Nutrition

Caring for a Senior Living with Frailty Caregiving Strategies Handbook

You may have questions related to nutrition, such as:

• Whatisthedifferencebetweengoodandpoor nutrition?

• Whyisitimportanttorecognizeeatinghabits?

• Howdoyourecognizeifapersonisatnutrition risk?

• Whathappenswhenthepersonyoucareforrefusesfood?

• Whatisthelinkbetweenmouthcareandnutrition?

Thischaptermayhelpyouanswerthesequestions.Byapplying,andadaptingthestrategiesinthischapter,youcanhelpthepersonyoucareformaintaingoodnutrition.

Introduction

Asacaregiver,youmayberesponsibleforplanningandpreparingmeals.Olderadultsexperiencingfrailtyhavehighratesofpoornutrition.Somepeoplefinditdifficulttomakenutritiousmealsforapersonexperiencingfrailty.

FactsaboutNutritionGood nutrition improves:

• Sleep.• Thinking,memoryandmood.• Bloodsugaranddigestion.• Energy,strength,andweight

management.• Blood pressure and heart

health.• Abilitytofightinfectionand

healfromillness.• Medicationeffectiveness.

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Nutrition I Caregiving Strategies Handbook

A Myth about Nutrition

Malnutrition cannot be prevented or treated in seniors.

Acommonlyheldmisbeliefisthatitisnotpossibletodoanythingaboutmalnutritioninthe senior population. With the rightknowledgeandinformation,malnutrition is preventable and treatable!

Good nutritionisdefinedastheactofeatingavarietyoffoodsnecessaryforhealthandgrowth.Poor nutrition (malnutrition)isdefinedasalackofintakeoffoodornutrients,leadingtopoorhealth.Dehydration is a condition that occurs whenthebodydoesnothaveenoughwatertofunctionproperly.Dehydrationoccurswhenapersondrinkslessfluidthantheamountoffluidtheylose.

The information in this chapter is not intended to replace the advice of a health care professional. Please consult a health care professional for advice about specific medical conditions. Look for our helpful tips on communicating effectively with health care professionals.

Recognizing Eating HabitsRecognizingaperson’seatinghabitsisthefirststeptosupportinggoodnutrition.Youmaynoticethepersonyouarecaringforiseatinglessthanusual.

Theremaybereasonsforchangesinaperson’seatinghabits,suchas:

• Knowledge:Doesthepersonknowhowtomakehealthymealchoicesand/orhowtocook or prepare their meal?

• Access:Doesthepersonliveclosetogrocerystoresormarkets?Doestheircommunityprovide meal delivery services?

• Money:Whathealthychoicesareavailablewithintheperson’sbudget?

• Social:Doesthepersonprefereatingwithothersoralone?• Culture:Whataretheperson’svaluesandnormsaboutmealsandfoodchoices?

• Medical:Arethereanyhealthreasonsthatmakeitdifficultforthepersontocheworswallow?Whatabouthealthreasonsthathavechangedthewayfoodtastesorsmells(e.g.medications)?Canthepersonphysicallyprepareameal(e.g.chop,carrypots,stir,peel, etc.)

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Nutrition

“As a caregiver,

I make all the

meals at home”

–Acaregiverfrom

ThunderBay,ON

Recognizing Nutrition RiskHow do you recognize if a person is at risk for poor nutrition?

Onceyoubetterunderstandaperson’seatinghabits,youcanscreenformalnutrition.

The Self-Mini Nutritional Assessment (Self-MNA®) is a questionnaire that can becompletedbyyouandthesenioryouarecaringfor.Thisquestionnairecanhelpyourecognizemalnutrition.Tocompletethe Self-MNA® see: Tool4.1:RecognizingMalnutrition.

How do you recognize if a person is at risk for dehydration?

Thefollowingisalistofsomeofthesignsyoumaynoticewhenthepersonyoucareforisnotgettingenoughfluid:

• Dry mouth:thepersonyoucareforcomplainsofwakingupwithadrymouth,oradrymouthduringtheday.

