Good nutrition is very important for all of the elderly, but it is especially important for those who are frail, disabled, helpless, and/or dependent. Elderly patients need the essential nutrients every day to maintain their present level of physical and mental functioning as well as to promote wellness and prevent the many complications which occur with dependency and immobility. In one study of 529 persons age 60 years and older, 90% believed that their own diet was good and that food affected the way they felt.1
Good nutrition is also an important factor in long life. In a study of 302 well elderly people age 85 and older, when asked to give reasons for their good health and longevity in an open-ended question, 21% mentioned good lifelong nutrition as one contributing factor. These well old-old individuals tended to eat three balanced meals all of their lives and did not eat many snacks.2
Too often, however, because frail older people cannot or do not have the manual dexterity, energy, or ability to feed themselves, they need to be fed by others. Some of the physical changes of aging can make feeding these kinds of patients dangerous, so specific safety factors need to be considered. If the patients are in a facility where they are fed primarily by nurse aides, the registered nurse should assure that the aides understand the hazards and safety factors involved in feeding the frail elderly.
Several physical conditions and factors affect the frail older person's ability to eat. Conditions such as arthritis, the most common chronic disease affecting the elderly,3 strokes, Parkinson's disease, other neurological disorders, and fractures of the wrists, elbows, or shoulders prevent the elderly from being able to safely handle silverware, glasses, and cups. In addition, persons who are edentulous or who have dentures that do not fit well cannot or will not eat some of the foods provided for them. According to Kart and Metress, "a denture wearer must chew food four times as long to reach the same level of mastication as a person with natural teeth."4
Anatomical changes which are common in the very old and which affect eating are: a) decreased ability to swallow because of less secretion of saliva and/or general dehydration; b) dilated esophagus; c) decreased peristalsis in the esophagus; d) decreased secretion of acid in the stomach; and e) hiatal hernia (very common in the obese elderly female). All of these changes increase the possibility of choking on food or fluid, régurgitation of stomach contents, and aspiration of food, fluid, and/ or stomach contents. These problems can cause respiratory arrest due to obstruction in the trachea and/or aspiration pneumonia, both of which can be fatal.
In the nursing home setting, a nurse aide should observe frail elderly patients while they are eating and, if they are being fed, feed them very carefully. If many patients are eating in a dining area, a licensed nurse should always be present to observe and be prepared, if needed, to perform the Heimlich maneuver on patients who are sitting in a chair.5
In one nursing home, there is a large window between one of the nursing stations and the dining room so that licensed nurses at the station can see the patients while they are eating. If the patient is blind, and has the use of his or her hands and mental capacity, the patient should be taught that the food is placed on the plate using the clock method (see Figure 1).
Feeding the Patient
The patient needs to be assessed for ability to swallow before placing any food or fluids in the mouth. "The [registered] nurse should test for strength of jaw opening and closing, tongue movement, soft palate elevation, cough and gag reflexes, and for degree of laryngeal elevation with attempts to swallow. "6 If the patient has some difficulty swallowing, it is helpful to say the word "swallow" as the food or fluid is placed in the patient's mouth. Also, if the patient has had a stroke, it may be helpful to massage the throat slightly on the affected side to help stimulate the swallowing reflex.
It is, of course, important to feed the patient slowly, varying and checking the food to be sure that it is not too cold or too hot. If the patient can not see well, the nurse aide should ask the patient when he or she is ready for the next bite, such as a touch on the back of the hand or a certain word. This prevents the patient from having to keep the mouth open all of the time and prevents choking if the food or fluid is placed in the patient's mouth unexpectedly. Touching the lower lip slowly with a spoon or glass will stimulate the patient to open the mouth.
If the patients can see, they should look at the food because seeing attractive food can be pleasant and increase the appetite. If the patient can not see, but can understand, the nurse aide should explain what foods are on the plate and ask the patient what sequence the food is preferred (for example, meat, potatoes, vegetable, salad). Some people eat ail of one type of food before eating the other foods. Others prefer one bite of each in order until all of it has been eaten. It is best to provide sips of fluid in between bites of food which aids in swallowing.
The nurse aide or other person feeding the patient should sit down in a comfortable position beside the patient. This helps to prevent rushing because the person feeding is more comfortable. It also helps the patient to think that the person is not in a hurry and may, therefore, eat more.
