Nrs Resource Manual

Identifying and Planning Assistancefor Home-based Adults who areNutritionally at Risk: A Resource Manual

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DEPARTMENT OF HUMAN SERVICESHOME 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)

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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 WoodJenny BaconAlison StewartSue Race

for the

Dietitians Association of Australia (Victorian Branch)

1/8 Phipps CloseDeakin ACT 2600Tel: and Fax: (02) (6282 9798)e-mail: [email protected]

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 HumanServices (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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PREFACEThis Resource Manual has been designed to demonstrate and advocate for the introduction ofnutritional risk screening and monitoring to the assessment process for adults in the Home andCommunity Care (HACC) Program.

The majority of these adult clients are frail older people. Others include the younger adult personwith disability (intellectual, psychiatric, physical), and the adult who is financially disadvantagedand living in alternative accommodation.

This Manual has been developed through the active leadership and committed work of theDietitians Association of Australia (Victorian Branch). Generous informed assistance wasprovided by the work of focus groups of assessment officers and local dietitians in the CentralGrampians 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 indisability and dietitians with many years experience working in this area. A national group ofdietitians developed the initial draft materials and the Victorian Reference Group oversaw thetrial of these materials and their final inclusion in this Manual.

The input on clients who are living in alternative accommodation has been made through thevoluntary work of the project officer with the Royal District Nursing Service Homeless PersonsProgram.

Indirect input from clients was made by the trial of a client information booklet Good Food andHealth Advice for Older People Who Want to Help Themselves with the assistance of carers and a largenumber of home-based elderly clients receiving community services in the City of GreaterGeelong.

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 toolwhich has been developed. It also gives many practical suggestions about solving client problemsand information on where further assistance may be sought for them. It has been possible tocombine the materials for nutritional risk screening and monitoring to the frail older person, thelow dependency client with a disability and the homeless adult without sacrificing the integrityof the needs of these very different population groups. In a few instances, the complex nutritionalneeds 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 Assistancefor Home-Based Adults Who Are Nutritionally at Risk which was commissioned and funded by theVictorian Department of Human Services Home and Community Care (HACC) Program.


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CONTENTSPreface

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 Assessmentand 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 forTermination 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 1INTRODUCTION


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1.1 SUMMARY OF THIS MANUAL AND ITS USEThis Resource Manual has been designed to demonstrate and advocate for the introduction ofnutritional 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 alternativeaccommodation) who require Community Services to remain living independently.

A simple tool for nutritional risk screening and monitoring has been presented in Section 1 anddescribed in Section 2 Nutritional Risk Screening and Monitoring. The tool consists of ten triggerquestions to increase awareness as to whether nutritional risk exists for the client. These triggerquestions are expanded further in Section 3 Nutrition and Health Issues.

The general assessment* which is conducted with the client explores the reasons why suchnutritional 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 rolesand functions of dietitians can take. Sections 7 to 9 provide a range of completed Case Studieswhich are self explanatory and Section 10 gives some examples which can be used for QualityImprovement 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 poorrecovery from surgery. Malnutrition may also lead to decreased appetite, dental problems,depression, apathy, and even dementia. Poor nutrition (sometimes malnutrition) is one of themajor 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 whileintervention 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 thevulnerable adult person living independently. While some stereotypes exist, it is important totarget individuals so that the effectiveness of intervention is increased.

As people mature and age, their nutritional requirements change. It is now known that althoughactivity decreases, nutrient requirements are the same (and sometimes increased) in older peoplecompared to younger adults. Dietary Guidelines for apparently healthy active adults relate to theprevention of premature death from cardiovascular disease and cancer. In the frail older personand the frail person with disability, there is more emphasis on their need for increased supportand 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 withdisability 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 skinbreakdown, and life quality. The ability to take nourishing foods and fluids becomes an essentialapproach for maintaining independence in any person. The interested reader is directed to theReferences 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 toprevent.

In this Manual, vulnerable people includes frail olderpeople, younger adults with a disability and financiallydisadvantaged adults living in alternative accommodation.


13Identifying and Planning Assistance for Hom

e-Based People Who are N

utritionally at Risk: A Resource Manual (2001)

NUTRITIONAL RISK SCREENING AND MONITORING TOOL

CLIENT: DATE:

INSTRUCTIONS:

Fill in the client’s name and the date you use the tool: tick the box whenthe 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 malnutritionACTION:❙ 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?

❙ Doesn’t take 1 3 3 4 5+ food plan most days (older people)?

❙ Doesn’t 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?





• The underweight adult has little body energy and nutrient reserves for use in timesof emergency such as illness and/or reduced food and fluid intake This is evenmore critical to health, if underweight is not usual

• Even a short bout of poor food intake and/or increased need for nourishment canprecipitate 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 sixmonths), it is a serious sign of decline which is more rapid and worse if the personwas underweight before the weight loss began

• Severe weight loss is a factor clearly associated with relatively higher rates ofmorbidity 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 andreduced fluid intake can rapidly lead to severe weight loss

• Many medical conditions affect food intake and the need for food and can be riskfactors 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 swallowingdifficulties

• As a result of these problems, major food groups may be omitted and the personmay avoid socialisation

• Severe deficiencies of some of the micro-nutrients can actually cause mouthproblems


• People are put at nutritional risk by any acute or chronic illness which causeschange in their usual diet

• Nobody should be on a modified or special diet, unless the aim and benefit of thediet is clearly known to them

• If a special diet is required for specific treatment, then it becomes very importantto follow it properly


• The vulnerable person may only buy foods which are easy to carry or easy toprepare and to cook

• A person who is unable to shop may not eat enough because of reduced foodchoice (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 2NUTRITIONAL RISK SCREENING ANDMONITORING


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2.1 NUTRITIONAL RISK SCREENING ANDMONITORING AS PART OF THEASSESSMENT AND INTERVENTIONPROCESS


REFERRALClient Information and Referral Process

GENERAL NEEDS ASSESSMENT AND MONITORING

NUTRITIONALRISK

SCREENINGAND

MONITORING

CLIENT CARE PLAN

COMMUNITY DEVELOPMENTEquitable accessSafe quality foodPublic transportShop locations

User friendly shopsLocal cafes and markets

RESOURCES

• Policies

• StaffDevelopmentand training

• Staff support

• Quality improvement

SIMPLEINTERVENTIONS

• Client and carerinformation

• Social support• Home carer

• Transport• Shopping• Food

preparation• Personal carer• Meals • Food safety• Delivered meals• Respite Care• Referral to

specialisationassessment and/or intervention and care

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2.2 THE NUTRITIONAL RISK SCREENING ANDMONITORING TRIGGER QUESTIONS

Nutritional risk definition: “The risk factors of poor nutritional status are characteristics that areassociated with an increased likelihood of poor nutritional status” (Nutrition Screening Initiative,1992).

Nutritional risk screening and monitoring definition: “The process of discovering characteristicsknown 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 initialassessment, and then at each monitoring stage thereafter: YES, to ONE OR MORE of thefollowing 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.

• A stable body weight at a low level (say 80-90%) over a period of years can be consistent withapparent health, but a bout of poor food intake and/or increased energy and nutrient needscan precipitate severe weight loss. As far as we know, it is unlikely that life can be sustainedwhen 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 isparticularly difficult for a vulnerable person to achieve on a consistent daily basis for weeksand 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 ismore 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 clearlyassociated 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 contributedto 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 swallowingdifficulties.

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?• A person 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?• A person 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, andpossible 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 theirlife quality and their health may also deteriorate.

• Even if life quality is obviously affected by overweight, the decision has to be made as towhether 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 vulnerablepeople who are underweight or of normal weight.

• Unintentional weight gain may be disadvantageous in overweight people with severe heartdisease 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 forthe client. The diagram in Section 2.3 shows these trigger questions listed in a way which can beeasily attached to the assessment form. More detailed exploration of these trigger questions canbe found in Section 3.


CONDUCTEDWITH CLIENTINFORMATIONAND SERVICESRECORD ANDCLIENT-CARERINPUT

OPTIONALPLACEMENT

ON ASSESSMENTFORM

OPTIONALPLACEMENT INCLIENTINFORMATIONAND SERVICESRECORD

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2.3 THE NUTRITIONAL RISK SCREENING ANDMONITORING TOOL FOR HOME-BASED ADULTS



CLIENT: DATE:

INSTRUCTIONS:

Fill in the client’s name and the date you use the tool: tick the boxwhen the answer to your observation is YES












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





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2.4 HOW DOES NUTRITIONAL RISK SCREENINGAND MONITORING FIT INTO ASSESSMENTAND PLANNING ASSISTANCE FORINTERVENTION?

The next diagram shows where this simple and quick method of nutritional risk screening andmonitoring can be used in association with the Client Information and Referral process or formsor any other assessment form or process. The Nutritional Risk Screening and Monitoring Toolmay 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 NeedsAssessment and Monitoring conducted with the client, which will probably reveal the reasonswhy the client is at nutritional risk.


