Responding to nutrition and hydration issues

There are many things we can do to improve a patient’s food and fluid intake and help prevent functional decline. Here are some recommendations.

Make nutrition and hydration a team priority

Food is as important as medicine. Nutrition should be a priority for everyone - the patient, their family and carers, the healthcare professionals and food service providers.

• Become ‘food aware’. Food and drink are as important as medication.
• Be alert that older people who are fasting for procedures, such as surgery, are particularly at risk. Follow local procedures and enlist the support from a dietitian to minimise poor outcomes.
• Follow the dietitian’s recommendations on food modification or special diets.
• Document treatment goals clearly, familiarise yourself with diet codes and ensure all staff can access this information.
• Consult with the dietitian to determine how and when foods will be fortified, for example with protein powders, glucose, skim milk powder and cream.
• Ask the speech pathologist for advice on food modification for patients with swallowing issues.
• Discuss with the dietitian introducing high calorie and high protein foods that can assist a patient increase their weight.
• Involve the patient in setting weight and calorie goals. Placing the patient at the centre of their care will assist in achieving clinical outcomes.
• Ask the patient what foods they like to eat. If the patient’s family wants to bring meals from home, advise them on choosing nutrient-dense foods.
• Check if meals are culturally appropriate.
• Order the right meal for the right person and enter the correct diet codes to avoid adverse events such as aspiration or allergic reactions.
• Work as a team to monitor food waste after meals (food charts can be used to correctly monitor food and drink consumption), this is a good indication of those needing assistance.
• Introduce programs, such as protected meal times which minimises disruptions to meal times or use identifiers such as red trays or domes to identify which patients need assistance during meals. Use volunteer programs to optimise intake.
• If space permits, consider establishing communal dining arrangements, to encourage socialising, combat loneliness and potentially improve dietary intake while in hospital.
• Consider using ward champions to promote best practice on your ward.

Help at meal times

Ask every patient if they need assistance to eat and drink and respond to their needs.¹

• Encourage communal dining where possible.
• Engage nursing staff, volunteers and family members to assist at meal times.
• Encourage patients to use the toilet prior to meals.
• If the patient can’t sit out of bed, use pillows to help them sit upright.
• Adjust the bed table so the tray is within reach.
• Clear the tray table of clutter or hazards.
• Remove or reduce distractions, such as bright lights, offensive smells such as urine bottles, and sounds especially for patients with delirium or dementia.
• Encourage people to wash their hands or provide hand hygiene gel prior to meals.
• Provide every patient with a serviette, cutlery and water.
• Put the utensils in front of the patient, check they can use them, and provide help if needed.
• Help patients open food packages.
• Monitor food waste. If a patient regularly leaves trays of uneaten food or untouched drinks, investigate.

Also you know how busy they are [hospital staff] and you don’t want to worry them - you’re not going ring the bell to ask them to open your fruit salad - so you just don’t do it. So either you don’t eat it or you wait for someone. Or if you’ve got someone from your family coming in that’s fine.
- Patient

Motivate the patient

Stimulating appetite and helping people eat and drink can make a difference.

• Help patients fill out their meal order form and educate them about good choices.
• Encourage the patient to sit out of bed for meals or eat in the communal dining area.
• Encourage patients to eat at meal times or to eat small meals regularly when they are most hungry and to indulge in their favourite foods.
• Offer patients snacks to keep them interested in food. Remember, the longer a patient goes without food for the more likely they will not feel hungry.
• Encourage the patient to keep hydrated. Offer drinks regularly.
• Acknowledge that a patient may be more motivated and interested to eat food they are used to. Engage family members to provide meals where possible.

Manage medications

Some medications can impact on appetite, cause dehydration and nausea, and contribute to under-nutrition.

• Ask the pharmacist to review the patient’s medication, look at possible side effects and drug interactions.
• Patients with swallowing problems may need assistance with taking medications and supplements. Some tablets may need to be given with food for ease of swallowing. Consult with the speech pathologist if you are concerned.

Consider the patient’s mood

• If a patient is feeling depressed, consider what could improve their mood, for example, allow them to eat in a social environment – invite family and friends to provide company.

Get them moving

Encourage patients to be active as this can stimulate appetite and enhance muscular strength and reduce the risk of pressure injuries.

• Encourage the patients to take regular breaks from their bed or chair and mobilise around the ward.
• Encourage them to have time away from the ward, if possible, outside. Sunshine helps lift a person’s mood and provides Vitamin D.
• Refer to a physiotherapist if the person has mobility problems.

Provide required protein

• Older adults need more protein in their diet than younger people, to help the body recover from illness, maintain functionality, assist with the inflammatory processes that occur with many diseases, and to be used as energy by the body when carbohydrate intake in inadequate.
• It is vital that people over 65 years maintain lean muscle mass and function and their protein intake should be at least 1.0 to 1.2 grams of protein per kilogram per day.² A dietitian can make recommendations on how to incorporate protein through foods or supplements, taking into account each patient’s needs and history.
• High-protein foods include cheese, yoghurt and dairy products; soy products including soy milk, tofu and tempeh; meat such as chicken, red beef and fish; pulses, lentils and beans; whole grains; eggs; nuts and seeds.
• Familiarise yourself with the benefits of a High Energy High Protein (HEHP) diet and work with a dietitian to prescribe this if necessary.

Consider using supplements

Nutrient and vitamin supplements can help elderly people achieve good nutrition.

• Ask the dietitian to assist with prescribing supplements. Supplements should be given two hours before meal times.³
• Some patients may not like the taste of supplements or have difficulty swallowing them. Discuss these concerns and tailor a treatment plan to the individual.
• Swallowing problems will affect a person’s ability to swallow supplements. If the patient has, or is suspected of having, dysphagia, refer them to a speech pathologist for assistance.

Ask about cultural preferences

Eating in hospital is very different from home; not just what we eat but how we eat.

• Check if the ward can accommodate the family bringing in appropriate foods that might stimulate the patient’s appetite and interest in food.
• Ask food staff if the patient’s food preferences can be met, for example, some cultures eat more of certain foods such as rice or pasta.
• Ask the patient how they like to eat their food, for example, if they like to eat with others arrange for family, friends or volunteers to be there.

1. Kurrle, S., Brodaty, H, Hogarth, R, Physical comorbidties of dementia. 2012: Cambridge University Press, New York.

2. Bauer, J., Biolo, G, Cederholm, T, Cesari, M, Cruz-Jentoft, AJ, Morley, JE, Phillips, S, Sieber, C, Stehle, P, Teta, D, Visvanathan, R, Volpi, E, Boirie, Y, Evidence-based recommendations for the optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. JAMDA, 2013. 14: p. 14.

3. Silverbook Australia, Medical care of older persons in residential aged care facilities. 2006: Tthe Royal Australian College of General Practitioners.