It is recognized that feeding dependent patients can be very time-consuming in nursing homes where many patients need to be fed. The home could encourage family members to be there for some mealtimes or recruit volunteers from nearby churches or other community organizations, as long as they are taught how to feed patients safely. Some homes employ persons especially for mealtimes only; for example, 7:30-9:30 am, 11:30 am-1:30 pm, and 4:30-6:30 pm to help with feeding patients.
Some nursing homes use a half-circle table in the recreation room for people who need to be fed. A nurse aide sits in the center and can feed several patients who may eat at different rates. The nurse aide can assist, feed, and observe all four or five patients as needed (see Figure 2). This arrangement also provides a more social environment for the patient than his or her room and may increase the appetite. However, it is better for patients who have had strokes not to attempt eating and conversation at the same time, because they may become confused and choke more easily.6
The patient will be more likely to have a positive attitude toward food and mealtime if self-feeding is possible and safe. Several types of special eating devices are available which will help patients feed themselves. Some are available from local hospital supply companies or can be ordered by mail. Simple examples of self-help utensils are: a) a plate with a suction cup to hold it in place; b) plastic bumpers for plates to push the food up against so the food does not slide off the plate; c) cups with a partial lid or a small opening (plastic travel cup) which can prevent spills; d) knit coasters stretched over the bottom of a glass or an adhesive-backed bathtub safety tread attached around the side of a glass to provide a non-slippery surface; e) velcro or foam rubber curler cover over the handle of a fork or spoon which will help keep the fork or spoon in the hand; f) a glove or pocket with a fork or spoon attached which can be handled better by some patients; and g) a swivel spoon or extra long-handled spoon will be helpful when motion is limited.7 Also, a plastic glass or cup, rather than glass, can be bent slightly into a funnel, which directs the fluid into the mouth and prevents spilling.
It is essential that the frail elderly be kept in a sitting upright or semiFowler's position while eating, and for at least one to two hours after eating "to allow gravity to assist with swallowing,"8 and to prevent possible régurgitation and aspiration, as previously mentioned. If the patient has to be restrained in bed, he or she should be placed on the side so that if régurgitation or vomiting should occur, there will be less danger of aspiration.9 A vest restraint which allows turning from side to side should be used instead of wrist restraints, with one tied on each side of the bed, which prevents turning. If a patient does choke or aspirate food or fluids, after emergency measures are taken, the licensed nurse should assess the patient's respiratory status and temperature carefully for several days.
Selection of Foods
The type, and especially the consistency of the foods, as well as the nutrient values are very important when feeding the frail elderly patient safely. If the patient can hold any type of food in the hand, finger foods are a good choice. Not only do they allow the patient some independence and choice of what to eat when, but they are also time saving for staff.
For example, the nurse aide feeding patients at the half-circle table can have some patients eat finger food while feeding other types of food to the other patients. Examples of excellent nutritious finger foods are:
- Meats - cubed or cut in small pieces
- Finger sandwiches with firm fillings such as cream cheese
- Toast - plain or cinnamon
- Toasted bagel with cheese spread
- Bread and butter
- Eggs - deviled or hard-cooked
- Cheese - strips, wedges, or dips
- Mixed cereals such as Wheat Chex or Rice Chex
- Crackers - plain, graham, party
- Fresh vegetables - radishes, turnips, carrots, celery, cauliflowerets, cherry tomatoes (vegetables such as carrots, celery, and cauliflower may need to be slightly cooked)
- Fresh fruit - apple slices, bananas, berries, cherries, seedless grapes, peaches, pears
- Dried fruits - apricots, figs, raisins, dates
- Pound cake
Patients who are edentulous do not necessarily need pureed foods to eat and swallow safely. In fact, they will probably eat better if they have foods prepared which look and feel like regular food, but which can be swallowed easily.
Most soft-cooked meats and vegetables can be cut into very small pieces or mashed if necessary. Even if larger pieces of food can be swallowed safely without chewing, there is no serious impairment to digestion.10 Crusts may need to be trimmed from some breads or toasts. Whole wheat bread is easier to chew and swallow than white bread which can become gummy when moist. Whole wheat bread also provides more bulk than white bread and helps to prevent constipation, usually a problem in the dependent elderly. Examples of nutritious appetizing foods for edentulous patients are:
- soups (e.g., cream soups)
- ground or chopped meats
- canned meats (e.g., potted meat)
- baked fish
- soft-cooked eggs
- soft-cooked vegetables and fruits (e.g., spinach and bananas)
- cooked cereals (e.g., oatmeal and cream of wheat)
- milk toast
- French toast
- pancakes, waffles
- pasta, noodles, macaroni, spaghetti
- soft cheeses (e.g., cottage cheese or pimento cheese)
- ice cream (without hard fruit or nuts)
- ice milk (e.g.. Sorbet)
Two 24-hour diets, 1200 and 1500 kilocalorie levels, for an edentulous patient are shown in Table 1.
