Eating poorly and loss of appetite have been estimated to occur in up to 25% of older adults living in the community, up to 62% of hospitalized older adults, and 85% of those living in nursing homes.1 Undernutrition in older adults is associated with a loss of independence and may result in complications such as polypharmacy, social isolation, and declining functional ability.2 The early identification of and interventions for undernutrition can help older adults to avoid complications, maintain a good quality of life, and live independently.2
Older adults who are unable to independently manage their nutritional status and self-care need caregivers to provide assistance. Caregiver nutritional support ranges from ensuring meal access and quality (food shopping and meal preparation) to feeding. According to the AARP Public Policy Institute's Home Alone Revisited report, nearly half of caregivers prepare special diets (no salt and/or low sugar diets, for example) for a family member.3 The challenges associated with meeting older adults' nutritional needs and preparing special meals, as well as practical tips and solutions, have been discussed in the previous article in this series (see “Eating for Healthy Aging,” Supporting Family Caregivers: No Longer Home Alone, November). These challenges are compounded if an older adult has a low appetite or swallowing problems that require modification of food texture, if an older adult needs additional support that requires the use of adaptive equipment or hand-feeding assistance, or if the caregiver must manage gastrostomy tube feedings. These are among the most difficult tasks caregivers perform. They require attention several times a day and can be time consuming, and many caregivers worry they'll make a mistake.3 More than 70% of caregivers providing a special diet learn how to manage this task on their own, according to the Home Alone Revisited report, with only two in 10 caregivers saying they received instruction from a health care professional.3 Caregiver stress has been significantly correlated with the nutritional status of the person being cared for, with higher caregiver burdens reported among those providing support for enteral nutrition and dysphagia.4
Nurses play a role in nutrition screening, education, and management across care settings. Working with caregivers to identify strategies for nutrition-related problems can lead to improved caregiver competence and satisfaction, enabling caregivers to provide better assistance to the older adults in their care. This article summarizes strategies caregivers can use to promote nutrition when an older adult requires dietary and feeding modifications. Such strategies, which may include altering food or fluid textures, providing hand-feeding support, using adaptive utensils, or managing low appetite or feeding tubes, take into account the psychological and social impact of meals on older adults and aim to improve the person's quality of life and the family's mealtime experience.
FOOD INTAKE AND NUTRITIONAL STATUS IN OLDER ADULTS
Undernutrition is mostly preventable but may be a cause or consequence of common chronic or age-related conditions. Three key nutritional problems in older adults that contribute to undernutrition are anorexia, dysphagia, and feeding difficulties related to dementia. If unmanaged, undernutrition can lead to a further decline in health and quality of life. Undernutrition may be evidenced by a low body mass index or unintentional weight loss and can result from specific nutrient deficiencies.
Many older adults experience a decrease in appetite, often described as “anorexia of aging.”5 Appetite is subjective and influenced by variations in feelings of hunger and fullness, with many older adults reporting diminished hunger, taste, and smell sensations, as well as early fullness and satiety. Physiological alterations due to disease, as well as emotional distress, can further contribute to anorexia. Dentition problems and various neuromuscular or head and neck conditions (throat cancer or an esophageal stricture, for example) can lead to dysphagia, fear of eating, rapid weight loss, and risk of aspiration pneumonia. Cognitive decline and Alzheimer's disease result in changes in a person's self-regulation and interest and ability to feed oneself. Undernutrition is common in this population.
Because the nutritional needs of older adults vary by person and may change over time, it's important that caregivers take a tailored approach to meals, considering the person's medical and other needs. This may require strict adherence to a medically necessary diet, or, near the end of life, liberalization of the diet to enhance quality of life. The nurse, working with the dietitian and medical team, plays an important role in educating family caregivers and addressing their concerns.
