (Department of Human Services), Ms Sue Gebert (Kew Residential
Services), Ms Barbara Villani (Dandenong Day Care Centre), Ms Robin Wood-Bradley (East
Bentleigh Community Health Centre), Ms Judith Wright (Consultant Dietitian)
186
Royal District Nursing Service Homeless Persons Program
Ms Teresa Swanborough (Coordinator), Ms Ann Delikat-Kowalski, Ms Margaret Ryan, Ms Judy
McWilliams, Ms Sue Spurling
Geelong Aged Care Services
Ms Debbie Wynd (Chief Dietitian, Barwon Health, Grace McKellar Centre), Ms Heather Ashcroft
(Coordinator, Belmont Day Care Centre, City of Greater Geelong), City of Greater Geelong
Community Services: Ms Barbara Lewis (Program Management Coordinator) and Ms Margaret
McNamara (Coordinator). Carer Team Leaders, Home Carers, elderly clients

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