• Yellow or dark (amber) urine:whenapersoniswellhydrated,urineshouldbelightyelloworalmostclear.

• Bad breath:thepersonyoucareforhasnoticeablebadbreathevenafterbrushingtheir teeth.

• Constipation:thepersonyoucareforhasnothadabowelmovementinthreedays.

• Tired all the time:evenafteragoodnightsleep,thepersonyoucareforcomplainsoffeelingtiredoryounoticelowenergyallday.

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Nutrition I Caregiving Strategies Handbook

Strategies for When a Person is Refusing to EatTheremaybemanyreasonsthatcausechangesinaperson’seatinghabits.Ifthepersonyouarecaringforrefusestoeatoriseatingmuchlessthanusual,youmaywanttoconsiderthefollowingstrategies:

Think Small and Simple.• Considerhavingsmallermealsonsmallerplates.Sometimesabigplatewithabig

portionlooksliketoomuchforapersonandtheymayrefusesaying,“Icouldn’tpossiblyeatallofthis”.

• Sometimeslessismore.Trylimitingthenumberoffooditemsonaplateandavoidingexcessiveuseofspicesandgarnishes.

• Ifthepersonpreferstoeatsmallmealsmorefrequently,havelotsofsmallhealthysnacksavailableduringtheday.

Consider Comfort.• Watchhowthepersonyoucareforchewsandswallows.Dotheyhavedifficulty?• Ensurefoodismoist,softandsafetoswallow.• Eatwiththepersonyouarecaringfor.Sometimespeoplefeelasocialconnectionwith

mealsandbeingwithotherscanmakeapersonfeelcomfortable.

Track Meals.• Useanotebookornutritiondiarytotrackfoodseatenthroughouttheday.Thiswillbe

usefultoreferbacktowhenyouarespeakingwithahealthcareprofessional.• Alsotakenoteofsnacking.Thepersonyoucareformightbegettingfullbeforemeals.

Consider Timing.• Thepersonyoucareformaynotbehungryatparticulartimes.Consideradjustingthe

routinebasedontheirappetite.• Manypeoplehaveafavoritemealoftheday.Trytogetasmanynutrientsandcalories

into this meal.

Speak with a Health Care Professional.• Apersonrefusingtoeatcouldbeasignofanunderlyinghealthissue.• RegisteredDietitianscanprovideyouwithadviceonhowtoaddnutritiouscalories

into your meals.• Seebelowforhelpfultipstocommunicatewithhealthcareprofessionals.

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Nutrition

The Link between Mouth Care and NutritionWhat do I need to know about mouth care and nutrition?

Theentiremouthislinkedtoaperson’snutrition.Takingcareoftheteethandgumsisimportant.Brushingandcleaningthemouthcanstimulateappetiteandmakeeatingmoreenjoyable.Painintheteeth,gums,and/ordenturescanmakeitdifficultforapersontoeat.Talktoadentistifyouarenoticingthesesymptoms.See Tool 4.2.2: MouthCarefortipsfromtheCanadianDentalAssociation.

Helpful Tips to Communicate with Health Care ProfessionalsItcanbehardtoknowwhattosaytoahealthcareprofessionalaboutnutrition.Itisimportanttobepreparedwhenyouspeakwithhealthcareprofessionalssothattheycanprovidethebesthelpandrecommendations.

The following are some helpful tips on how to communicate with health care professionals:

Offer detail.• Themoredetailyoucanprovideaboutachangeinaperson’snutrition,themorea

healthprovidercanworkoutdifferentstrategiestohelp.• Important details include:

• When did this start?• Howlonghavetheyhaddifficulty?• Howmuchdifficultydotheyhave?• Whathaveyoutriedsofar?

• SharetheresultsofthecompletedSelf-MNA®.• Keeptrackofweeklyweightandwritedownmealsandsnacks.• Notefoodsandliquidsthataredifficulttocheworswallow.• Beyondexplainingwhoyouareandtherelationshipyouhavewiththeperson,offer

detailsaboutyourcaregivingrole,andthesupportyouprovide.