REFERRALClient Information and Referral Process

GENERAL NEEDS ASSESSMENT AND MONITORING

NUTRITIONALRISK

SCREENINGAND

MONITORING

CLIENT CARE PLAN

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2.5 GENERAL ASSESSMENT INCLUDESFACTORS RELEVANT TO NUTRITIONAL RISK

1) Household management problemsa) 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 problemsa) 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) Doesn’t take 1 3 3 4 5+ food plan most days (frail older person)?

c) Doesn’t 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 sideeffects such as loss of appetite, taste change, nausea, diarrhoea, constipation, fatigue anddrowsiness (causing reduced food intake).


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7) Gastro-intestinal problemsa) Nausea and vomiting

b) Diarrhoea

c) Constipation

d) Incontinence

e) Regurgitation

f) Rumination

8) Breathing problems

9) Other medical problemsa) 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 client’s need for nourishment

10) Alcoholism and substance abuseMore detailed explanation can be found in Section 4 for the general needs assessment factorswhich are related to nutritional risk.

Nutritional risk increases when the person is affected by anincreasing number of these factors.

Deterioration in health and loss of independence can result fromunder-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


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2.6 CHECKLIST FOR INTERVENTIONSimple intervention strategies have been provided thoughout this Manual and an outline of thesestrategies has been given below.

1) Food and nutrition informationa) 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

SIMPLEINTERVENTIONS

• Client and carer information

• Social support

• Home carer

• Transport

• Shopping

• Food preparation

• Personal carer

• Meals

• Food safety

• Delivered meals

• Respite care

• Referral to specialisationassessment and/or intervention and care


CLIENT CARE PLAN

28

3) Client referral for further assessment and/or interventiona) 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 REQUIREDTry TWO weeks of simple intervention strategies (less time if severe weight loss); if no responserefer to a specialist. Monitoring at monthly intervals (or more frequently), by one of the teammembers to determine if nutritional risk still exists.

To determine if nutritional risk still exists, this is accomplished by review of outcomes, and bestdetermined by repeat of Nutritional Risk Screening:


CLIENT: DATE:

INSTRUCTIONS:

Fill in the client’s name and the date you use the tool: tick the boxwhen the answer to your observation is YES


















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The care process and plan then begins againOn the next page (Section 2.8), a Case Study form has been provided for clients in NutritionalRisk Screening. A number of Case Studies have been shown in Sections 7 to 9, and Section 10 isabout Quality Improvement using Nutritional Risk Screening processes.





Nutritional risk increases when the person is affected by an increasing number of generalneeds assessment factors.

Deterioration in health and loss of independence can result from undernutrition and perhapsmalnutrition.

NAME:

ADDRESS:

NUTRITIONAL RISK SCREENINGYES, to one or more of these questionsmeans that nutritional risk exists

GENERAL NEEDS ASSESSMENTThe factors which are relevant to nutritionalrisk for this client

INTERVENTIONBriefly consider what, if any, action you cantake (including referral)

MONITORING*Repeat nutritional risk screeningHow often should this be done? Who can monitor?



Reduced appetite or reduced food or fluid intake?








*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 theteam members is recommended to ensure that the most effective intervention has been implemented.

Signature: Position: Date:

2.8 NUTRITIONAL RISK SCREENING CASE STUDY FORM




Checklist of general needs assessment factors which are related to nutritional risk:

1) Unable to feed selfa) Physical disabilityb) Sensory disabilityc) Mental/ behavioural problems

4) Social problem affecting food/fluid intakea) Bereavement, depression, social

isolationb) Reduced motivation

7) Medical problems/increased food anddrink needsa) Elevated body temperature, feverb) Impaired wound healing

2) Household management problemsa) Financial difficultyb) Organisational difficulty

5) Medical problems/reduced access food/fluid.a) Weight loss, muscle wasting,

reduced mobilityb) Breathing problems

8) Major disorders/changed nourishmentneedsa) Metabolic disorders (diabetes/

renal/liver)b) Cancerc) Gastro-intestinal disorders

3) Personal hygiene and food hygiene problems

6) Medical problems/reduced intake/absorptiona) Nausea and vomiting b) Diarrhoeac) 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, socialtrainer

c) Day care, respite cared) Nursing caree) Social supportf) Volunteer transportg) Case managementh) Medical care, dental carei) Nutritional carej) Counselling, informationk) Living skills programl) Other allied health resourcesm) Disability servicesn) Client care plan with client-carer input

3) Client referral for assessment and interventiona) Visiting nurseb) Doctorc) Dietitiand) Occupational therapiste) Speech pathologistf) Social workerg) Physiotherapisth) Dentisti) Psychologisth) Delivered mealsi) Diabetic educatorj) Other

33Identifying and Planning Assistance for Home-Based People Who are Nutritionally at Risk: A Resource Manual (2001)

2.9 NUTRITIONAL RISK SCREENING IN OTHERSETTINGS

2.9.1 Discharge Planning and Temporary Home CareEmergency or temporary home care may be required for a person under the followingcircumstances:

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.

NUTRITIONAL RISK SCREENING AND MONITORING TOOLCLIENT: DATE:

INSTRUCTIONS:Fill in the client’s name and the date you use the tool: tick the boxwhen the answer to your observation is YES

















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2.9.2 Retirement Villages, Supported Residential Services,and Day Care Centres, Sheltered Workshops, andShelters

1) Nutritional Risk ScreeningThe Nutritional Risk Screening tool can also be used in these settings. It is possible to observeand monitor the trigger questions, as follows.

• Obvious underweight - frailty?

• Unexplained weight loss?

• Reduced appetite or 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?

Always record your observations about different people, and if these observations persist try toachieve some preventive strategies or intervene in some way.

If you have the opportunity to apply the trigger questions of Nutritional Risk Screening with thegroup (either directly, or indirectly by observation), use the forms in Section 10 to create yourreport and to look at the group as a whole.

2) Discussion of food and health issuesOpportunities 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 createsome discussion and increase their awareness of the importance of what they eat and drink.

A creative 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 thispurpose. The local dietitian will be able to assist in the development of your program, provideappropriate brochures and leaflets, and perhaps attend on some occasions.

A mealtime is an ideal time to talk about food, nutrition, and health.

3) Apparently healthy and active older peopleIf the older group is apparently healthy and active, you may wish to ask them to fill in the tentrigger questions in Nutritional Risk Screening above. This will increase awareness of food andnutrition and health issues and promote much discussion.


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SECTION 3NUTRITION AND HEALTH ISSUES

In this Manual, vulnerable people include frail elderlypeople, adults with disability, and financiallydisadvantaged 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 nutrientreserves for use in times of emergency such as illness or reduced food and fluid intake. This iseven more critical to health, if underweight is not the normal situation for the particular person.

A stable body weight at a low level (say 80-90%) over a period of years can be consistent withapparent health, but a bout of poor food intake or increased needs can precipitate severe weightloss. 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 betaken in daily food and drink than the body requires on a daily basis. This is difficult for avulnerable person to maintain on a consistent basis for weeks and perhaps months.

Prevention of underweight is highly desirable in the vulnerable person. Those who aremoderately 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 can’t 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 weightdown?

• 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 person’s 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).


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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 skimmilk 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

• A multi-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 weightloss as well)


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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 lb145 4’ 9” 46.3 to 56.8 7 st 3 lb to 8 st 12 lb147 4’ 10” 47.5 to 58.3 7 st 6 lb to 9 st 1 lb150 4’ 11” 49.5 to 60.8 7 st 10 lb to 9 st 7 lb152 5’ 0” 50.8 to 62.4 7 st 13 lb to 9 st 10 lb155 5’ 1” 52.9 to 64.9 8 st 4 lb to 10 st 2 lb158 5’ 2” 54.9 to 67.4 8 st 8 lb to 10 st 8 lb160 5’ 3” 56.3 to 69.1 8 st 11 lb to 10 st 11 lb163 5’ 4” 58.5 to 71.7 9 st 2 lb to 11 st 2 lb165 5’ 5” 59.9 to 73.5 9 st 5 lb to 11 st 7 lb168 5’ 6” 62.1 to 76.2 9 st 10 lb to 11 st 13 lb170 5’ 7” 63.6 to 78.0 9 st 13 lb to 12 st 5 lb173 5’ 8” 65.8 to 80.8 10 st 4 lb to 12 st 9 lb175 5’ 9” 67.4 to 82.7 10 st 7 lb to 12 st 13 lb178 5’ 10” 69.7 to 85.5 10 st 12 lb to 13 st 5 lb180 5’ 11” 71.3 to 87.5 11 st 2 lb to 13 st 9 lb183 6’ 0” 73.7 to 90.4 11 st 7 lb to 14 st 2 lb185 6’ 1” 75.3 to 92.4 11 st 11 lb to 14 st 6 lb188 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 65years. This range is higher than that for other people, and approximates a body mass index of 22-27.


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3.1.2 Healthy Weight Range for Adults 16 to 64 YearsIt is difficult to provide one simple healthy weight range for younger adults. These clients rangefrom 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 moreimportant for morbidity and mortality than actual body weight.

