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Dining with Dementia Patricia M. Iorio, MS, RD, LDN March 29, 2013

Objectives  Participants will understand how the dementia diseases may affect nutrition status.  Participants will be able to apply solutions to nutrition concerns associated with dementia.  Participants will understand how using a person centered approach will enhance the dining experience for a person with dementia and reduce the incidence of nutrition related problems.

What is Dementia?  Comes from the Latin de meaning apart and mens from the genitive mentis meaning mind  Progressive deterioration in cognitive function  More than expected from normal aging  More common in the elderly  Can affect adults of any age

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Dementia Diseases Alzheimer’s Disease – Most common type  Targets portions of the brain crucial to remembering, thinking and reasoning  Dense bundles of fibers formed by tau inside the neurons alter plaques and tangles  Accumulation of plaques and tangles makes neurons shrink and disappear “Alzheimer’s is the cleverest thief, because she not only steals from you, but she steals the very thing you need to remember what’s been stolen. 
” Jarod Kintz, This Book Has No Title

Healthy Brain

Alzheimer’s Brain

Notice the shrinkage of the alzheimer’s brain.

Dementia Diseases  Multi-Infarct Dementia – Caused by multiple strokes  Fronto-temporal Dementia – Shrinking of the frontal and temporal lobes of the brain  Huntington Disease – Neurological disorder characterized by dementia and abnormal body movements

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Dementia Diseases  Creutzfeldt-Jakob Disease – Rare, rapidly progressive fatal degenerative brain disorder  Normal Pressure Hydrocephalus – Caused by blockage of the flow of cerebrospinal fluid and compression of brain tissue  Lewy Body Dementia – Build up of Lewy Bodies in the nuclei of neurons in areas that affect memory and motor control  Wernickee-Korsakoff Syndrome – Thiamine deficiency associated with alcoholism

Impact of Dementia  U.S. – 5.4 million with Alzheimer’s Disease  CDC - 7.7 million by 2030/ 16 million by 2050

Three fold increase!  14% of those over age 71 have some form of dementia  People with dementia constitute 47% of nursing home residents American Health Care Association, OSCAR data report; nursing facility patient characteristics report, June 2009 update. Washington, DC, 2009.

Impact of Dementia  $140 Billion paid by Medicare & Medicaid to care for people with dementia “Alzheimer’s is already a crisis and it’s growing worse with every year” according to Harry Johns, president and CEO of the Alzheimer’s Association

2012 Alzheimer's Disease Facts and Figures, Alzheimer's Association.

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CMS and Dementia Care  Developed a national partnership to improve dementia care and optimize behavioral health  Hopes to reduce unnecessary antipsychotic medication use through person centered interventions for dementia  Promotes a multi-dimensional approach: Rethink – our approach to dementia care Reconnect – with residents via person centered care practices Restore – good health and quality of life

Person Centered Care

Dining with Dementia “Food is the heart of the home and most often one of our life’s daily pleasures.” LaVrene Norton, from Nourish the Body and Soul

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Provide a calm atmosphere in dining room Liberalize diets to promote food first Provide adequate time for meals Serve water with meals to promote hydrated mucosa

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Distracting !

Check the Environment Crowded, distracting dining rooms with loud noises from background, staff conversations and vocal diners lead to agitated, impatient residents with feeding problems.

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Lighting Noise Tableware and Table Designs Gardens Personalized Space

Dining with Dementia  Dining styles to consider: Restaurant style offering the resident to select from a menu Buffet style which brings the food aroma to the dining room and allows the resident to make choices at the time of the meal Neighborhood dining offering decentralized dining in smaller dining rooms Family style dining offering the residents the opportunity to select from family style bowls or platters placed on the table

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Feeding Difficulties  Half of dementia residents lose some ability to feed themselves  Apraxia – impaired ability to perform skilled or purposeful movements  Agnosia – impaired recognition or comprehension of sensory stimuli  Decreased or abnormal sense of smell & taste  Taste changes may decrease appetite  Lack of memory of what utensils are for  Dry mouth makes swallowing difficult  Agitation causes resident to become restless

Feeding Difficulties  Chronic illness and meds can decrease appetite  Vision may decrease and create increased confusion during meals  Short attention span cause loss of interest in meals  Unusual odors may decrease appetite  Inability to communicate with caregiver may confuse resident  Forgetfulness to eat

Nutritional Concerns & Solutions Early Stage:  Forgetfulness/Loss of concentration  Anxiety/Depression  Changes in food preferences may occur  Unable to hold attention through a meal  May be distracted by environment at mealtimes

Early Stage Solutions:  Avoid noisy large dining areas  Serve resident promptly after seating  Constantly supervise, cue and encourage at meals  Redirect when necessary  Serve one course at a time  Family style dining