SCREENING FOR MALNUTRITION
The Determine Your Nutritional Health checklist is a tool designed to indicate an older adult's risk of poor nutritional status (over- or undernutrition).6 Developed in the early 1990s by the Nutrition Screening Initiative, this checklist has been validated as a malnutrition screening tool in the community.6,7 The checklist includes a series of statements to which the older adult may or may not agree, and a numerical value is assigned to each “yes” response. Scores from 0 to 2 indicate a “good” nutritional score, with rescreening recommended in six months; scores from 3 to 5 point to a moderate nutritional risk and trigger recommendations to improve one's lifestyle and eating habits, connect with community services, and be rescreened in three months; and scores of 6 or higher indicate high nutritional risk and the need for the older adult, caregiver, and health care provider to work together to improve the person's nutritional status. For an adaptation of the checklist that nurses and family caregivers can use with older adults, see The DETERMINE Your Nutritional Health Checklist.
MEETING THE CHALLENGES OF LOW APPETITE
Observing poor food intake and involuntary weight loss in a loved one can be stressful for caregivers, particularly those caring for an older adult who has dementia and multiple chronic conditions.4 It's important to help caregivers understand that refusing food or a lack of interest in eating is a reflection of older adults' illnesses, not of their feelings for caregivers or their efforts.
The first line of treatment is to assess for an underlying cause of low appetite.5 Start with an assessment for dementia, depression, and delirium and implement appropriate interventions if the person has any of these conditions. Strategies to increase appetite include the use of nutritional educational programs, exercise, meal adjustments (such as flavor enhancement), oral nutritional supplements, and megestrol (Megace).8 In addition, caregivers should know to alert the older adult's health care provider to changes in appetite, because some medications are known to cause poor appetite, dry mouth, and changes to the way food tastes.
There are several changes caregivers can make at home to address low appetite. If they notice that the older adult seems to be overwhelmed by a large plate of food, for instance, they can use smaller plates or serve smaller portions, which may be more appealing. Another strategy is to increase the nutrient density of the food consumed, so every bite counts. For example, when making oatmeal, prepare it with milk rather than water. The same approach can be taken with other foods: add ice cream, fruit, or protein powder to smoothies, which can also be made with milk instead of water; add gravy to potatoes or meat and sauces to a wide variety of foods; add a chopped egg to a green salad or tuna salad. In addition, buying small, preportioned foods—peanut butter crackers, string cheese, pudding cups, applesauce pouches, fruit cups, yogurt—helps to ensure caregivers have quick, easy, nutritious snacks on hand. Other commercially prepared products, such as nutritional drinks, can be served cold or frozen (as popsicles). If there is a time of day when the older adult's appetite is best, the caregiver should encourage her or him to eat a few more bites. It may also be helpful to offer a small snack before bedtime to increase the total daily calories consumed. For additional information, see “Tips for Managing Low Appetite” in the Information for Family Caregivers tear sheet.
MODIFYING FOOD TEXTURE
It may be necessary to modify food texture if a person has dental problems, such as loose teeth, ill-fitting dentures, impaired tongue movement and lip closure, or problems with swallowing. Problems with the oral processing of foods and dysphagia can be chronic and often occur simultaneously with other medical conditions. These issues, particularly swallowing problems, can cause anxiety in caregivers, who are often concerned with providing foods that are both safe for the person to eat and enjoyed by all family members. A recent systematic review found an increased caregiver burden—often characterized as “heavy”—among caregivers of older adults with dysphagia.9 Nurses can encourage family caregivers to request a referral from the older adult's primary care provider for the evaluation of swallowing problems by a speech therapist. A speech therapist can assist in identifying the least amount of texture modification required for safe swallowing and help family caregivers to identify foods that require minimal modification. It's also recommended that caregivers learn how and when to do the Heimlich maneuver, in case of emergency.