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Nutrition I Caregiving Strategies Handbook

Ask questions.What might be causing the observed changes in the person you are caring for?

• Healthcareprofessionalsmaywanttofigureoutwhysomeonemayhavechanged,especiallyifthischangeissomethingthathascomeonquickly.Theymayreviewmedications,askaboutdailyroutineandhabits,andmayconsiderdoingmedicalteststounderstandmore.

What support does the community have to offer for nutrition? • Healthcareprofessionalswillshare

theirknowledgeaboutRegisteredDietitians,nutritionists,geriatricteamsandcommunityprogramsthatsupportnutrition,mealdelivery,anddiningclubs.Theywilltellyouiftheythinkareferralisnecessary.

Helpful tips to communicate with health care professionals

Nutritional Safety: When to Speak to a Health Care Professional

• Ifthepersonyouarecaring forisshowinganyofthefollowingsigns:• Obviousandoccasional

coughingduringmealsand/oraftersipsoffluid

• Rapidweightlossorweightgain(withinsixmonths).

• Complainingofpainduringchewingorswallowing.

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Nutrition

Strategies to Manage NutritionHow does meal planning support nutrition?

Planningmealsaheadoftimecanhelpyousavemoneyandmakemorenutritiouschoicesforthepersonyouarecaringfor.Herearesometipstomakemealplanningeasier:

Make time.• Consideryourscheduleandthetimeyouhaveavailabletogoshopping.Book

groceryshoppinginyourcalendarandmakeitapriorityinyourschedule

Grab a notebook.• Decidewhatyouandthepersonyoucareforwouldliketoeatinadvance.Write

theseideasdowninanotebookthatyoucanreferbacktolater.• Addtoyourgrocerylistasyouthinkofeachitem,andkeepithandytosavetime.• Don’tforgetthelittlethings!Includenutritioussnacksforeasyaccesswithlittleto

no preparation needed. • Includefluids.Therearecertainfoodsthatcountasfluid(e.g.yogurt,soups,some

fruitsandvegetables).• Savemoneyandtimebystickingtoyourlist.

Get Inspired.• Reviewasampleweeklymealplanner(SeeTool4.2.1:SampleMealPlan).• Enjoy!Preparethemealsthatyouenjoytogether.

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Nutrition I Caregiving Strategies Handbook

Finding Additional SupportHow do you find additional support related to nutrition?

Askahealthcareprofessional.AqualifiedhealthcareprofessionalcanpointyouintherightdirectiontofindinformationaboutRegisteredDietitians,nutritionists,geriatricteamsandcommunityprogramsthatsupportnutrition.

Look online. • RefertoCanada’sFoodGuide:https://food-guide.canada.ca/en/healthy-food-choices/• Searchfornutritionalprograms,mealdeliveryservicesandcongregatediningby

browsingtheHealthline,healthservicesforOntariowebsiteat:www.thehealthline.ca/. Afterselectingyourregion,enterthesearchterm“meals”.

• BrowseUnlockFood.caforinformationonnutrition,healthyeating,recipes,videosandinteractivehealthyeatingtoolsat:http://www.unlockfood.ca.

• EatRightOntario[http://www.unlockfood.ca/EatRightOntario/media/ERO_PDF/en/Seniors/Food-For-Healthy-Aging_E_Apr19-(2).pdf]isagreatguidetohealthyeatingforolderadults(Dr.H.Keller,DietitiansofCanada,2012)thatincludesrecipesandinformationonmaintainingahealthyweight,eatingrequirednutirentsforolderadultsonabudget,andstayinghydrated.

• Forinspiration,reviewasamplemealplanfortheweekthathasbeencreatedbyDietitiansofCanada(SeeTool4.2.1:SampleMealPlan).