Active adults 16 to 64 yearsThe healthy weight range for active younger adults 16 to 64 years is shown on the next page, andis always applied with common sense.

Vulnerable, and highly dependent peopleIt 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 intakeand perhaps a higher need for nourishment.

An arbitrary choice of body weight standard can be made and considerable care needs to betaken in deciding what is the person’s best weight. For practical reasons this may be on the lowside (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 thebody weight when the person has the best health and life quality. It may come back tomaintenance of the client’s usual weight.


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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 lb145 4’ 9” 42.1 to 52.6 kg 6 st 9 lb to 8 st 4 lb147 4’ 10” 43.2 to 54.0 kg 6 st 11 lb to 8 st 7 lb150 4’ 11” 45.0 to 56.3 kg 7 st 1 lb to 8 st 12 lb152 5’ 0” 46.2 to 57.8 kg 7 st 4 lb to 9 st 1 lb155 5’ 1” 48.1 to 60.1 kg 7 st 8 lb to 9 st 6 lb158 5’ 2” 49.9 to 62.4 kg 7 st 12 lb to 9 st 11 lb160 5’ 3” 51.2 to 64.0 kg 8 st 0 lb to 10 st 1 lb163 5’ 4” 53.1 to 66.4 kg 8 st 5 lb to 10 st 6 lb165 5’ 5” 54.5 to 68.1 kg 8 st 8 lb to 10 st 10 lb168 5’ 6” 56.4 to 70.6 kg 8 st 12 lb to 11 st 1 lb170 5’ 7” 57.8 to 72.3 kg 9 st 1 lb to 11 st 5 lb173 5’ 8” 59.9 to 74.8 kg 9 st 6 lb to 11 st 11 lb175 5’ 9” 61.3 to 76.6 kg 9 st 9 lb to 12 st 0 lb178 5’ 10” 63.4 to 79.3 kg 9 st 14 lb to 12 st 6 lb180 5’ 11” 64.8 to 81.0 kg 10 st 3 lb to 12 st 10 lb83 6’ 0” 67.0 to 83.7 kg 10 st 7 lb to 13 st 2 lb185 6’ 1” 68.5 to 85.6 kg 10 st 11 lb to 13 st 6 lb188 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

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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 ismore 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 clearlyassociated 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 medicationis taken, this may require review.

Relevant comments:• I think that I am losing weight

• My clothes don’t 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 kgweight loss

Over 1-month 5 3.5 kg 3 kg 2.5 kg 2 kgOver 1-3 months 7.5 5.3 kg 4.5 kg 3.8 kg 3 kgOver 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 kgweight loss

Over 1month More than 5 % More than More than More than More than3.5 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 than7 kg 6 kg 5 kg 4 kg


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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 skimmilk powder and topping for a high energy milk shake, Actavite, Milo. Improve tolerance bynot giving large amounts at first (refer Section 5.3.3.1)

• Ask a dietitian about nourishing snacks to take between meals

• A multi-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)


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3.3 REDUCED APPETITE OR REDUCED FOODAND FLUID INTAKE?

In the underweight person, a short period (more than one or two days) of reduced appetite andreduced food and fluid intake can rapidly lead to severe weight loss.

Many vulnerable people miss meals and so don’t get enough energy and nutrients from theirfood. 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, andnot eat any other food that day.

Some people follow special diets that were prescribed many years ago that may no longer beappropriate or needed (refer Section 3.5).

Illness can cause poor appetite, and treatment may even include ‘diets’ which limit the foodswhich can be eaten and reduce enjoyment of food. Loss of appetite can sometimes be related to achange in medication. Taste and smell sensations are reduced in vulnerable people, and these canbe further reduced by some medications (refer Section 4.6).

Illness can also increase the need for food. Common diseases such as Alzheimer’s, dementia,Parkinson’s disease, infections, fractures and hyperactivity all increase the need for additionalenergy from food (Section 4.5). Adults who are not taking 6 to 8 cups of fluid every day areprobably 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 enoughfood 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?


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Simple interventions:• 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 don’t 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 incups 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 togroup meals or distant friends; look to include them in other social activities which includesome 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 Mealson Wheels), day care, occupational therapy, physiotherapy.


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3.4 MOUTH OR TEETH OR SWALLOWINGPROBLEM?

It is very difficult for people to ingest enough nourishing food (with variety) if their teeth ordentures are loose, broken or missing, or if they have a sore tongue and gums, or any swallowingdifficulties. Oral health involves teeth, gums, dentures, swallowing and dryness or pain in themouth.

Problems include missing teeth, ill-fitting dentures, teeth grinding, chewing and swallowingdifficulties, cracked or sore lips, dry mouth, sore tongue, gingivitis, and pain or sensitivity to hotor cold.

As a result of mouth or teeth problems, many people may omit some foods or an entire foodgroup from their diet. These problems may affect food and fluid intake, nutritional quality of thediet and socialisation.

Severe deficiencies of micro-nutrients (iron, folate, riboflavin, ascorbic acid) can actually causemouth problems.

Meat (a valuable source of protein, iron, zinc and energy, and other micro-nutrients) is the mostcommon 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, andintervention in this area of health may be very important for some clients. Specific medicalproblems can also occur (dysphagia, cancer) which cause even more complex problems.

A swallowing 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 don’t 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)?


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• 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?

Simple interventions:• 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 onMeals 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 aproblem (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 tokeep 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 (Difficultyin swallowing should always be investigated by a doctor, with possible referral to a speechpathologist and dietitian)


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3.5 FOLLOWS A SPECIAL DIET?Vulnerable people are put at nutritional risk by any acute or chronic illness which causes changein 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 client’s nutritional needs willchange over time.

Individuals often get mixed messages about food and diet from doctors, dietitians, and wellmeaning 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 takeare 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 clearlyknown 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 itproperly. This will ensure that the client’s health and well being improves, which makes it worththe effort.

Relevant comments:• I am sick of this diet

• I only follow it when I am sick

• My doctor says that I shouldn’t 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 clearlyknown 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?


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Simple interventions:• 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 forthe person now or if the person/carer does not know the reason why a modified diet is beingfollowed, or if the aim of the diet is not clear, always refer the person to the doctor and/ordietitian

• After firm encouragement and a trial period with a modified or special diet, consider cessationafter 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 tomake 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.


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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 theyhave not been shopping for some time) people may not know or remember what foods areavailable. A person 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 don’t know what to eat when I don’t 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?

Simple interventions:• 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)


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3.7 UNABLE TO PREPARE FOOD?Vulnerable clients may not be physically or mentally capable of preparing and cooking food. Thislack of independence can have serious effects on their enjoyment of it, and their intake of foodand 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 ofchoice (no ideas, no prompts), a reduced level of independence, possible dislike of the foodsoffered, or reduced life quality.

Relevant comments:• I am not always able to cook for myself

• I don’t like the way she cooks the food

• I don’t 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


Check outcome: Unable to prepare food?

Consider referral: occupational therapist (for assessment and aids), dietitian (for assessment andinformation), social worker (such as finance for utensils), local government services.


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3.8 UNABLE TO FEED SELF?A person 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 ofindependence, 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 don’t like the way she cooks the food

• I don’t 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


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 AdultsFeeding high dependency adults is often time consuming and difficult. If it isn’t done withsufficient 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 person’s nutritional healthimproves towards the best weight for their best health.

Factors which need to be considered to reduce feeding problems and poor nutrition in highdependency 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 thelungs); food aspiration may also occur without any noise, when the person with silentaspiration 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 CLIENT’S FEEDING ROUTINE IN ANY WAY• ALWAYS REFER FOR SPECIALIST ADVICE (DOCTOR, DIETITIAN)


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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 individual’s food and fluid preferences

• Consider taste, smell and appearance of the plated food, and the temperature of the food anddrink

• 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 foodsand 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 areunderweight 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 withoutexpert 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 aSpecialist

Feeding problem Referral

Consistent refusal of food and/or fluids? Dietitian, doctor, pharmacist, social worker, psychologist

Gum or tooth disease? Visiting nurse, dentistCan’t reach meal and feed self? CarerCan’t sit in chair comfortably to feed? Occupational therapist, physiotherapistIs a feeding program required? Dietitian, speech pathologistFood or fluid dribbles out of mouth? Speech pathologistCoughs, gags or chokes while feeding or Speech pathologist, dietitianimmediately afterwards?A meal takes more than 40 minutes to eat? Doctor, dietitian, speech pathologist,

physiotherapistA physiological problem with swallowing Speech pathologist, doctoror silent aspiration?Gurgly ‘wet’ voice during or after meals?Gut not functioning? DoctorWill texture modification be sufficient to Doctor, dietitian, speech pathologistmake feeding safe?

Continue to monitor at regular intervals byNutritional Risk Screening and Monitoring

* Modified from the Nutrition Decision Tree (Dear & Webb, 1996).


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3.9 OBVIOUS OVERWEIGHT AFFECTING LIFEQUALITY?