NURSE FEEDING MULTIPLE PATIENTS
Foods which are easily swallowed should be chosen for the old-old frail elderly, especially for those who have had strokes, and for those who have difficulty swallowing for any reason. Foods should be chosen which are "high in texture, taste, temperature, and smell to stimulate the senses and improve muscle function."8
Older patients often choke more easily on clear liquids, for example, than soft foods. Uncooked milk should be used sparingly with the patient who has chronic obstructive pulmonary disease because it causes secretions to be thicker and less easy to expectorate.
Applesauce is convenient, rather inexpensive when purchased in bulk form, and commonly given to the elderly especially for administering medications. There is, however, some belief that the particles can "break apart . . . and be aspirated."6 More solid foods such as mashed potatoes, medium cooked eggs, yogurt, ice cream, jello, fruit ices, custards, and puddings are easier to swallow.6,11
Timing and Size of Meals
Questions have arisen about the best times of the day for older people to eat. Should they have the largest meal at noon or in the evening? If the largest meal is at noon, they may be less likely to choke or aspirate because they are more alert then. However, if the evening meal is light and given early (for example, in a nursing home at 4:30 pm) and there are no PM snacks, patients may not sleep as well because they become hungry during the night. Schlenker and Osborne suggest smaller, more frequent meals, four or five times a day, rather ihan three large ones, especially if the older person has had a stroke or any kind of abdominal stress.
This plan may be impractical in an institutional setting because of staffing patterns.7·8 Lastly, these frail elderly patients should have good oral hygiene after meals, whether they have teeth or not. Some older patients "deliberately avoid foods which stick to their teeth or to their dentures" if they know that they are not going to be able to clean their mouth or dentures after eating.10
Mouth care of the institutionalized elderly is often lacking. If patients have their own teeth, they need to be cleaned well to prevent loss. If they have no teeth, mouth care is essential to prevent infection and provide comfort. A clean mouth will make the food taste better as well as help to prevent irritation and infection.
Many frail, dependent elderly people have few pleasures in life. Therefore, a sufficient quantity of appetizing nutritious food presented and given in a safe and pleasant manner should help to maintain or improve their physical and mental functioning.
TWO 24-HOUR DIETS FOR EDENTULOUS PATIENTS
- 1. Todhunter NE: Lifestyle and nutrient intake in the elderly. In Wmick M (Ed.). Nutrition and aging. New York: John Wiley & Sons, 1976.
- 2. Hogstel M & Kashka M: Staying healthy after 85. Geriatr Nurs 1985; Jan-Feb.
- 3. American Association of Retired Persons. A profile of older Americans. 1987.
- 4. Kart CS & Metress SP: Nutrition, the Aged, and Society. Englewood Cliffs, NJ: PrenticeHall, 1984, p. 110.
- 5. Phillips V: Nursing home care of the older adult. In Hogstel MO (Ed.), Nursing care of the older adult. New York: John Wiley & Sons, 1981.
- 6. Ozuna JH: Nursing strategies for common neurological problems. In Patrick ML, Woods SL, Craven RF, Rokosky JS, & Bruno PM(EdS.), Medical-surgical nursing. Philadelphia: JB Lippincott, 1986.
- 7. Schlenker ED: Nutrition in aging. St. Louis: Times Mirror/Mosby, 1984.
- 8. Osborne PA: Cerebrovascular disorders. In Patrick ML, Woods SL, Craven RF, Rokosky JS, & Bruno PM (Eds.), Medical-surgical nursing. Philadelphia: JB Lippincott, 1986.
- 9. Rose J: When the care plan says restrain. Geriatr Nurs 1987; 1(8):20-21.
- 10. Roe DA: Geriatric nutrition (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall, 1987.
- 11. Robinson N: Dietary needs. In Hogstel MO (Ed.), Nursing care of the older adult (2nd ed. J. New York: John Wiley & Sons, In press.
TWO 24-HOUR DIETS FOR EDENTULOUS PATIENTS