Find a specialist. • Dietitianscanhelpsupportyouthroughindividualcounselingornutritionprograms

andworkshops.Tospeaktoalocaldietitianfreeofcharge,browsethefollowingwebsitewww.dietitians.ca/find.

Check the Community.• Askpublichealthunitsand/orcommunityhealthcentresinyourarea.• Askyourlocalgrocerystore(s)toseeiftheyofferappointmentswithdietitians.• Readabouthowtogetnutritiousmealsdeliveredtoyourdoor:• TakealookattheMealsonWheelswebsitehttp://www.mealsonwheels.ca/.• TakealookattheHearttoHomewebsitehttps://www.hearttohomemeals.ca/.

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Nutrition

SummaryThischapterhasexplainedhowtofigureoutaperson’seatinghabitsandwhattheymightmean.Thischapterhasalsoprovidedstrategiesforyoutotrythatsupportnutrition.Nowyoucanstarttodevelopstrategiestosupportnutritioninthepersonyoucareforandfindthehelpyouneed.

Nutrition Resources

Tool 4.1: Recognizing Malnutrition – Using the Mini Nutritional Assessment

Seepage64and65.

TodownloadyourowncopyoftheSelf-MNA® online version, visit:https://www.mna-elderly.com/mna_forms.html.

FormoregeneralinformationontheMiniNutritionalAssessment, visit:www.mna-elderly.com.

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Nutrition I Caregiving Strategies Handbook

Self-MNA®

Mini Nutritional AssessmentFor Adults 65 years of Age and Older

Complete the screen by filling in the boxes with the appropriate numbers.Total the numbers for the final screening score.

Screening

Has your food intake declined over the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

A0 = severe decrease in food intake1 = moderate decrease in food intake2 = no decrease in food intake

Last name: First name:

Date: Age:

B How much weight have you lost in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, 2 or 3) in the box to the right.

0 = weight loss greater than 3 kg1 = do not know the amount of weight lost2 = weight loss between 1 and 3 kg3 = no weight loss or weight loss less than 1 kg

C How would you describe your current mobility?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = unable to get out of a bed, a chair, or a wheelchair without the assistance of another person

1 = able to get out of bed or a chair, but unable to go out of my home

2 = able to leave my home

D Have you been stressed or severely ill in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0 or 2) in the box to the right.

0 = yes2 = no

E Are you currently experiencing dementia and/or prolonged severe sadness?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = yes, severe dementia and/or prolonged severe sadness

1 = yes, mild dementia, but no prolonged severe sadness

2 = neither dementia nor prolonged severe sadness

Please total all of the numbers you entered in the boxes for questions A-E and write the numbers here:

[

Self-MNA®

Mini Nutritional AssessmentFor Adults 65 years of Age and Older

Complete the screen by filling in the boxes with the appropriate numbers.Total the numbers for the final screening score.

Screening

Has your food intake declined over the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

A0 = severe decrease in food intake1 = moderate decrease in food intake2 = no decrease in food intake

Last name: First name:

Date: Age:

B How much weight have you lost in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, 2 or 3) in the box to the right.

0 = weight loss greater than 3 kg1 = do not know the amount of weight lost2 = weight loss between 1 and 3 kg3 = no weight loss or weight loss less than 1 kg

C How would you describe your current mobility?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = unable to get out of a bed, a chair, or a wheelchair without the assistance of another person

1 = able to get out of bed or a chair, but unable to go out of my home

2 = able to leave my home

D Have you been stressed or severely ill in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0 or 2) in the box to the right.

0 = yes2 = no

E Are you currently experiencing dementia and/or prolonged severe sadness?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = yes, severe dementia and/or prolonged severe sadness

1 = yes, mild dementia, but no prolonged severe sadness

2 = neither dementia nor prolonged severe sadness

Please total all of the numbers you entered in the boxes for questions A-E and write the numbers here:

[

Self-MNA®

Mini Nutritional AssessmentFor Adults 65 years of Age and Older

Complete the screen by filling in the boxes with the appropriate numbers.Total the numbers for the final screening score.