Normal to moderate overweight is a protective factor in the vulnerable person. Body fat providesa readily available energy store and is a safeguard in times of stress (infections, trauma) orreduced 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 tofollow a very strict diet which cannot provide enough nourishment for them to maintain theirphysical activity and life quality. An overweight person who goes on a very restricted diet is atrisk of muscle wasting, infections and associated morbidity and mortality.

In making a decision about whether a weight loss program should be commenced in a vulnerableoverweight person, life quality should be considered. The answer lies in the balance between anyexpected improvement in life quality with a small slow weight loss, versus any expecteddeterioration in life quality due to a very restricted diet, muscle wasting and associated healthrisks.

A better option for older adults may be omission of high energy refined foods and a goal ofweight maintenance. This is also the best option for people with a disability who have disorderswhich are associated with obesity (Prader Willi syndrome, Down syndrome).

Relevant comments:• It doesn’t 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 haven’t 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?

Simple interventions:• 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 foryounger 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


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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 asimportant 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 onlyaccounts 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, orproblems with mobility), unintentional weight gain may be disadvantageous; in this case itmay 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 can’t stop eating

• I want fried foods, sweets, chocolates

Further questions:• Are you hungry?

• Have you had any activity today?

• Are you lonely?

Simple interventions:• 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 nourishingdiet of the 1 3 3 4 5+ food plan (for older people) or the 1 2 3 4 5+ food plan (for youngeradults), 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


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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 4GENERAL ASSESSMENT OF FOOD ANDNUTRITION ISSUES


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4.1 Summary of General Assessment Factors AffectingFood 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) Doesn’t take 1 3 3 4 5+ food plan most days (older person)?

c) Doesn’t 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 sideeffects such as loss of appetite, taste change, nausea, diarrhoea, constipation, fatigue anddrowsiness (causing reduced food intake).

7) Gastro-intestinal problemsa) Nausea and vomiting

b) Diarrhoea

c) Constipation

d) Incontinence

e) Rumination

f) Regurgitation


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8) Breathing problems

9) Other medical problemsa) 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 client’s 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 DIFFICULTIESThe amount of money that an adult has to spend on food each week may restrict the variety andamount of food bought (see weekly food budget below). More expensive foods such as meatcontain many important nutrients. Adequate diets can be purchased on limited income but itneeds care and knowledge to do so.

Some people may not spend enough on food even when they have sufficient money to buy anadequate 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 personis not getting enough nourishment. People suffering economic hardship on a low income can findit difficult to buy enough food, and to buy food which supplies them with adequate nourishment(energy and nutrients). A consequence can be the effect of poor nutrition on quality of life andhealth, which can progress into malnutrition.

Relevant comments:• I don’t 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 budgetThe minimum amount of foods needed for an adult to obtain adequate nourishment (but not totalenergy) 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 competitivesupermarket, the total bill comes to about $30 a week. So it costs even more than this to buyenough food to satisfy energy needs and appetite.


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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 thatan adult needs each week to purchase food which will meet their own basic need fornourishment.

A younger active adult will need to spend even more than $30 a week on food for adequatenourishment.

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 assistpeople on low incomes, and can also conduct supermarket tours


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4.3 SOCIAL PROBLEMSEating is usually a social activity and meals eaten with others are often more enjoyable; eatingalone can lead to reduced interest in food. Reliance may also be placed on ready prepared orsnack foods rather than on maintenance of cooking skills.

Reduced food intake is common when people are experiencing social isolation, bereavement ordepression. Vulnerable people may have even less motivation to eat or drink, for known orunknown 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?

Simple interventions:• 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 havemeals with family and neighbours on a regular basis

• Encourage social activities where meals are provided-Adult Day Care, Craft Groups, AdultDay 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 oneperson, resources), doctor (for management of depression)


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4.4 PERSONAL HYGIENE AND FOOD HYGIENEPROBLEMS

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 andcasseroles

• Don’t refreeze food after thawing (package in small quantities instead)

• Don’t 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 foodcontamination

Check outcome: No tummy aches, diarrhoea etc ?

Consider referral: visiting nurse, doctor, dietitian


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4.5 MENTAL HEALTH PROBLEMSPoor 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 thereforeimportant to address these problems to achieve the best possible health and nutrition for theperson.

Poor mental health may include depression and acquired brain injury. Other common problemsaffecting cognition include dementia, Parkinson’s disease, Alzheimer’s disease, intellectualand/or psychiatric disability. Change in mental state can result from the use of alcohol orsedatives when taking particular types of medication, or the chronic use of alcohol.

Severe micro-nutrient deficiencies (folate, vitamin B-12, thiamin, niacin), and dehydration canalso 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 can’t 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 person’s living situation and conditions?

• Are all medical problems under control?

• Are medications having side effects?

Simple interventions:

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 Alzheimer’s 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 OFMEDICATION DAILY)

The more medications taken, the more likely these medications are to interact and produce sideeffects such as loss of appetite, taste change, nausea, diarrhoea, constipation, fatigue anddrowsiness, with reduced food intake.

Medications can also affect nutrient needs and may alter the body’s response to nutrients andmedications (drug-nutrient and drug-drug interactions). Drug-nutrient interactions areexacerbated by poly-pharmacy, ageing, and marginal food intakes or existing nutritionaldeficiencies.

Taking more than three medications can increase the chance of these effects, and can lead toweight 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 thepharmacist can inform them of any possible interactions. If the effectiveness of drug therapychanges 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 theinstructions?

• 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 person’s diet changed?


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• Has the person’s nutrition and weight declined since drug therapy began?

• Is the person taking other medications bought over the counter or in the supermarket?

Simple interventions:• 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


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 theclient’s level of blood vitamin K (another anti-coagulant). If the person does not have a change ofdiet, 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, cookedbroccoli and spinach. If a person begins to take large amounts of these foods or omits their usuallarge intake of these foods, it may affect their Warfarin requirement. An effect may also occur ifthe person suddenly and drastically increases or reduces their intake of other foods which containlower 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 VOMITINGReduced fluid and food intake can result from nausea and vomiting, and lead to dehydration andweight loss.

Nausea and vomiting can be caused by poor personal hygiene, poor food hygiene, foodcontamination, medication side effects illness and disease.

Relevant comments:• I am feeling a bit sick

• I am getting very thirsty

• I don’t 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?

Simple interventions:• 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 feelslike

• 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 client’s usual foodpattern

• 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 DIARRHOEADiarrhoea results from malabsorption of fluid or food (wasted fluid or food). It can causeabdominal 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)?

Simple interventions:

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


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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)


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4.9 CONSTIPATIONConstipation can cause abdominal bloating, discomfort and reduced food intake, and may be dueto 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?

Simple interventions:• 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)


Check outcome: Gradual improvement in regularity and ease ofbowel actions (over months)?

Consider referral: visiting nurse, doctor, dietitian


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4.10 INCONTINENCEAlways 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 causedby one or more of the following:

1) Constipation (refer Section 4.9); faecal impaction leads to lack of awareness of the fullnessof the bladder; the bowel is full and presses on the bladder causing discomfort and perhapsurine 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) Parkinson’s 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


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Simple interventions:• 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-incontinenceis 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 OLDERPERSON

Asthma, chest infections and emphysema are conditions which cause difficulty with breathingand cause the body to work much harder. Thus more energy is used and it is difficult to takesufficient dietary energy to maintain a good body weight. This may also cause meal disruption bycoughing and spluttering.

People with breathing problems need one and a half times more energy in their diet due to theextra effort required for breathing. More energy is used and it is difficult to take sufficient dietaryenergy to maintain a good body weight when people experience breathing problems.

A diet high in carbohydrate results in even more carbon dioxide being produced by the body forexpiration through the lungs.

As less carbon dioxide (for expiration) is produced from the metabolism of fat, fat intake is abetter source of some of a person’s energy than carbohydrates for the older person with breathingproblems. In younger adults increase in fat intake may need to be balanced with the prevention ofcardiovascular disease.

Relevant comments:• I can’t get enough air when I’m 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?

Simple interventions:• 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


Check outcome: Some ease of eating, maintenance of body weight ?

Consider specialist referral: dietitian


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4.12 OUTLINE OF SOME MEDICAL PROBLEMSAFFECTING 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, Alzheimer’s disease (refer Section 4.5)

3) Major medical disorders which change the client’s 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) Parkinson’s 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.


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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?

Simple interventions:• 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 DiabetesDiabetes may be simple (treated with diet only), moderate (treated with diet and tablets) or morecomplex (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 longterm complications of diabetes.

Many older people have had this problem a long time, often without the benefit of enoughinformation to look after themselves in the best way.

Simple interventions:• 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; thoroughyearly 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 diseaseWhen 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 termdevelopment of medical problems.

Some older people have avoided the premature development of major problems withcardiovascular 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 theirquality of life and independence. Depending on the individual the balance of their dietary needsstarts to change to support weight maintenance, independence and quality of life.

Simple interventions:• Check the person’s 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 tomore 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 5DIETARY 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 dietaryfibre

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 PATTERNSAdults have a lifetime of eating and drinking experiences, and they often have established a fairlyset 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, providingstructure for the day and giving them control over ‘something’ in their difficult lives. Their foodbehaviour is probably linked to preservation of their identity and personality, and the nurturingand 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 person’s 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 theirawareness and allow response in the required direction.

