Malnutrition can progress rapidly and is completely devastating to the health of older people living at home. It is essential that community care workers are aware of the signs, and that they deliver positive food messages to their clients, writes Ngaire Hobbins.
If you ask any older person what they want most of all in life from now on I bet they will say it is to stay independent and productive. Community care provides the tools people need to do just that when it might otherwise slip away.
I know how dedicated, caring and professional the community care workforce is because I’ve been there; it’s the reason I came to the speciality of gerontology as a dietitian. I became a carer while I was taking a break from dietetic work. I absolutely loved the work, especially the interaction with the wonderful, interesting clients.
However, from a nutritional point of view, the experience was challenging. Far too often I found myself confronted with people I knew were eating inadequately, even to the point of malnutrition. I watched clients struggle physically and mentally merely because they were not eating to support the unique needs of their ageing bodies.
Not only could they have benefited from nutritional guidance, many would have avoided hospital admissions or delayed their move into residential aged care. It would only have taken an understanding that their food needs were not the same as those of younger people, and an eating plan in line with their actual needs.
So I know first-hand that community care workers, at the frontline, can assist clients to achieve adequate food intake and help identify those who need appropriate assistance. Malnutrition is not always immediately physically obvious but is easily identified when workers know what to look for. Early identification of those at risk and arranging appropriate professional assistance from dietitians and associated allied health professionals as early as possible is pivotal.
The new Commonwealth Home Support Program, which is in the final stages of development, will have a validated malnutrition screening tool embedded in its national screening and assessment process. That will mean clients entering the system who are at risk will be quickly identified so they can receive assistance, but day-to-day vigilance is essential to ensure they continue to eat adequately or get the support they need to do so.
The unique nutrition needs of clients
Some things remain the same with age: it is just not possible to maintain body organs (including the brain), to fight infection, to repair wounds, to recover from illness or surgery or to remain physically and mentally strong without an adequate supply of the nutrients that all those processes need.
But that becomes increasingly important with advancing age: age-related changes in all body systems impact nutrition needs – body muscle is gradually lost from middle age on and that can result in impaired support for immune function, tissue repair and organ renewal processes as well as impacting the availability of fuel for the brain. Add to that wear and tear accumulated over the years, the impact of more frequent minor injuries due to reduced skin integrity and of chronic health conditions and medications. These challenges increase the need for protein and the nutrients that maintain cell health, including antioxidants. Poor food intake – often fuelled by adherence to age-inappropriate health messages – and age-related inefficiencies in accessing them from food reduces their availability.
The challenge of poor appetite
I mention appetite as it is often the main confounder of an older person’s ability to get the nutrition they need. Yet it really needs a whole, separate discussion because it is so very complex. I spend a significant amount of my time in clinical practice teasing out the many threads that are at play in the repeated refrain “but I’m just not that hungry”. There are age-related changes in physiology and digestive processes that play a part and they are impacted also by the effect of many, many medications, by grief and life experience, by culture, family beliefs and more.
Suffice to say that appetite makes mistakes all the time. If it was perfect, if it really told us exactly what we needed to eat, obesity would be easy to avoid and unintended weight loss wouldn’t occur.
Care workers must be aware of these appetite mistakes, rather than accepting that older people “don’t need to eat as much”. Sure, smaller appetites are common, and I’m not suggesting that people need to eat so they end up feeling unwell, but the fact is they need either the same amount if not more of some nutrients than do younger adults. The solution is to pack more into what is eaten – fortifying drinks and meals with high protein supplement powders, choosing nutrient dense foods. There are many strategies outside the scope of this discussion, but which a dietitian could address.
The impact of food and health ‘chat’
Conversation and social engagement is naturally an essential part of the work of community care organisations and their frontline workers. But it is essential that staff give useful food messages that encourage food intake. Unfortunately some clients will suffer guilt or avoid eating certain foods of benefit to them when ‘health chat’ by others paints those foods as bad or unhealthy.
I have done it myself. I may need to avoid the slice of cake with the coffee I’m sharing with my client, but it’s not helpful for my client struggling with poor appetite if I use words like naughty or indulgent; especially for a client who has lost weight or is struggling to eat adequately. That same piece of cake is not only calories to boost intake in my client, but may well trigger a flagging appetite back into action.
It’s supremely important that care workers are aware of the different nutritional needs of older people and that they don’t unwittingly impose their own food beliefs or own nutritional requirements on their clients. It’s usual to chat about food but ensure you are positive about the foods that are fine for frail older clients; even if you are envious you can’t have an extra helping of the cake as I frequently am.
See Community Care Review magazine (May issue) for an extended version of this story including tips for community aged care workers.
Ngaire Hobbins is an accredited practising dietitian specialising in the care of older people, a lecturer in dementia studies at the University of Tasmania, and author of the book Eat To Cheat Ageing. Contact email@example.com
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