Screening

Has your food intake declined over the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

A0 = severe decrease in food intake1 = moderate decrease in food intake2 = no decrease in food intake

Last name: First name:

Date: Age:

B How much weight have you lost in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, 2 or 3) in the box to the right.

0 = weight loss greater than 3 kg1 = do not know the amount of weight lost2 = weight loss between 1 and 3 kg3 = no weight loss or weight loss less than 1 kg

C How would you describe your current mobility?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = unable to get out of a bed, a chair, or a wheelchair without the assistance of another person

1 = able to get out of bed or a chair, but unable to go out of my home

2 = able to leave my home

D Have you been stressed or severely ill in the past 3 months?[ENTER ONE NUMBER]Please enter the most appropriatenumber (0 or 2) in the box to the right.

0 = yes2 = no

E Are you currently experiencing dementia and/or prolonged severe sadness?[ENTER ONE NUMBER]Please enter the most appropriate number (0, 1, or 2) in the box to the right.

0 = yes, severe dementia and/or prolonged severe sadness

1 = yes, mild dementia, but no prolonged severe sadness

2 = neither dementia nor prolonged severe sadness

Please total all of the numbers you entered in the boxes for questions A-E and write the numbers here:

[

Tool4.1:RecognizingMalnutrition–UsingtheMiniNutritionalAssessment

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Nutrition

Now, please CHOOSE ONE of the following two questions – F1 or F2 – to answer.

Question F1Height (cm) Body Weight (kg)

147.5150

152.5155

157.5160

162.5165

167.5170

172.5175

177.5180

182.5185

187.5190

192.5

Group

Less than 41.1Less than 42.8Less than 44.2Less than 45.6Less than 47.1Less than 48.6Less than 50.2Less than 51.7Less than 53.3Less than 54.9Less than 56.5Less than 58.2Less than 59.9Less than 61.6Less than 63.3Less than 65.0Less than 66.8Less than 68.6Less than 70.4

0

41.1 – 45.342.8 – 47.244.2 – 48.745.6 – 50.447.1 – 52.048.6 – 53.750.2 – 55.451.7 – 57.153.3 – 58.854.9 – 60.656.5 – 62.458.2 – 64.259.9 – 66.161.6 – 67.963.3 – 69.865.0 – 71.866.8 – 73.768.6 – 75.770.4 – 77.7

1

45.4 – 49.647.3 – 51.748.8 – 53.450.5 – 55.252.1 – 57.053.8 – 58.855.5 – 60.657.2 – 62.558.9 – 64.460.7 – 66.462.5 – 68.364.3 – 70.366.2 – 72.468.0 – 74.469.9 – 76.571.9 – 78.673.8 – 80.875.8 – 82.977.8 – 85.1

2

49.7 or more51.8 or more53.5 or more55.3 or more57.1 or more58.9 or more60.7 or more62.6 or more64.5 or more66.5 or more68.4 or more70.4 or more72.5 or more74.5 or more76.6 or more78.7 or more80.9 or more83.0 or more85.2 or more

3

Please refer to the chart on the left and follow these instructions:1. Find your height on the left-

hand column of the chart.2. Go across that row and

circle the range that your weight falls into.

3. Look to the bottom of the chart to find out what group number (0, 1, 2, or 3) your circled weight range falls into.

Write the Group Number(0, 1, 2, or 3) here:

Lastly, calculate the sum of these 2 numbers. This is your SCREENING SCORE:

Write sum of questionsA-E (from page 1)h

Question F2 DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.

Measure the circumference of your LEFT calf by following the instructions below:Loop a tape measure all the way around your calf to measure its size.Record the measurement in cm:If less than 31cm, enter “0” in the box to the right.If 31cm or greater, enter “3” in the box to the right.

Write the sum of questions A-E (from page 1) here:

Lastly, calculate the sum of these 2 numbers. This is your SCREENING SCORE:

Screening Score (14 points maximum)12–14 points: Normal nutritional status8–11 points: At risk of malnutrition0–7 points: Malnourished Copy your SCREENING SCORE: [

If you score between 0-11, please take this form to a healthcare professional for consultation.