Provision of choice in taking action is usually helpful to people and they will often welcomeassistance with food budgeting. The assessment officer, service provider and the carers mustalways consider the food life experiences of their client, and respect their food habits andpatterns.

Only when there is substantial and known benefit to a person, should consideration be given tochanging their basic food habits and pattern of eating. On these occasions, modification of theirusual 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 issuesPeople 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 issuesEthnic, cultural and religious groups have different attitudes, knowledge and roles for manymatters, 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, preferablyof their own background

• Need for additional reassurance and information, preferably from someone of their ownbackground

• 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 eyecontact, 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 effectivecare)

• Attitude to medication-fear of loss of control and lack of knowledge and understanding ofhow 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 adietitian, 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 basalmetabolic rate and activity level.

Although the basic energy requirement is less than for younger adults, the requirement forprotein, vitamins and minerals remains the same. Requirements for some nutrients may evenincrease (such as calcium).

Hence, the nutrient density of the older person’s diet must be greater in order to maintainnourishment and optimal nutritional health. It is therefore more difficult for older people to meettheir nutrient requirements, as they require the same amount of nutrients from a smaller amountof food.

In addition, in the presence of disease or trauma, both energy and nutrient requirements in olderpeople may increase, thus increasing their need for food at a time when their appetite may bereduced.

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 beappropriate for frail older people who have difficulty obtainingsufficient energy from their food due to increased requirements orreduced appetite.

In these circumstances extra nourishment and more sugar and fatmay 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 tobetter meet the nutritional needs of frail older people. Some frail older people require an evenlarger amount of food to maintain their weight.


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The following will provide sufficient nutrients for older people who are not underweight and/ordo 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 (preferablyhigh fibre)

And extra foods from these five groups according to appetite and level of activity

IndulgencesUnless weight reduction is essential, one or two extras such as a piece of cake, a scone, a fewlollies or a glass of wine can be enjoyed. A small appetite means that taking the most nourishingfoods first is the best thing to do, followed by the less nourishing foods (indulgences).

SaltSalt and salty foods can be used sparingly, and according to taste, except when a special low saltdiet is required for medical reasons (high blood pressure, fluid retention).

Fluids6-8 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 longperiods, 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 andindependently living to being vulnerable, perhaps non-ambulant and highly dependent. Some dietary principles have been given below.

Dietary guidelines for people 16-64 years1) 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 foodsone 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 cerealsone 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


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IndulgencesUnless 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.

SaltSalt 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

Fluids6-8 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 youngeradults: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:




• Heal a wound






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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 thedaily food plan, and often for months and years to:




• Heal a wound





When clients need increased nourishment the best thing for them to do is to eat slightly smallermeals 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 meanstaking foods of higher value rather than increased quantities which would be the other wayround 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 ausual mealtime (overnight may be a good time in the long break between the evening mealand 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

• A multi-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 ulcerwill heal up when you are back to your best weight)

• Always monitor weight if possible


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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 weightloss as well)

Some vulnerable people need extra nourishment to achieve theirbest weight


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5.3.3.1 High Energy Foods and DrinksSolid foods and thicker foods and fluids with the least water in them are usually high in energyvalue.

The food group which is the highest in energy value by weight is fat, then alcohol. Starchy foodsand 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 fruitsand vegetables.

High energy foodsTo 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 drinksSpecial drinks can add extra food energy (kilojoules) and nutrients to the daily diet. Considerserving small amounts of these drinks if food intake is very small. These drinks are not a mealreplacement and are best taken in small amounts as between meal snacks. They are best servedcold

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 energymilk shake, or an icecream soda

• Soups are useful providing they are not too watery and providing extra ingredients are addedsuch 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 mixturenot drunk within 24 hours must be thrown out to avoid possible bacterial growth.


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IN A PERSON WITH SWALLOWING DIFFICULTIESTHERE MAY BE RISK OF FOOD AND FLUID LUNG ASPIRATIONSO:• DO NO HARM• DO NOT FORCE FEED• DO NOT CHANGE CLIENT’S FEEDING ROUTINE IN ANY WAY• ALWAYS REFER FOR SPECIALIST ADVICE (DOCTOR, DIETITIAN)

Some vulnerable people need extra nourishment to achieve theirbest weight


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5.4 THE IMPORTANCE OF FLUID INTAKEMany vulnerable people (particularly frail older people and people with a disability) do not drinkenough fluids.

This may be because of fear of incontinence or ‘accidents’ or because their toilet is difficult forthem to use, particularly at night. Insufficient fluid intake will usually make incontinence worsein the long run.

Drinking too little fluid can lead to constipation and dehydration, raised body temperature andperhaps stroke. We should all drink 6-8 cups of fluid daily. This can be water, tea, coffee, fruitjuice, 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 don’t have anything to drink after 4 pm

• I don’t have the soup-it is too much fluid

• I don’t 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?

Simple interventions:• 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 doesn’t 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 severefeeding problems may require the addition of thickeners to their fluids. This thickness MUSTNOT 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


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5.5 ALCOHOL AS PART OF A VULNERABLEPERSON’S 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 toalcohol at lower doses than other people.

Points to remember about alcohol as part of a vulnerable person’s diet:

• As older people often have lower body weight than younger people, they have reducedtolerance to alcohol

• They are also at risk of alcohol withdrawal at much lower doses of alcohol (for example, aslittle as the daily use of 1-2 standard drinks of an alcoholic beverage in a small frail olderperson)

• 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 resultin alcohol withdrawal symptoms (such as confusion and disorientation)

Alcohol interacts with many medications, and the combined effect may make the client feelworse. It can also affect the financial and social situation of your client. Excessive intake ofalcohol 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 attendingAlcoholics 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


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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 offalls)

• Encourage the person to limit alcohol intake to one to two standard drinks a day and to haveat 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, AlcoholicsAnonymous, alcohol and drugs 24 hour professional advisory services (refer Appendix 2)


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5.6 VITAMIN DVitamin D is important in maintaining the integrity and strength of the muscle and skeleton andteeth.

Regular exposure of the skin to sun, say 1-2 hours direct sunlight per week in Summer), allowsthe client’s 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 houseboundpeople is the daily intake of vitamin D enriched table margarine(read the label to make sure that the margarine is vitamin Denriched).

Housebound people or people who are always fully covered up and have little or no exposure todirect sunlight are at risk of vitamin D deficiency, and should also take vitamin D (5-190 mcgvitamin D daily) supplements.


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5.7 USE OF VITAMIN AND MINERALSUPPLEMENTS

If a frail older person, person with a disability or homeless client has not been eating properly formore than four days, recommend a low dose vitamin and mineral supplement with food, three orfour times weekly until the person is eating normally.

In frailty and/or serious gastric disturbance, intramuscular injection of vitamins and mineralsupplements should be considered once weekly for a few weeks.

Frail older people have a similar/increased need for vitamin and mineral supplements comparedto young adults. Their need for vitamin and mineral supplements may be even higher in thepresence of disease.

Points to remember about vitamin and mineral supplements:

• Vitamin and mineral supplements are taken best in doses corresponding to the RDI’s(recommended dietary intakes)

• Liquid form vitamin and mineral supplements taken with food may be better tolerated inunderweight people

• Much higher doses of vitamin and mineral supplements are not required

• Vitamin and mineral supplements are yet another expensive medication and may not betolerated- they may cause gastric upset.

Refer to Section 5.6 for more information about vitamin D.


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5.8 HOW TO BE WELL-NOURISHED ON MEALSON 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 deliveredmeal (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 thatit 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 sufficientenergy 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 somesalt.

Meals on Wheels is ONLY PART of the daily diet for any person. For more detail, refer Section 5.3.1for older people and Section 5.3.2 for people 16 to 64 years.

At least three meals every day are recommended for all vulnerableadults


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5.9 OUTLINE OF SOME FOOD AND DIETARYPROBLEMS

Food and dietary problems vary enormously in their variety and complexity. If the client ismotivated 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 beingmet. 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 aremodified 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 offood 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 anddietitian

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 eatthem through poor cooking skills, inadequate food preparation facilities, and lack ofinformation about food availability and how to make better choices.

If you need more information on a person’s food or fluid intake, thefollowing 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 yourobservations.

If the person is a poor historian, use a checklist of food groups. This list can also be used to checkfood 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 eatand 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 FoodPeople who have socially unacceptable and abnormal eating and drinking behaviour may beexercising their control over their environment and relationships in the only way in which theycan demonstrate it. It is important to try and separate such behaviour from genuine physical ormental ill health.

A frail older person may not recognise new foods and a person with an intellectual disability whohas limited experience with food behaviour may refuse to eat new or different foods. Refusal toeat 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 theperson 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 willmake more effort to overcome any mental or physical difficulty encountered while eating anddrinking. 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 strengthin the feeding and breathing functions as well as improvement in appetite.

