Things are looking up for aged care. Nudging retirement and refusing to eat slop, baby boomers are spurring action.
Celebrity chef Maggie Beer is a recent inspirational voice and champion for healthier food that tastes good. Her foundation is dedicated to training cooks and chefs in aged care to prepare meals driven by “superfoods” like chickpeas, lentils and kale.
Director of Nutrition Professionals Australia, Anne Schneyder, has laid down the gauntlet for Aged Care Accreditation Standards in nutrition and hydration, saying “access to adequate food and nutrition in a form that is enjoyable … is a fundamental right for all residents in our aged care homes.”
Foodservice Australia is holding an aged care summit in May this year to present stakeholders with the “the latest trends and techniques” in meal preparation.
A key issue that needs to be addressed is prioritising food in aged care budgets.
Appalling statistics have revealed more money is spent on food for Australian prisoners than pensioners. Our spend of $6.08 per resident per day puts us behind Europe, the US and Canada, whose food budget has increased as ours decreased. AMA president Michael Gannon described this as a “national disgrace.”
Half the surveyed aged-care residents suffered malnutrition – a major risk factor for sarcopenia and related issues like increased risk of falls, fractures, pressure injuries, poor quality of life and hospitalisation.
The paradox is that malnutrition costs money. So it’s really a no-brainer to invest in good food. Indeed, evidence suggests spending on quality care can improve savings – with improved quality of life a welcome by-product.
Protein and energy are two key essentials for older people with poor appetite, to avoid loss of muscle mass and strength. A good variety of fresh produce from all food groups supplies the nutrients needed for optimal health and immunity.
Various factors need to be considered when providing food in aged care, including dentition, swallowing, dexterity, reduced taste, smell and appetite, personal preferences and providing choice. Some may have allergies or special diets, or need staff member assistance to eat.
These and other considerations need to be factored into Residential Aged Care Accreditation standards. The Dietitian’s Association of Australia identified a need for guidelines to include “robust nursing and food systems to implement care plans,” and assessors involved in accreditation processes with in-depth knowledge of nutrition and food service delivery.
Ultimately, if meals and food choices are appealing, older people are more likely to eat. The environment is also important. Cooking smells, communal eating, pleasant, relaxed surroundings and attractive food presentation can all stimulate appetite.
Former chef Peter Morgan-Jones, Executive Chef and Food Ambassador at HammondCare, challenged himself to whip up a tasty meal for a man suffering early dementia. He had limited swallowing ability and had been restricted to pureed food for 18 months.
He craved baked beans, scrambled eggs and crispy bacon. And he got it – homemade Boston baked beans in a puree batter, pureed scrambled eggs and crispy bacon ground into dust. He was “overjoyed.”
As Maggie Beer says, “It’s all about giving equal measures of pleasure and nutrition. Without pleasure, what is there in life?”
Most of us long ago abandoned our childlike delight of playing with food; watching rapturously as it flowed through our fork, kneading it into a ball, belligerently breaking it up and squishing it through our fingers.
Some lucky adults get to do this for a living. The International Dysphagia Standardisation Initiative (IDDSI) applies such tests to determine if food is safe for people with different stages of dysphagia – including the ‘Fork Drip Test’, ‘Fork Pressure Test’, and the ‘Chopstick Test.’ What fun.
But it’s an important and serious matter for older people who suffer from stroke or other conditions that make swallowing difficult, and may choke or suffocate if food goes down the wrong way.
IDDSI was only recently launched in Australia, with support from Speech Pathology Australia. Proportion Food representatives attended the inaugural IDDSI Australian User and Industry Forum 2018.
Chief support officer for ProPortion Foods, Nikki, says she was impressed by “the willingness for collaboration between multiple parties – speech therapists, dietitians, food service staff, management and industry.
“There was an overwhelming positivity around the need for standards from a patient safety point of view.”
Following instructions from Peter Lam and Dr Julie Cichero (IDDSI Co-Chairs), delegates and speech pathologists tested a range of foods, including ProPortion Foods’ SmartserveTM which was classified as Level 4 Puree.
Smartserve products are “soft-textured dairy desserts and snacks high in protein.” They come in 10 different flavours and are easy to open.
The IDDSI ‘Level 4 Puree’ classification – designated green – places the food in the ‘pureed’ food and ‘extremely thick’ liquid categories, comparable to the National Dysphagia Diet’s ‘Dysphagia Pureed’ category.
As with level 3 (liquidised/moderately thick), the designation overlaps between food and drink categories. Considering feedback from food service professionals, IDDSI retained separate text labels depending on whether the item is required as a food or drink.