All trademarks are owned by Société des Produits Nestlé S.A., Vevey, Switzerland.© 2012 Nestlé. All rights reserved.

© SIGVARIS

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Nutrition I Caregiving Strategies Handbook

Tool 4.2.1: Weekly Meal Plan - Sample

Forinspiration,reviewthisweeklymealplannercreatedbyDietitiansofCanada:http://www.unlockfood.ca/EatRightOntario/media/ERO_PDF/en/Menu%20Plans/.SampleFamilyMenuPlan_en.pdf

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Nutrition

4.2.2: Mouth Care

Youmayfindthatprovidingdentalcaretoaseniorexperiencingfrailtyischallenging.TheCanadianDentalAssociationhascreatedanonlinewebpageaboutmouthcaretipsforcaregivers.

When caring for a person’s natural teeth:

• Letthepersonsitatthesinkandstandbehindthem.Thisway,youcanmakethesamemotionscleaningtheirteethaswhenyouarecaringforyourownteeth.

• Useasofttoothbrushoranelectrictoothbrush.Askthepersonyouarecaringfortotellyouifyouarebrushingtoohard.

• Havethepersonyouarecaringforrinsewithwarmwaterwhendone.• Toseemoreofthesetipsincludingtipsaboutdenturecareandcareofthemouth

tissues, visit: http://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/tips.asp.

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Nutrition I Caregiving Strategies Handbook

ReferencesNutrition

CanadianDentalAssociation.(2019).Tips for caregivers.Retrievedfrom: http://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/tips.asp.

Capezuti,E.,Zwicker,D.,Mezet,M.,&Fulmer,T.(2008).Evidence-based geriatric nursing protocols for best practice: Third edition.NewYork,NewYork:SpringerPublishingCompany.DietitiansofCanada.(2019).UnlockFood.ca.Retrievedfrom: http://www.unlockfood.ca/en/default.aspx.

ElderCarelink.(2019).An elder refuses to eat: what should a caregiver do?Retrievedfrom:http://www.eldercarelink.com/Other-Resources/Health/elders-refusal-to-eat.htm.

GovernmentofCanada.(2019).Canada’s food guide.Retrievedfrom: https://food-guide.canada.ca/en/healthy-food-choices/.

NestléNutritionInstitute.(2012).Self-MNA® mini nutritional assessment for adults 65 years of age and older.Retrievedfrom:https://www.mna-elderly.com/mna_forms.html.

Ramage-Morin,P.L.,Gilmour,H.,&Rotermann,M.(2017).Nutritionalrisk,hospitalizationandmortalityamongcommunitydwellingCanadiansaged65orolder.Health Rep.,28(9),17-27.

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Nutrition

Notes

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Bladder Health I Caregiving Strategies Handbook

RegionalGeriatricProgramsofOntarioc/o1000DePalmaDriveSuite2H-16CobourgONK9A5W6

905372-6811x7798www.rgps.on.ca

FormoreinformationontheSeniorFriendlyCaregiverEducationProjectandthe RegionalGeriatricProgramsofOntario,pleasevisitwww.rgps.on.ca.FormoreinformationontheSeniorFriendlyCaregiverEducationProjectandthe RegionalGeriatricProgramsofOntario,pleasevisitwww.rgps.on.ca/caregiving-strategies.

©2019RegionalGeriatricPrograms(RGPs)ofOntario. Permissiongrantedtousewithouteditingandwithappropriatecitation.

Ifreproducingoradaptingthecontentinthehandbook,RGPOmustbecredited astheauthorwiththefollowingcitation:

RegionalGeriatricProgramsofOntario.(2019).CaregivingStrategiesHandbook:ProvidingCareandSupportforaSeniorLivingwithFrailty.Retrievedfromwww.rgps.on.ca/caregiving-strategies