Simple interventions:• 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 anddrinking

• Good lighting, an attractive table and crockery all assist

• Conversation about the mealtime and the food should always include the actual names of thefoods and the drinks

• Attractive and recognisable food, with plenty of time to chew and swallow each mouthful isvery 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 beassisted 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 foodor fluid for an interval of time, or alternatively the person can be temporarily removed from thesetting in which the problem is occurring. Success in resolving or reducing the abnormalbehaviour will only result if consistent action is taken. Positive reinforcement should beencouraged. The same sequence of events must occur every time the inappropriate behaviouroccurs.

Possible referral for particular advice: always consult a psychologist or dietitian if problemspersist


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5.9.3 High Dependency Adults with Feeding Problems WhoRequire Foods and Fluids Which are Modified inTexture

Adults with high food-related dependency are more likely to be underweight. Suchunderweight can affect the musculature of the body SO MUCH that it weakens the muscleswhich operate chewing and swallowing food (and breathing). Improvement in body weighttowards the normal range can provide great benefits to the individual with improvement inchewing swallowing (and breathing). After gaining sufficient weight, some people even begin toachieve feeding themselves!

When high dependency people require foods and fluids which are modified in texture (thickenedor thinned):

• Always give the person the opportunity to enjoy a wide range of foods served in anappropriate 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 lookattractive; hot foods may require reheating after blending

• Avoid using water to soften foods because it reduces the nourishment and taste value of thefood; use sauces, gravies, soup, broth or milk with savoury foods, and milk, juices or syrupswith 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 personhas much more difficulty chewing and swallowing and is more difficult to feed than a personof more normal body weight.

FOOD AND FLUID LUNG ASPIRATION RISK:• DO NO HARM• DO NOT FORCE FEED• DO NOT CHANGE CLIENTS FEEDING ROUTINE IN ANY WAY• ALWAYS REFER FOR SPECIALIST ADVICE (DOCTOR, DIETITIAN)

Adequate nourishment and fibre value is most important.The daily food and fluid intake should provide sufficient energyto achieve or maintain a desirable body weight.


129

5.10 BRIEF COUNSELLING METHODSSome people are very resistant to health information and other information that you might givethem. It is challenging to find a way to motivate clients who are reluctant to change what theyare doing.

The best approach is to find something small in their area of motivation or interest which ispractical 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 usefulactivities.

The ability to change is restricted by poor quality of life and ill health. Conversely, small changesin 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


131

SECTION 6WAYS DIETITIANS CAN ASSIST HOME CARECLIENTS AND SERVICES


133

6.1 SUMMARY OF ROLES AND FUNCTIONS OFDIETITIANS IN HOME-BASED CARE

Actual and potential ways dietitians can assist home care clients and services with food andnutrition 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 peoplewho 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 generalor 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 FoodServices:

a) Relationship to local commercial and other food-related activities

b) Community food service review

c) Food service training


134

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 theknowledge and skill to investigate the problem in some detail, and provide information whichhas 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


135

• 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 doesn’t taste good to me

• I have trouble chewing and swallowing*

• My pills are upsetting me and I can’t 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


137

SECTION 7CASE 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


139

7.1 CASE STUDY NUMBER ONE: WOMAN, 75 YEARS, RECENT HOSPITAL DISCHARGE

Identifying and Planning Assistance for Home-Based People W

ho are Nutritionally at Risk: A Resource M

anual (2001)

A 75 year old woman lives alone. She recently fell and fractured her hip (neck of femur).

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




Nutritional Risk Screening and Monitoring Case Study Form

Nutritional risk increases when the person is affected by an increasing number of generalneeds assessment factors.Deterioration in health and loss of independence can result from undernutrition and perhapsmalnutrition.

NAME: Case study number one: woman, 75 years

ADDRESS:

NUTRITIONAL RISK SCREENINGYES to one or more of these questions meansthat nutritional risk exists



MONITORING*Repeat nutritional risk screeningHow often should this be done?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 hipPressure sores

Impaired mobilityDepression, grief, social isolationSevere 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 programGrief counselling

Refer to dentistOccupational therapist(assessment of mobility)

Provide information to client anddaughter re small frequent meals andhigh 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 isrecommended 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



anual (2001)

A 75 year old woman has severe emphysema and uses a ventolin pump daily.

She lives in a one bedroom flat, is on a pension, and doesn’t 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 couldn’t 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.






NAME: Case study number two: woman, 75 years

ADDRESS:









Mouth or teeth or swallowing

problem?






life quality?


Reduced mobilityShortness of breath

Severe weight loss (30%)

At risk (no phone)?Social isolationDepression?Finances?

Personal care decreasing

Poor knowledge of food needs?

Misses breakfastSmall evening mealNo sugar

Refer for case managementHome care daily?Day care attendance?

Refer to doctor for shortness of breath

Refer to visiting nurse for medicationand personal care

Occupational therapist (kitchen safety)

Financial counselling?

Talk with daughterEncourage small frequent meals, milkand increased sugar intake

Monitor nutritional risk

Case manager as requiredVisiting nurse to monitor every twoweeks 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 ) isrecommended to ensure that nutritional risk has been decreased through the most effective intervention.


143

7.3 CASE STUDY NUMBER THREE: MAN, 74 YEARS, RECENT STROKE,REFERRED BY DOCTOR



anual (2001)

A 74 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.






NAME: Case study number three: man, 74 years

ADDRESS:


GENERAL NEEDS ASSESSMENTIdentify the factors which are relevant tonutritional risk for this client








problem?






life quality?


Recent stroke, drowsyPsychological issues (concerned aboutwife); reduced mobilityBladder problems, constipationSevere weight loss (3 kg in one month)

Decreased fluid intake(500 ml per day)?

Fear of chokingDentures not used?

Wife feeds himWife inappropriately avoids high fatfoods for himLow bread, milk intake

Refer to doctor (prostate, constipation,medication, drowsiness)

Visiting nurse support

Refer to speech pathologistRefer to dentistCarer support

Refer to dietitian for client/carereducationSmall frequent meals

Information to client and wife re foodand 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 isrecommended to ensure that nutritional risk has been decreased through effective intervention.


145

7.4 CASE STUDY NUMBER FOUR: MAN, 72 YEARS, ALCOHOL ABUSE,FRAIL, REVIEW REQUESTED BY HOME CARER



anual (2001)

A very 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.




Nutritional Risk Screening and Monitoring Study Form


NAME: Case study number four: man, 72 years

ADDRESS:


GENERAL NEEDS ASSESSMENTIdentify the factors which are relevant tonutritional risk for this client




?? Unintentional weight loss?




problem?


?? Unable to shop for food?




life quality?


High alcohol intakeUnwell (leg ulcers)

Social isolationDehydration?Occasional incontinence

Decreased mobility

Unsafe environment

No housekeeping skills

Not eating Meals on WheelsPoor irregular food intake

Visiting nurse (leg ulcers, dermatitis)

Family conference

Doctor review (alcohol, legs,incontinence)Vitamin supplements?

Home care with specific tasks andexternal supportPersonal care?Improve socialisation? music? meals?Family?

Occupational therapist (safety)

Establish relationship, take dietaryhistory, find out food preferences, plateMeals on Wheels, supervise regularmeals

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



147

7.5 CASE STUDY NUMBER FIVE: WOMAN, 71 YEARS, MEALS ON WHEELS NOT USED, REFERRED BY VOLUNTEER



anual (2001)

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 doesn’t 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 doesn’t recognise the packet containing Meals on Wheels.

She is losing weight.

A couple of times she has suffered from dehydration and urinary tract infections with associated acute brain syndrome.




Nutritional Risk Screening Case Study Form


NAME: Case study number five: woman, 71 years

ADDRESS:










problem?






life quality?


Limited socialisationSon’s behaviour and insight?

Lacks insight

Deteriorating personal careResistant 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

* 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 isrecommended to ensure that nutritional risk has been decreased through effective intervention.Signature: Position: Date:

149

7.6 CASE STUDY NUMBER SIX: WOMAN, 85 YEARS, OVERWEIGHT,MANY MEDICAL PROBLEMS



anual (2001)

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.

A blood 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).

A ‘sugar 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.






NAME: Case study number six: woman, 85 years

ADDRESS:










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 homeassessmentPhysiotherapist assessment-hydrotherapy if possible?

Friendly visitingMedication review

Home care-shop, home dutiesArrange assistance if required

Suggest regular meals and low fat lowsugar 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


ADULTS WITH A DISABILITY

List of Case Studies: Adults with a DisabilityNumber 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


153

8.1 CASE STUDY NUMBER ONE: WOMAN, 21 YEARS, SEVERE WEIGHT LOSS, CEREBRAL PALSY, REFERRED BY MOTHER



anual (2001)

A woman, 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.




Nutritional Risk Screening and Monitoring Study Form Nutritional risk increases when the person is affected by an increasing number of generalneeds assessment factors.Deterioration in health and loss of independence can result from undernutrition and perhapsmalnutrition.

NAME: Case study number one: woman, 21 years

ADDRESS:




MONITORING*Repeat nutritional risk screeningWho can monitor these risks? How often should this be done?