Level 4 is measured using the fork drip test; the amount of food or liquid that flows through the fork’s prongs determines its level of thickness. Level 4 puree will remain on the fork, with some forming a “small tail” underneath.
Australia’s implementation of IDDSI, replacing currently approved Australian standards, has three phases: awareness, preparation, adoption.
Stage one, which started December 2016, was an awareness building venture amongst all relevant sectors.
Stage two, now underway as of January 2018, involves preparing and approving processes, protocols, materials and products, and training clinicians, staff and relevant stakeholders.
The recent forum marked an important step forward for Stage 2. The next step, on track for May 2019, will see the new IDDSI system introduced for commercial use, transition and integration.
When people think about causes of malnutrition, they might consider poor appetite, chewing difficulties or illness as likely candidates. Yet many health professionals would know that even something seemingly trivial, like not being able to open food packaging, can be a major obstacle to eating well.
Opening food packaging can require strength, dexterity and fine motor skills that many vulnerable people don’t have—especially older adults.
Inaccessible food packaging is often an issue in hospitals, particularly when there is no-one to help patients open single serve and portion-controlled food items. The NSW Special Commission of Inquiry into Acute Care Services found that many patients need help to open food packaging, and reported that this can be a significant barrier to nutrition.
A Canadian study of 132 cognitively healthy nursing home residents found that 37.4% of residents were at risk of malnutrition—and food packaging was identified as one of the primary contributing factors.
Disabilities like arthritis can present a major obstacle to opening food packaging for people of all ages.
Arthritis Australia’s Consumer Director, Wendy Favorito suffers from arthritis herself and has experienced the resulting emotional struggles, like public embarrassment and lack of independence by having to rely on other people, and physical obstacles to basic daily tasks like cooking simple meals for her family.
If her husband weren’t there to help her, Favorito writes that it would just mean going without. “It is unacceptable that common items are so difficult to open for a large portion of people in our community when some simple packaging solutions exist.”
As Fergal Barry, Partnerships Manager of Arthritis Australia, stressed in a CHOICE interview, this problem will keep growing along with our aging population if it is not addressed.
Even in the general population, food packaging is not a trivial issue. Researchers at Nottingham University in the UK reported that over 60,000 people needed hospital treatment for injuries from trying to open difficult packaging, often resorting to using scissors or knives. Other injuries include wrist strain from trying to loosen jam jar lids. According to CHOICE interviews, experts believed Australians would face a similar problem.
This phenomenon has a name. ‘Wrap Rage’ is defined by Wikipedia as “the common name for heightened levels of anger or frustration resulting from the inability to open packaging’.
A healthy 30-year old male expressed frustration trying to open the plastic wrapping on crumpets, according to a more recent UK report which claimed that “Millions suffer ‘wrap rage’ battling to open modern-day packaging.”
For vulnerable people, accessible design is even more vital. The Nottingham University inquiry’s main finding was that packaging is easier to open when there is a larger surface area to grab onto. But there is much more complexity to making packaging accessible. Guidelines published by Arthritis Australia further include ease of grip and control, avoiding sharp edges, adequate grasping points on seals, texture, and salient, legible fonts.
For organisations seeking user-friendly products for vulnerable populations, Arthritis Australia set up an Initial Scientific Review (IRS) which rates products according to their accessibility. A database of these ratings is available for various pre-packaged and portion-controlled foods used by the food service industry.
Just $6.08 per resident per day is the average spent on food and ingredients in Australian aged care facilities, according to a recent study. The prevalence of malnutrition in aged care facilities is estimated to range anywhere between 32-72 percent, and a decrease in food budget and expenditure could further negatively affect the nutritional status of aged care residents .
A recent nutrition and dietetics study examined the 2015-16 financial year expenditure on catering within Australian residential aged care facilities. The study comprised of 817 aged care facilities, representing 64,256 residential beds.
The study reported that average food expenditure decreased 5 per cent from $6.39 to $6.08 per resident per day. Expenditure on oral nutritional supplements and food replacements, however, increased by 128 per cent .
Supplements can provide a short-term benefit to complement the nutrition intake for residents suffering malnourishment or weight loss. This is particularly the case where older adults require an increase in energy and good quality protein.
However, supplements do not improve the resident’s long-term quality of life, nor do they address the underlying cause of the malnutrition or weight loss . Aged care experts agree that a nourishing, food-first approach will have a better long-term impact on the resident’s quality of life .
Figure 1 .