Dementia Gateway: Eating well for people with dementia

Case study: The finger food solution: supporting independence at mealtimes

It is about all staff working together as a team to find solutions that can support the person with dementia at mealtimes to preserve their dignity and promote independence.

Read the full case study:

• Understanding the situation - 1. Research and development findings Open

  The care team drew on various resources from the 'Food for thought' project run by the Alzheimer's Society from 2001 to 2004. The Department of Health-funded project began with research investigating many aspects of nutrition and eating for people with dementia in a range of care settings (including people living at home), and went on to offer training on this topic and to produce a range of leaflets and practice guides aimed at professional and informal carers.

• Understanding the situation - 2. Views collected from key people Open

  Dorothy's daughter was informed but not directly involved.

  The care staff were concerned that Dorothy was declining food even when they were helping her to eat. Dorothy's ability to communicate verbally had declined over time and staff found it hard to understand the few words she used. However, her non-verbal behaviour at mealtimes suggested to staff that she was unhappy and didn't want to eat when they tried to assist her.

  Dorothy's one daughter lived a long way from the care home and was unable to visit regularly, but she was told about Dorothy's difficulties. She was worried about this, and in particular how this might affect the progression of Dorothy's dementia.

• Actions Open

  The care team set out to:

  • support Dorothy to eat independently at mealtimes
  • improve Dorothy's enjoyment of mealtimes
  • prevent further weight loss.

  The team decided to offer Dorothy food that could be eaten without cutlery, that is, finger foods. They would still prompt and guide her to eat, but not use a spoon to help Dorothy to eat. They would keep track of Dorothy's progress by:

  • observing and recording Dorothy's response to the finger food meal, that is, her facial expressions and body language, and her food intake daily.
  • recording and monitor Dorothy's weight weekly.

  The team needed to establish whether Dorothy was having difficulty swallowing – this may have explained why Dorothy was declining food. A speech and language therapist assessed Dorothy's ability to swallow and didn't find any problems.

  It was clear that Dorothy was finding it challenging and frustrating to use cutlery. From her non-verbal behaviour, she did not appear to enjoy being assisted by staff to eat with a spoon. The speech and language therapist suggested finger foods as a way to support Dorothy to eat independently without the need for cutlery.

  The catering manager and dietician worked together to prepare a meal plan that included nutritious high calorie finger food based on Dorothy's likes and dislikes, and offered choice at each mealtime. They also developed a snack menu to provide extra calories between meals to help reduce further weight loss – this included things like small cup cakes, buttered mini-scones, small slices of fruit cake and cubes of cheese with fruit. The emphasis was on providing a high energy or calorie dense diet as Dorothy's appetite had been poor and her weight had dropped.

  Care staff would guide Dorothy's hands if she appeared to forget the next stage of the process. This was particularly important at the beginning of the meal when Dorothy began trying the finger food options.

• Results Open

  Initially, Dorothy was slow to eat food with her fingers and staff were concerned that this strategy wasn't going to work. However, the care home manager and speech and language therapist encouraged the staff to keep going. They said staff would need to work hard to support Dorothy through the initial stages of this new way of eating. They suggested staff give Dorothy regular prompts and, when necessary, assist her by guiding her hand from the plate to her mouth if she appeared to struggle with the next sequence.

  Over time Dorothy appeared to become more familiar and comfortable with eating food using her fingers. She seemed more content and happier at mealtimes and staff noted that she was smiling and looking more relaxed.

  Staff observed that Dorothy's appetite improved and she gradually ate more of the finger food offered. Staff tried offering extra food at meal or snack times too when Dorothy seemed hungry.

  The staff kept a record of Dorothy's weight each week. The dietician assessed Dorothy's nutritional status and supported the catering team to develop a nutritionally balanced, enriched finger food menu, as well as supporting staff in monitoring her progress.

  After three weeks on the finger food menu, Dorothy's weight had stabilised. Weight gain was not as rapid as staff would have liked but the fact that it was no longer decreasing was evidence of some success. Staff continued to observe and monitor Dorothy's progress and weight.

  The team kept Dorothy's daughter informed of her mother's progress, the difficulties she was encountering and the concerns of staff. She was able to give helpful information about Dorothy's food preferences.

  Because of Dorothy's limited verbal communication, staff relied heavily on their observations of her non-verbal cues. Based on this, staff felt that Dorothy was coming to enjoy mealtimes more once again

• Advice for others Open

  This practice is sustainable – it is about all staff working together as a team to find solutions that can support the person with dementia at mealtimes to preserve their dignity and promote independence.

  Training and ongoing support is vital for all staff to help to develop their insight and understanding of dementia. Good nutritional care and support requires a flexible approach, an understanding of the person and the involvement of all staff, not just caterers. Continued access to external support (for example, a dietician and speech and language therapist) is important so that the care team can review practice and discuss any further difficulties or challenges that may arise.

  Don't assume that this is a 'blanket' solution for every person with dementia who experiences difficulties at mealtimes. Each person needs an individual assessment before the team can decide the most suitable support. However, if appropriate, this practice could be taken up by others to help promote dignity and independence.

• Financial implications  Open

  In terms of resourcing, there was some initial investment in staff time to develop the approach, but this was an expected part of the catering role. The catering manager established that there were no significant extra costs involved in providing the finger food menu. It was similar to the standard menu but prepared in such a way that food could be eaten without cutlery. For example, staff cut roasted meat into chunks, small roast potatoes or potatoes into easy-to-hold wedges and vegetables such as carrot or broccoli florets into small pieces. They made snacks available for all residents and most could be eaten easily without cutlery, so there was no real additional cost. Other residents also required a high calorie-enriched diet so catering staff were already ordering extra butter, cream and milk powder.