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Nutritional Concerns and Solutions Middle Stage:  Short term memory impaired  Difficulty finding words  Impaired ability for ADL’s  Failure to recognize food temperatures  Failure to understand proper use of utensils

Middle Stage Solutions:  Constant redirection to meals and snacks  Prompt & cue  Plan menu with finger foods and “on the go”  Maintain calm environment  Serve meals with only fork and spoon (care plan)  Keep good food preference records

Nutritional Concerns and Solutions Late Stage:  Significant communication difficulties  Deterioration of motor skills  Unable to feed self  Swallowing impairments  Weight loss in spite of high calorie intake  Refusal to eat  Preference for liquids over solids

Late Stage Solutions:  Utilize all possible safe interventions  Hold their hands, Smile  Provide scents of food to stimulate meal memories  Modify food textures to promote safe intake  Alter menu to provide most nutrients through liquids for residents preferring liquids  Use positioning and feeding techniques

Menu Planning Ideas Fruits & Vegetables • Fruit cut into bite size • Canned fruit drained • Sliced cooked al dente vegetables with dressing on the side • Leaf wrap for veg or sandwich filling • Fruit or vegetable juice in a mug with handles and lids • Potato puffs, tater tots, french fries, baked potato cubes, potato latkes • Fruit bars

Entrees • Strips of meat with dipping sauce on side • Egg sandwiches • Cheese cubes or sticks • Chicken tenders, patties, fingers, strips • Eggs, hard cooked • Baked fish, cakes, sticks • Burritos • Sandwiches, quartered • Quesadilla • Tofu, firm • P,B & J sandwiches • Bagel and lox

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Menu Planning Ideas Starch: • French toast sticks • Pierogi • Pancakes, sliced or rolled • Tortilla, corn, potato chips with salsa or dip on the side • Waffle strips • Biscuits, bagels, muffins, scones, bread sticks, garlic bread

Dessert: • Served in mini pastry shells, ice cream cones or mini tart cups • Dips for fruit • Brownies • Cake in bite size pieces • Cookies, bars • Turnovers • Ice cream sandwiches and novelty ice cream • Cupcakes

CMS Survey Process

Systematic Process Care Plans

• To determine the underlying causes of behaviors in persons with dementia

• To include plans for residents with dementia that address behaviors and are followed for all residents

Care Planning Oral Function • Dry Mouth • Dentition

Intervention  Evaluate meds to avoid dry mouth  Provide mouth care before/after meals  Offer liquids during the day  Provide cold beverage at start of meal  Dental consult  Provide food/beverage per tolerance

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Care Planning Cognitive Impairment • Forgetting to eat, chew, swallow • Refusing to go to the dining room • Spitting food

Intervention  Demonstrate model dining behaviors – eat with resident  Verify resident is alert and awake prior to meal  Offer one utensil at a time  Announce meal ahead  Evaluate food consistency  Offer simplified foods and finger foods  Simplify table settings

Care Planning Cognitive Impairment • Combative behaviors • Inappropriate behaviors

Intervention  Reduce background noise  Provide verbal and visual cues  Provide hand over hand assistance  Make eye contact when communicating  Reduce distractions such as TV, radio  Accommodate resident preference for eating location, meal schedule

Care Planning Cognitive Impairment • Wandering or pacing during meals

Intervention • Allow resident to walk around until meal arrives • Provide food on the go • Seat resident with back to a wall and table in front so it is harder to leave • Use physical prompts to reorient back to the meal, such as guiding resident back to the table, placing a utensil in resident’s hand • Use finger foods

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Care Planning Cognitive Impairment • Refuses food and drinks

Intervention  Obtain and update food preferences  Encourage first mouthful, may need to initiate this step  Provide verbal cues and descriptors of food/drinks  Offer beverage before meal to stimulate appetite  Ensure eyeglasses, dentures are in place  Encourage physical activity prior to meal  Offer finger foods

Did you Know? Musical memories often outlast verbal memories in AZ residents?

Residents with dementia are often more confused at sundown?

Working memory resides in the prefrontal lobes?

Putting it together  Meal time can be extremely challenging for residents with degenerative brain disorders  Goal is for a relaxed, enjoyable environment  Maintain dignity and self-esteem of resident  Keep person centered care in mind  Individualized care planning  Rethink our approach to dementia care  Reconnect with residents via person centered care practices  Restore good health and quality of life

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Resources • • • • • • •

www.nhqualitycampaign.org/ www.ascp.com/ www.amda.com/ www.ahcancal.org/ www.leadingage.org/ www.americangeriatrics.org/ www.alz.org/

Questions? I now begin the journey that will lead me to the sunset of my life. I know that for America, there will always be a bright dawn ahead. Ronald Reagan

Thank you! [email protected]

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