?? Mouth or teeth or swallowing problem?




?? Unable to feed self?



Sick (bronchitis)?

Fibre, fluid intake?Quality of vitamised food and thickenedfluidsReliant on mother

Anti-convulsant medication?

Refer to doctor

Consult schoolteacher

Take dietary historyRefer to speech pathologist anddietitian?

Support for mother

Seek more information on drugsAdd in sugar and fatHigh energy thickened drinks

1-2 weeks

Refer to dietitian, especially if noimprovement in 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 isrecommended to ensure that nutritional risk has been decreased through the most effective intervention.


155

8.2 CASE STUDY NUMBER TWO: WOMAN, 28 YEARS, OVERWEIGHT,MILD INTELLECTUAL DISABILITY, REFERRED BY HUSBAND



anual (2001)

A woman, 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







ADDRESS:




MONITORING*Repeat nutritional risk screeningWho can monitor these risks? How oftenshould this be done?











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 interventionsOne 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 isrecommended to ensure that nutritional risk has decreased through the most effective intervention.Signature: Position: Date:

157

8.3 CASE STUDY NUMBER THREE: MAN, 33 YEARS, OVERWEIGHT,DOWN SYNDROME, REFERRED BY DOCTOR



anual (2001)

A man, 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.




Nutritional Risk Screening and Monitoring Case Study FormNutritional risk increases when the person is affected by an increasing number of generalneeds assessment factors.Deterioration in health and loss of independence can result from undernutrition and perhapsmalnutrition.

NAME: Case study number three: man, 33 years

ADDRESS:


GENERAL NEEDS ASSESSMENTThe factors relevant to nutritional risk for thisclient


MONITORING*Repeat nutritional risk screeningWho can monitor these risks? How oftenshould 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 interventionsOne 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


FINANCIALLY DISADVANTAGED ADULTS

LIVING IN ALTERNATIVE ACCOMMODATION

List of Case Studies: Financially Disadvantaged Adults

Living in Alternative AccommodationNumber 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


161

9.1 CASE STUDY NUMBER ONE: MAN, 27 YEARS, UNWELL ANDUNDERWEIGHT, LIVING IN SQUAT, NEEDS TEMPORARY CRISIS CARE



anual (2001)

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.




Nutritional Risk Screening and Monitoring Form

Nutritional risk increases when the person is affected by anincreasing number of general needs assessment factors.Deterioration in health and loss of independence can result from undernutrition and perhapsmalnutrition.

NAME: Case study number one: man, 27 years

ADDRESS:




MONITORING*Repeat nutritional risk screeningHow often should this be done? 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

Doesn’t 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 isrecommended to ensure that nutritional risk has been decreased through the most effective intervention.


163

9.2 CASE STUDY NUMBER TWO: WOMAN, 40 YEARS, LACK OFHOUSING, HOMELESS, NEEDS TEMPORARY CRISIS CARE



anual (2001)

A very 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 doesn’t 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.




Nutritional Risk Screening and Monitoring Form



ADDRESS:







?? Reduced appetite or reduced



problem?






life quality?


Mental health problemsPoly-drugsMedical problemsGastritis, diarrhoea, constipationPast history of substance abuse(alcohol and drugs)Social problemsPersonal and food hygiene problemsFood has run out in the past weekIrregular meals or less than 3 meals adayDoesn’t take 1 2 3 4 5+ food plan

Omitted to have one or more of the foodgroups yesterdayLow food skillsUnable to access secure, clean foodstorage and preparation areaBegging 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 servicesRefer to food aidConsider long term food and nutritionsupport

Visiting nurse to monitor medicalproblems, alcohol and drugs, dentalproblems and nutritional risk

Consider financial counselling andissues about access to children

Consider referral to HACC Services forMeals on Wheels or supervision ofquality and quantity of food intake

Long term: when accommodationstabilises, promote increased foodaccess skills, budgeting, shopping skills, food information, foodpreparation, 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 toensure that nutritional risk has been decreased through the most effective intervention.Signature: Position: Date:

165

SECTION 10QUALITY IMPROVEMENT FOR NUTRITIONALRISK SCREENING AND MONITORING


167

10.1 QUALITY IMPROVEMENT FOR NUTRITIONALRISK SCREENING AND MONITORING

The usefulness of nutritional risk screening and monitoring to staff and clients will be evaluatedfrom time to time. What will you achieve by nutritional risk screening and monitoring and howwill you measure this?

Evaluation of the value of nutritional risk screening and monitoring will be carried out byyourself.

It is even better if your team is able to pool their results; it shares the work involved andproduces more meaningful results which can then form the basis of team discussion and decisionmaking.

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 achange 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 thehospital discharge planner

• Client and carer questionnaires (refer Section 10.2, 10.3)


169

10.2 RECORD OF RESULTS FOR NUTRITIONAL RISK SCREENING ANDMONITORING

10.2.1 Types of nutritional risks in the home-based adultsIdentifying and Planning Assistance for Home-Based People W


anual (2001)

It is easy to keep records of the results of nutritional risk screening and monitoring on this form. The results canthen be used to review the client group and plan better services for them, or to advocate on their behalf aboutmatters which affect them in their local community.

DATE Client recordnumber

No riskidentified

Underweight-frailty?

Unintentionalweight loss?

Reducedappetite or

reduced foodand fluidintake?

Mouth orteeth or

swallowingproblem?

Follows aspecial diet?

Unable toshop for food?

Unable toprepare food?

Unable tofeed self?

Obviousoverweight

affecting lifequality?

Unintentionalweight gain?

TOTAL

170

10.2.2 Number of nutritional risk factors in the home-based adultsTransfer the information from the form on the previous page to this one, in terms of the number of risks identifiedfor each person.

The results can then be used to review the client group and plan better services for them.



anual (2001)

Date Client recordnumber

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 youfeel 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 communityservices if we know whether they are useful and what our clients think aboutthem. You can always reach us in the office on telephone...............................


173

10.4 REGISTER OF CLIENT COMMENTS AND COMPLAINTS ANDREASONS 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



anual (2001)

175

APPENDICES


177

APPENDIX 1: DEFINITIONSACAT is the Aged Care Assessment Team. This is a Commonwealth Department of Health andAged Care funded program which provides comprehensive assessment of a person’s ability toperform their daily living activities, and information on residential options and in-homeassistance available to the older person. These responsibilities include assessment for admissionto government subsidised hostels, and nursing homes.

Assessment is defined by the HACC Program as “A process by which consumers’ need forformal HSACC Services is evaluated. Assessment considers all the consumer needs and mayinvolve an evaluation of other factors, such as the availability of informal care and theconsumer’s ability to pay where fees are charged for a service. Assessment is conducted in closeconsultation with the consumer” (Commonwealth of Australia, 1991).

Assessment officers assess the needs of individuals in the HACC target group for communityservices, prepare individual care plans with them, and continue to advocate for the client asrequired.

Community dietitians are usually employed by community health centres. They may workacross all phases of the life cycle from infants to the older person, or they may be employed toprovide food, nutrition and dietetic services to particular population groups.

Community services officers are assessment officers for Aged Services. These officers assess theneeds of individuals in the target group for community services and prepare individual careplans with the client.

DAA (Vic) is the Dietitians Association of Australia (Victorian Branch). The Dietitians Associationof Australia (DAA) is the national body representing dietitians throughout Australia, withbranches in all States and Territories.

DAA (Vic) Rehabilitation and Aged Care Special Interest Group This group is committed toexcellence of practice in food, nutrition and dietetics in the areas of rehabilitation, aged care anddisability.

Food issues are defined as client characteristics and problems which are related to client foodneeds.

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 toprovide 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 providersreceive $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) asbeing: “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 theirnutritional health needs.

Nutritional needs of a client means the need for fluid, energy, and the macro- and micro-nutrientswhich 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 arebest provided in excess to correct for one or two days of poor or no food intake. Nutritional needsmay be altered to treat and/or correct specific medical problems such as diabetes, and chronicobstructive airways disease.

Nutrition counselling “provides individualised guidance on appropriate food and nutrientintakes, taking into consideration health, cultural, socioeconomic, functional and psychologicalfactors. 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 extremeinstances, 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 thatmay be taken by many different health and social service professionals as well as family and communitymembers. 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 specialisedmedical and/or dietary treatment,... are all examples of nutritional interventions” (Nutrition ScreeningInitiative, 1992).

Nutritional risk can be simply defined as “the risk of poor health for nutritional reasons”. A more complex and accurate definition has been provided: “The risk factors of poor nutritionalstatus are characteristics that are associated with an increased likelihood of poor nutritionalstatus. 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 withdietary or nutritional problems. Its purpose is to differentiate individuals who are at high risk ofnutritional 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 medicaldiagnosis and treatment as well as nutrition counselling, as a specific component in acomprehensive health care plan” (Nutrition Screening Initiative, 1992).