The main textural parameters include hard versus soft foods, thick versus thin liquids, and foods that are cohesive and hold together versus those that fall apart in the mouth. It's important to provide caregivers with specific guidance on appropriate texture modifications, including the differences among regular, soft, and pureed foods, and to make them aware of strategies to reduce the risk of choking. Such knowledge can increase their competence and reduce their workload and anxiety. Caregivers should know, for example, that a soft food diet includes such foods as cooked cereal, pudding, yogurt, mashed potatoes, scrambled eggs, tofu, and dal, and that thicker liquids include shakes and smoothies. Inform caregivers that fruit nectar may be easier to swallow than thin, clear liquids. Other tips include using instant potato powder to thicken soups or an immersion blender to add extra body and thickness to vegetable soups. A variety of commercially available thickening agents can also be used to thicken anything from water to juice and broths, and some beverages can be purchased already thickened.
If chewing is difficult for an older adult, caregivers shouldn't give them hard, chewy, dry, or crumbly food. Cooked vegetables, for instance, are preferable to raw; adding gravy or sauce can help to soften and moisten foods. It may also be helpful to chop, mash, or puree food using a fork, knife, or food processor. Remind caregivers that food needs to be appealing and tasty to ensure eating is a pleasant experience. Generally, pureed foods are poorly accepted because of unappealing changes in appearance, texture, and taste. Caregivers should offer foods that are as close as possible to their normal texture. For additional information, see “Tips for Modifying Food Texture,” Information for Family Caregivers.
USING ADAPTIVE EQUIPMENT
Some chronic conditions, such as arthritis and dementia, as well as poststroke effects, affect people's ability to feed themselves. Adaptive equipment (also called assistive devices or aids) includes any object or tool that maximizes independence in an activity of daily living, such as eating.10 This may include products such as utensils with bigger handles to make gripping easier, cups with built-in straws for drinking independently, and plates with raised edges to make food scooping easier. Adaptive equipment can be a critical element in maintaining or restoring independence in older adults and in preventing decline.10
Occupational therapists and other health care professionals can assist in identifying and prescribing adaptive equipment that is covered by most insurance policies. Equipment can also be purchased directly from medical supply companies.
MANAGING GASTROSTOMY TUBE FEEDINGS
In some older adults who have poststroke effects or chronic conditions—such as cancer or gastrointestinal disorders that cause swallowing problems—a feeding tube may be surgically placed through the abdominal wall into the stomach. It's important that nurses ensure caregivers are familiar with the terms and language used regarding feeding tubes. For instance, nurses should know there are several types of feeding tubes: nasal, gastrostomy, gastrojejunal, and jejunal. Because caregivers may hear the phrase “PEG tube,” nurses should clarify that this refers to a percutaneous endoscopic gastrostomy tube and is often used to describe all gastrostomy tubes. Other terms caregivers need to become familiar with include “flushing,” “bolus” and/or “continuous feeding,” “residual,” and “stoma.” This information provides caregivers with the baseline knowledge necessary for managing a feeding tube.
Feeding tubes may increase caregiver anxiety, particularly regarding how to provide nutrients safely and how to troubleshoot problems. Also, it can be difficult for caregivers to accept a recommendation that a feeding tube be used to manage an older adult's nutritional needs, particularly for a long period of time. It's not unusual for caregivers to feel sadness and regret that their loved one can no longer enjoy food by mouth.11 Caregivers may need help accepting the need for feeding therapy and the reassurance that, with practice, they will become more comfortable managing the feeding tube.
Caregivers need step-by-step directions for the administration of a feeding, including a list of care management, technical, and nutrition-related tasks.12 Training needs can be bolstered by involving a registered dietitian, who can provide families with home enteral training.12 Nurses and dietitians together can develop comprehensive training plans using a checklist of tasks to guide educational sessions.11, 12 Such sessions might include a review of the information in “Tips for Managing Gastric Tube Enteral Feedings” and a viewing of the accompanying video (see Information for Family Caregivers).
Caregivers should be instructed to gather all necessary supplies and wash their hands before beginning the feeding. They should examine the tube insertion site to make sure the skin is not reddened, inflamed, or seeping fluids. The caregiver should also clean the top of the enteral feeding formula can before opening it and pour the prescribed amount into an empty, clean container. The person receiving the tube feeding should be upright. This can help to prevent reflux and assist with stomach emptying. Sitting in a chair is best; if the person is in bed, the head of the bed should be raised to at least a 45° angle, and she or he should be well supported (by using a pillow, for example).
