Nutrition in residential care homes

Clive Bowman FRCPMedical Director BUPA Care Services

bowmanc@bupa.com

Parliamentary Food and Health ForumWestminster 20th March

Life expectancyLife expectancy at 65 reaches record level

National Statistics 2006

Workhouse women

(Leeds)

What constitutes malnutrition

The Last Refuge revisitedhttp://www.open.ac.uk/hsc/lastrefuge/home.htm

Institutional Care 1959

The candlewick way of death Untold Stories 2005 Alan Bennett

The turnover of residents is quite rapid since whoever is quartered in this room is generally in the later stages of dementia. But that is not what they die of. None of these lost women can feed herself and to feed them properly, to spoon in sufficient mince and mashed carrot topped off with rhubarb and custard to keep them going, demands the personal attention of a helper, in effect one helper per person. Lacking such one-to-one care, these helpless creatures slowly and quite respectably starve to death.This is not something anybody acknowledges, not the matron or the relatives (if, as is rare, they visit), and not the doctor who makes out the death certificates. But it is so.

Understanding and dignity

“Significant weight loss marked the beginning of the end of theirlives for each of my long-lived parents and parents-in-law (three of whom had dementia), but once we were able to accept this and stopped trying to 'feed them up' food ceased to be such a worry. They each developed idiosyncratic tastes and my late father happily ate a doughnut a day but almost nothing else for several years. My mother, now in her 90th year, eats only toast,spicy rice dishes and jelly babies. To her relief we have finally stopped trying to persuade her to vary her diet and my brother and I now cook and freeze small quantities of what she likes to eat. With this bespoke meals service my very frail mother continues to live alone in her own home and appears to be meeting her nutritional needs.”

Dr Ansell, Senior lecturer Department of Health Sciences, University of YorkeBMJ 2006

Care Home 2006

2006 Census

• 751 homes responded

• 32,301 residents returned out of population of

40,843 - a return of 79%

• Average age 83.6 years

• 93.7% of residents in long term care

• 71% state funded, 29% self funded

2006 Census

• 72% immobile or reliant on assistance

• 62% confused or forgetful

• 86% had one or two diagnoses driving need for care

• 11% no clinical driver for care

• 54% care related to dementia, stroke or Parkinsonism

• 24% confused, immobile and incontinent

Food and well being: dignity on the ward 1988

From Poor Law rulesto a

cook chill debacle

Axbridge Union Workhouse was erected in 1837 The Infirmary 1903

Dignity on the ward 1998

• The report found that some NHS staff were overtly ageist and lacked respect for the elderly.

• Frank Dobson: 'older people have the right to top quality care‘ Many were not given enough to eat or drink, some were put on trolleys before being admitted to wards and others were bundled out of hospital before they were well enough to be discharged.

Health Advisory Service 2000

Healthcare professionals involved in starting or stopping nutrition support should:

• obtain consent from the patient if he or she is competent• act in the patient’s best interest if he or she is not competent to give consent • be aware that the provision of nutrition support is not always appropriate.

Decisions on withholding or withdrawing of nutrition support require a consideration of both ethical and legal principles (both at common law and statute including the Human Rights Act 1998).When such decisions are being made guidance issued by the General Medical Council and the Department of Health should be followed.

Getting the balance right

“Garlic bread” outrage echoed in lime green jelly crime

Care for the elderly that is very hard to swallow“Four residents out of ten in old folks’ homes could be malnourished, says a report. Fran Abrams went undercover to investigate”“ ….followed by lurid lime-green jelly with squirty synthetic cream. Several residents were sitting in front of half-eaten food. …..Later I asked Clive Bowman, the medical director of BUPA Care Services, why such unappetising fare was being served…. He insisted that elderly people loved jelly, and said the brightgreen colour would help those with poor eyesight to identify what was on their plate. “You are imposing your values on our customers,” he said. “You have to be very careful in doing that. I have to say when I go to a care home on a Friday and fish is being served, the smell does not always appetise me. But very often that is what people expect.”

The Times June 2 2006

BUPA care homes & nutrition

• Chef’s Best / Chef’s Forum• Fruit• Quiet mealtimes in dementia care• Light Bites / Night Bites• Picture guides• Feeding aids• Training and awareness• Commitment to translate policy into practice

Key points

• Food and mealtimes are a key part of life in care• Nutrition in care homes is not simply a question

of food or feeding• Weight loss may be a physiological adaptation to

declining fitness (e.g. in heart disease)• Accelerated weight loss may signal the transition

from living with chronic disease to the onset of a terminal decline (including dementia).

• Greater understanding is required.