179

APPENDIX 2: MORE INFORMATION ON HARM REDUCTION IN ALCOHOL ABUSE

Practical guidelines1) 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 withdrawalAlcohol withdrawal becomes apparent in the first 24-72 hours after cessation of continuous druguse or excessive recent use of the drug. It is during this period that incidental alcohol withdrawalcan 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 whichcan mask alcohol withdrawal, and

3) Those who are treated with opiates (for example. pethidine) and other pain killers andsedatives (for example. benzodiazepines) which can mask alcohol withdrawal and delay itsappearance.

In a few individuals, alcohol withdrawal is so severe that it can cause difficult behaviour andperhaps result in serious injury to the person and bystanders or death from withdrawalcomplications.

The prevention of incidental alcohol or drug withdrawal (in particular, alcohol withdrawal) is animportant 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 clinicalmanagement 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 healthprofessionals) with access to services, counselling and information on drugs and alcohol.

ALCOHOL AND DRUG ORGANISATIONS

ADF (Australian Drug Foundation), Victoria409 King Street, WEST MELBOURNE 3003Telephone 03 9278 8100The ADF has an extensive library which provides resource and reference material to anyone, particularlyhealth workers. There is a lengthy publication list of printed material, posters and videos. Call the Librarianto arrange access.

ARBIAS (Alcohol Related Brain Injury Advisory Service)226 Gertrude Street (PO Box 213). FITZROY 3065Tel 03 9417 7071The aim of ARBIAS is to assist people disabled through alcohol or other substance related brain injury tolive and function to their full potential in the community. ARBIAS provides assessment, accommodationand support.

TURNING POINT ALCOHOL AND DRUG CENTRE INC.54-62 Gertrude Street, FITZROY 3065Telephone 03 9254 8061; Fax 03 9416 3420Turning Point is a non-government organisation established to provide leadership in therapeuticinnovation, research and evaluation, and education and training in the alcohol and drug sector in Victoria.It is affiliated with St Vincent’s Hospital and the University of Melbourne.

VAADA (Victorian Alcohol and Drug Association)3 Alexander Parade, COLLINGWOOD 3066Telephone 03 9416 0899; Fax 03 9416 2085VAADA is the peak body for Victorian organisations and individuals with an interest in reducing thehealth economic and social consequences of the use of alcohol and other drugs. VAADA runs an annualconference.


181

APPENDIX 3: REFERENCES AND RESOURCES

Nutritional Risk Screening and Monitoring ProjectPublications and MaterialsWood, B. 1996, Identifying and assisting people who are nutritionally at risk: Part I: Report, DietitiansAssociation 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, DietitiansAssociation of Australia (Victorian Branch), Melbourne.

Wood, B. 1997, Identifying and assisting people who are nutritionally at risk. Proceedings of the DietitiansFocus 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, DietitiansAssociation of Australia (Victorian Branch), Melbourne.

Wood, B., Bacon, J., Stewart, A. & Race, S. 2000, Identifying and Planning Assistance for Home-BasedAdults 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-BasedAdults 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 forOlder People, Family and Carers 2000, Aged Care and Mental Health Division, VictorianGovernment Department of Human Services, Melbourne.

General ReferencesAmerican Dietetic Association 1993, ‘Dining skills. Practical interventions for the caregivers of theeating-disabled older adult’: American Dietetic Association, Chicago.

Anon 1996, ‘Development of the Australian nutrition screening initiative’, Australian Journal onAgeing, vol. 15, no. 15.

Bacon, J. 1995, ‘Famine in the midst of plenty: Nutritional status of the frail elderly’, ProceedingsNutrition Society, vol. 19, pp. 152-156.

Baghurst, K., Hertzler, A., Record, S.J. & Spurr, C.1992, ‘The development of a simple dietaryassessment 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 usedwith 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 toassist 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 CommunityCare 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-Englishspeaking 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 andintervention’, West Sydney Intellectual Disability Support Group Inc, Epping, Sydney.

Madden, R. & Hogan, T 1997, ‘The definition of disability in Australia: Moving towards nationalconsistency’, 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 futuredevelopment’, 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 developmentaldisabilities in Residential Care’, Community Services Commission, Strawberry Hills, NSW.

What is happening in ANSI. ‘The Australian nutrition screening initiative’, 1995 DAA Newsletter,May.

Wood, B. Morrison, M. & Atkinson, M. 1998, ‘A Training Manual for Carers’, Ballarat HealthServices, Ballarat.

Wood, B. Morrison, M. & Atkinson, M. 1998, A Resource Manual for Carers, Ballarat HealthServices, Ballarat.


183

ResourcesCOOKING FOR ONE OR TWOHome Economics Institute of Australia (Vic) Inc.PO Box 143,CARLTON SOUTH 3053A small paperback recipe book.

COOKING SMALL EATING WELLHawthorn Community Education Project24 Wakefield StreetHAWTHORN 3122Telephone: 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 theirinformation and cooking skills. The emphasis is on preparing dishes and meals for one or two people.

COST CUT WITH CANNED FOODSAustralian Nutrition Foundation (Victorian Division)c/- Caulfield General Medical Centre260 Kooyong Road,CAULFIELD 3162Telephone/Fax: 03 9528 2453

A VHS video tape with recipes for economical meals using canned foods.

FOOD CENT$ PROJECTHeal Promotions Services BranchHealth Department of Western Australia189 Royal Street, EAST PERTH, 6004

A program which targets people on low to moderate incomes. This program takes community workersthrough 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 ITSpeech Pathology DepartmentRoyal Melbourne HospitalChester StMOONEE PONDS 3039

An innovative video that aims to demonstrate the need for and preparation of thickened fluids for peoplewith particular swallowing difficulties.


184

A WORLD OF FOOD: A MANUAL TO ASSIST IN THE PROVISION OF CULTURALLYAPPROPRIATE MEALS FOR OLDER PEOPLECommonwealth Department of Human Services and Health.Australian Government Publishing ServiceGPO Box 84CANBERRA 2601

A manual designed to assist facilities to meet the food-related needs of older non-English speakingbackground people in a culturally appropriate way. It shows how simple it can be to make mealtimesenjoyable for older people from non-English speaking backgrounds and how to adapt existing menus to accommodate cultural and individual preferences.

SWALLOWING DIFFICULTIESMotor Neurone Disease Association of VictoriaPO Box 262CAULFIELD SOUTH 3162Telephone: 03 9596 4761Freecall 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 WELLAustralian Pensioners’ and Superannuation FederationSuite 628-24 Kippax StreetSURRY HILLS 2010Telephone 02 281 4566Fax 02 281 5951

A 20 minute video and resource kit.

THERE’S MORE TO QUITTING THAN QUITTINGCentre for Education and Training in Addiction Studies MelbourneRoyal Melbourne Institute of TechnologyDepartment of Social WorkMELBOURNE 3000

The stages of change in giving up addictive behaviours. A 15minute video training resource for counsellorsworking with substance users.

THE MANAGEMENT OF AGGRESSION IN DRUG AND ALCOHOL AFFECTED PERSONSNSW Nurses Association43 Australia StreetCAMPERDOWN 2050Telephone 02 550 3244

Professionally produced 50 minute record of an actual one hour lecture with self-teaching booklet.


185

APPENDIX 4: PROJECT FOCUS GROUPSCentral Grampians RegionMs Alex Tascas (Regional Aged Care Manager), Ms Robin Reeves, Ms Faye McLeod, Ms LynneHyett (Coordinators), Ms Jane Allen, Ms Meredith Atkinson, Ms Amanda Collins, Ms Lee-AnneDolon, 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 RosalieSheehan, Ms Val Stevens

Central Wellington Gippsland Region (Central Wellington Health Service, WellingtonCommunity Care)Ms Leona Mann (Director), Ms Belinda Greening (Domiciliary Care Coordinator), Ms JuliaChurches, 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 RegionCity 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 CouncilAged 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 DietitiansMs Simone Austin, Ms Meredith Atkinson, Ms Jenny Bacon, Ms Katherine Bathgate, Ms RhondaGilbert, 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 DisabilityDr 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 DisabilityMs Jenny Bacon (Bendigo Health Care Group), Ms Margaret Cox (Caulfield Community HealthCentre), Ms Jeanette Delatycki (Department of Human Services), Ms Sue Gebert (Kew ResidentialServices), Ms Barbara Villani (Dandenong Day Care Centre), Ms Robin Wood-Bradley (EastBentleigh Community Health Centre), Ms Judith Wright (Consultant Dietitian)


186

Royal District Nursing Service Homeless Persons ProgramMs Teresa Swanborough (Coordinator), Ms Ann Delikat-Kowalski, Ms Margaret Ryan, Ms JudyMcWilliams, Ms Sue Spurling

Geelong Aged Care ServicesMs Debbie Wynd (Chief Dietitian, Barwon Health, Grace McKellar Centre), Ms Heather Ashcroft(Coordinator, Belmont Day Care Centre, City of Greater Geelong), City of Greater GeelongCommunity Services: Ms Barbara Lewis (Program Management Coordinator) and Ms MargaretMcNamara (Coordinator). Carer Team Leaders, Home Carers, elderly clients


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