Before and after each feeding, the gastrostomy tube must be flushed with water to make sure it stays open and clear. Before administering the prefeeding flush, the caregiver should first check for residual feeding by drawing back on the syringe. Any of the prior feeding should not return to the syringe. If more than 30 mL of fluid fills the syringe, the caregiver should stop and notify a health care provider. If minimal or no fluid is returned, the feeding may proceed. Caregivers should be assisted in the development of a system to record nutrition-related intake and output data, including residual amount, type and amount of tube feeding, flush type (tap water, for example) and amount, and bowel movement size and consistency (to monitor for diarrhea and constipation).
Instruct caregivers to watch the older adult for signs of coughing or reflux during each step in the process. If these signs are observed, caregivers should stop the feeding immediately and notify the health care provider. In the absence of such signs, caregivers can proceed with the feeding using a bag and tubing or a syringe. If using a syringe, hold it above the level of the person's stomach (caregivers should be told not to use the plunger to deliver the feeding). After the feeding is complete, caregivers should flush and then clamp the feeding tube and disconnect the syringe.
Preventing a tube clog is a priority; therefore it's important for caregivers to know what not to use with the feeding tube, including crushed pills, which may clog the tube; a wire or sharp object, which can puncture the tube if used in an attempt to resolve a clog; and cranberry juice or carbonated beverages, which many nurses erroneously believe can unclog a tube (there is a lack of evidence of efficacy, and the acidity of these fluids may actually worsen the problem).13-16 Evidence supports the use of water as the best choice to prevent clogging and to initially unclog a feeding tube.13 Caregivers should be instructed to use warm water to flush the tube to loosen the blockage. If this doesn't work, they should call the primary care provider.
Caregivers can support the older adult's oral health and comfort by using lemon-glycerin swabs (short-term use only) and water-moistened swabs to moisten the person's mouth. Older adults who can follow directions carefully can brush their teeth and rinse their mouth with water or use products for dry mouth, such as a moisturizing spray, gel, or oral rinse (Biotene products, for example). Other comfort measures include sucking on an ice cube or a piece of sugar-free candy. Eating is a social time, so sitting together and talking with the person during the feeding is important. Also, remind caregivers that, if preferred, the feeding can take place while the person is seated at the table during a family meal.
HAND-FEEDING ASSISTANCE FOR PEOPLE WITH DEMENTIA
Dementia significantly impairs a person's cognitive, functional, and sensory abilities. As the disease advances, these impairments affect a person's ability to feed her- or himself. Cognitive changes include aphasia, in which the person loses the ability to use or understand language, making caregivers' nonverbal cues more important than words. Functional changes include apraxia, in which a person may lose, for example, the ability to use utensils. In advanced dementia, the palmar grasp reflex may reappear, causing people to grasp objects placed in their hands and not release these objects voluntarily.17 This reflex can compound the challenges older adults may have with managing utensils. Sensory changes include the loss of peripheral vision and a diminished sense of smell, and some people with dementia develop a preference for sweet foods.17-19
When a person with dementia has changes in vision, her or his caregivers can provide high-contrast place settings (a black placemat and white cup, napkin, and plate, for example) and position items where the person would expect to find them (the cup in the top right corner, plate in the middle, and silverware to one side). If the person uses these items and then places them elsewhere, caregivers should move them back to their customary position to make them easier to find. One's sense of taste normally declines with age, so it may be helpful for the caregiver to use spices the older adult likes, as well as introduce new ones; lemon juice can also enhance the flavor of food. Many people with dementia are partial to sweet foods and show a preference for foods like ice cream, applesauce, and desserts. Knowing this, caregivers can try adding a small amount of sugar to the foods they prepare (when cooking carrots, for example) to increase meal intake. Trial and error is the best approach when seeking to determine which foods and sugar amounts are best.
