Malnutrition a Complex Issue

It is acknowledged that causes of malnutrition in Aged Care are complex and that many facilities have striven to improve the nutritional quality of their meals.  Despite these efforts, high levels of malnutrition persist and residents in aged care are among the most nutritionally vulnerable people in New Zealand. It is often not the meals themselves that are the problem but the mode and manner of their delivery and that this is particularly so with the evening meal.

Consider this scenario observed during a meal audit: Catering staff work as a team to provide the evening meal according to the menu and to have it ready on time. The meal comprises soup, a savoury dish, a side salad and fruit or a high protein dessert for frailer residents.  Health Care Assistants (HCA) collect the scan boxes and proceed to the dining areas where some residents are waiting at tables whilst many others remain in bed.

Although it is only 5pm, an HCA has done the rounds with the evening cup of tea taking the edge off hunger.   To speed things up, the HCA decide to whom they will offer soup or to start with the savoury dish, it is problematic to serve both at once particularly at the bedside.  The side salad does not get a look in. The HCA has not checked the menu and guesses the flavour of soup based on appearance. The savoury dish is a quiche with an appetising aroma. It is placed by the resident without any descriptive or encouraging comments.  The resident states that she doesn’t want it so it is removed without any remonstration and dessert offered.  One resident sits on her own unable to initiate eating. Although there are two Registered Nurses (RNs) neither takes any notice, only one is busy with the drug round.  Eight minutes go by and then an HCA arrives to assist the resident to eat her lukewarm meal.  The overall consequence is an extremely low calorie and nutrient intake at the evening meal.

Another observed scenario demonstrates superb teamwork between Care and Catering staff.  Soup and the meals for residents who need to be fed are collected 15 minutes before the collection of the main meal.  All residents who are able to are encouraged to eat at the table which is set with correctly placed cutlery and colourful mats, conferring status on the occasion.  The atmosphere is convivial and other activities are ceased.

Soup is served to the seated residents whilst frailer residents are fed in their rooms. Meanwhile, an HCA returns to the kitchen to collect the rest of the meal which is served in appropriate sequence to the seated residents. The menu is known and understood by HCAs and adequate explanations provided when asked for.  A nearby RN maintains an awareness of the meal service to ensure that it runs smoothly.  Most of the meal components are consumed resulting in well-fed residents.

Whilst many facilities have excellent protocols for the detection of weight loss and subsequent malnutrition, this is a plea to consider the meal service in its entirety and for staff to be actively involved in ensuring their residents eat well.

The following recommendations will help avoid the first scenario:

  • maintain regular training of care staff on nutrition and best practice in the dining room
  • create a pleasant eating environment and make each meal ‘an occasion’
  • ensure the displayed menu is up to date and incorporates any last-minute changes
  • nominate a dining room champion to take oversight of meals, especially weekend evening meals. The champion should help identify residents who are not eating well or who have a hunger surge because they are recovering from a recent illness and require extra
  • encourage all staff to be involved so that mealtimes are a highlight and adequate food is routinely consumed
  • ensure there are enough staff available to assist
  • offer each course sequentially so that consumption of each is encouraged
  • consider plate waste: does a particular resident always leave most of the meal? Is there a dish that is consistently unpopular and therefore a recommendation to delete it from the menu is appropriate?

Each meal of every day is an important opportunity for adequate nutrient intake. Making small changes to eating environments, staff priorities and the meal service process will result in residents eating more and will help combat malnutrition in aged care.

Contributed column:
Niki Russell - NZRD
Prem Nand - NZRD
Nicole Taylor - NZRD
Kirsten Garcia - NZRD
Chris Cook (retired dietitian)