Before offering eating assistance, caregivers should be encouraged to watch the person to determine her or his self-feeding abilities. Promoting independence is most important; caregivers should provide tailored support based on the person's ability during a given meal or day. They should also look for patterns in the way the person eats to maximize intake. For example, if a person with dementia eats her or his entire breakfast, the caregiver may want to increase the amount of food offered during this meal to increase the total number of calories the person takes in each day. Breakfast is often a meal of finger foods—a slice of toast or bacon, for instance. If this meal tends to be successful, the caregiver may find that offering finger foods during lunch and dinner can increase the person's daily caloric intake. It's also helpful to offer frequent, small snacks in between meals and at bedtime. The key here is to watch what the person can and will do at each meal or snack and adapt care to the person's abilities and preferences at that moment.
Because dementia leads to a short attention span that requires frequent redirection, it's important to provide verbal and visual cues that help the person maintain attention on the meal. Verbal cues, including the use of short phrases (such as “eat your food” or “take a drink”), can be coupled with nonverbal cues (such as mimicking eating). When possible, eat meals together. Nonverbal cues include body language and facial expressions, and a calm and unrushed approach to mealtimes often works best. If the person is experiencing a problem with initiating or executing the movement of food from the plate to the mouth, caregivers can add a sensorimotor cue; for example, by using a hand-feeding technique.20, 21 If the older adult can hold a utensil, the caregiver should start with the over-hand technique, in which she or he guides the utensil by placing one hand over the hand of the person eating. If the older adult cannot hold a utensil, caregivers should offer finger foods or use the under-hand technique, in which they place their hand under that of the person eating, holding and guiding the utensil. Rather than starting with the direct-hand technique (spoon-feeding), save this approach for when the person has late-stage dementia, as it's the least engaging for the person and can create excess disability. Use modifications of each technique, as needed, to compensate for limitations in upper extremity movement or visual changes.
See “Tips for Hand-Feeding Assistance in People with Dementia” and the accompanying video in Information for Family Caregivers to learn more about the subtle yet distinct differences between the hand-feeding techniques. In addition, nurses and caregivers may find it helpful to view videos that demonstrate feeding modifications based on the ability of the older adult (see videos produced by one of us, MKBM, at https://melissabphd.com/nosh).
COPING WITH MEALTIME BEHAVIORS IN PEOPLE WITH DEMENTIA
A primary symptom of advanced dementia is aphasia, which prevents the person from communicating her or his needs to caregivers. Nonverbal behavior is the primary—and likely only—form of communication for a person with advanced dementia. Given this, caregivers should be encouraged to interpret behaviors observed during meals as communication, rather than as a form of resistance. For example, if a person doesn't open her or his mouth when offered food, the caregiver should try another strategy. Caregivers can offer a different type of food or a sip of water; ensure the person can see the food offered (an important visual cue); and check the food's taste, texture, and temperature. By contrast, interpreting a person not opening her or his mouth as a refusal to do so—or as care resistance—typically leads the caregiver to stop offering assistance.
Problem-solving for behavioral issues can be challenging and time consuming, but exploring alternative solutions before assuming the person is simply refusing to eat can result in increased food intake.21, 22 If a caregiver is struggling with managing difficult eating behaviors, the nurse should observe the mealtime interaction between the caregiver and the older adult to determine if there are any patterns to the person not opening her or his mouth, for example, and if optimizing verbal, visual, and sensorimotor cues would help to promote food intake.
KEY REMINDERS FOR CAREGIVERS
Mealtimes pose some of the greatest challenges for family caregivers. Nurses can help by being aware of the strain experienced by families who prepare and provide special diets. In addition to exploring caregivers' concerns and providing information about dietary and feeding modifications, nurses should remind caregivers of the importance of integrating the mealtimes of older adults and families, to the extent possible, to promote the social and emotional benefits of eating. They should also emphasize the value of observing and recording successful approaches, so these can be used regularly during meal preparation or feeding.
Information for Family Caregivers
Tips for Managing Low Appetite
- Correct dental, vision, or hearing deficits with dentures, glasses, or hearing aids.
- Encourage physical activity and eating with others.
- Recognize that an older adult's lack of interest in food is not a reflection of your efforts.
- Talk with the primary health care provider about changes in appetite to determine possible causes, such as dementia, depression, delirium, or an infection.
Food preparation strategies.
- Flavor foods—using pepper, herbs, and spices—based on individual preferences.
- Encourage the older adult to eat a few more bites during each meal.
- Use smaller plates and offer smaller portions.
- Choose nutrient-dense foods to make every bite count. For example:
- Use milk instead of water in oatmeal and smoothies.
- Add ice cream, fruit, or protein powder to a smoothie.
- Add gravy to potatoes and sauces to food.
- Add chopped egg to tuna salad.
- Offer small, preportioned foods, such as peanut butter crackers, ice cream, string cheese, pudding, applesauce pouches, fruit cups, or yogurt.
- Try freezing nutritional drinks and serving them cold or frozen (as popsicles).
Tips for Modifying Food Texture
Problems to look out for.
- Loose teeth.
- Dentures that don't fit.
- Trouble with tongue movement or closing lips to swallow.
- Coughing or choking on food or fluids.
What to do.
- Report any problems to the primary care provider for evaluation.
- Work with a speech therapist to identify the best texture for swallowing.
- Learn how and when to do the Heimlich maneuver.
Soft food strategies.
- Avoid hard, chewy, dry, or crumbly foods.
- Cook vegetables (rather than serving them raw).
- Offer cooked cereal, pudding, mashed potatoes, scrambled eggs, yogurt, or tofu.
Pureed food strategies.
- Puree regular or soft foods prepared for family meals in a food processor.
- Use an immersion blender to puree the solid contents of soups.
Thickened fluid strategies.
- Make shakes and smoothies.
- Add instant potato powder to thicken soups or liquids.
- Use commercially available products to thicken water, juice, and broths.
Tips for Managing Gastric Tube Enteral Feedings
Managing bloating, cramps, nausea, and diarrhea.
- Make sure the enteral feeding formula is at room temperature and not cold.
- If odors (due to medicine or food) are causing nausea, develop a strategy to minimize them.
- Stop the feeding and wait an hour before restarting.
- If symptoms persist for more than 24 hours, contact the primary care provider.
- Increase the amount of water and fluids, up to double the usual amount of water.
- Try giving half a cup of prune juice daily, followed by 60 mL of water flush.
- Talk to the primary care provider about switching to a formula that has fiber added.
- Talk to the primary care provider about adding a mild laxative.
- Every feeding should have a water flush before and after to make sure the tube stays open. One to two cups of additional fluids may be needed.
- A change in mental status or a fall may be an early indicator of dehydration. Other possible signs are a decrease in urine production, a furrowed tongue, a decreased amount of saliva and/or dry oral mucosa, sunken eyes, upper body weakness, a rapid pulse, and a decrease in axillary sweat production.
- Skin turgor is not a reliable clinical assessment in older adults given the normal loss of skin elasticity in aging.
Tips for Hand-Feeding Assistance in People with Dementia
Promote independence during meals (self-feeding).
- Watch the person during meals to see what she or he can do independently.
- Use verbal cues to keep attention on eating, using short phrases such as “take a bite of food” or “it's time to eat.”
- Use nonverbal (visual) cues to help the person understand your words, such as by mimicking the act of eating.
If help is needed, use a hand-feeding technique.
- Over hand: If the person can hold the utensil but needs help getting food from plate to mouth, put your hand over the person's hand, gently guiding the food into the mouth.
- Under hand: If the person cannot hold the utensil, put your hand under the person's hand, holding and guiding the utensil.
- Direct hand: If the person cannot eat independently, try spoon-feeding. Because the person is not engaged in the act of putting the food into her or his mouth, make sure the person sees and is aware of the approaching food.
Family caregiver instructional videos about special diets can be found on AARP's website:
For additional information, visit AARP's Home Alone Alliance web page:
Resources for Nurses
a Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.