Appropriate nutrition and hydration are critical to the health of all older people. Poor nutrition amongst older adults within long-term care settings is purportedly common.
A study of twenty-one Victorian aged care services concluded that the provision of meat and dairy foods, important sources of protein, did not meet the recommended levels at that time. Furthermore, the study concluded that 68% of people in the study were malnourished or at risk of malnutrition 7. The consequences of poor nutrition are significant and often irreversible for older people. Malnutrition is associated with a range of health risks, including an increased incidence of falls and fractures, infection, and time needed to heal or recover from injury 4. Aged care residents with poor nutrition, including malnutrition, are at greater risk and severity of pressure injuries, loss of bone and muscle mass/strength, frailty, reduced functional capacity and greater care needs. They are also at heightened risk for healthcare-associated infections and mortality in hospital.
There are a number of contributing factors that lead to malnutrition in older people including poor dentition, multiple medications, difficulty swallowing and low appetite 8. Additional risk factors include age, sex (female), cognitive impairment, behaviours associated with dementia, level of dependency, and not consuming all foods offered 9, 10.
Weight loss is not a normal part of ageing. In residential aged care unexplained weight loss is a key measure of the National Aged Care Quality Indicator Programme. For many residents the food provided within the aged care service is their only source of food and drink. This means residents are entirely dependent on the organisation providing sufficient suitable, appealing, and texture appropriate food to meet their nutritional requirements. When such nutritional requirements are met, residents who are underweight or losing weight are more likely to regain weight and those with a healthy body weight will maintain their weight 11.
It is a common misconception that older people, particularly those living in RACSs, need less protein, vitamins, minerals and calories than younger people. Daily calories (or kilojoules) required for older adults are greater than traditionally thought. While many residents are no longer active, the amounts of vitamins and minerals needed remain much the same throughout life. In fact, protein, calcium and vitamin D requirements are higher in older people than younger adults 11.
Furthermore, dehydration amongst aged care residents is a common and dangerous problem. Meeting the hydration needs of older adults within residential aged care can be challenging. Recommendations for fluid intakes are approximately 1.5L daily, yet achieving this target can be compromised by a range of factors 12. Residents can be more prone to dehydration due to diminished sense of thirst, poor oral intake, swallowing disorders, refusal of fluids, inadequate staffing assistance, medication, illness, fear of choking, fluids offered are not to the individual preferences, poor access to fluids (being able to see and reach), inability to manage a cup or glass and dislike of thickened fluids. Some residents may also intentionally limit their fluid intake to minimise incontinence or the need to go to the toilet 11.
Nutritious food is important for general wellbeing as well as positive social experiences. Nutritious food can also support the prevention of chronic disease and enhanced recovery from illness. However, within residential aged care, food is more than a vital component of good health in itself. Food can fulfil the expression of cultural identity, act as a conduit between past and present life, and imbue a sense of wellbeing, routine and emotional comfort in an unfamiliar setting 13.
The mealtime environment has been described as a focal point for the broader experience of older adults in residential care. The experience or mealtimes can be enhanced through understanding how residents interact with one another, accommodating their preferences, and encouraging autonomy specific to dining 14.
What is important to older adults living in residential aged care?
Eating is not only essential to physical survival but is also important to meet human emotional and social needs. To a RACS resident the dining experience may represent the quality of comfort, care, and social relationships 15.
Several studies have found that the quality of food and beverage services influence resident satisfaction within RACS settings 16-19. The greater the quality and choice of food and beverage offered in this setting, the higher the levels of satisfaction reported 20, 21.
Tenderness of meat, taste and flavour of food, and quality of ingredients have been identified as important food quality attributes by older adults living in RACSs. Food sanitation, food handling, personal hygiene, and clean appearance of food staff are important service quality attributes 22. Meal presentation and appropriate temperatures can also influence food service satisfaction amongst aged care residents 23.
Conversely, dissatisfaction with food quality and/or choice has been linked with lower food and fluid intake and a poorer quality of life 3, 24.
The significance of personal food preference does not diminish with age 25. Personal preferences, including a choice of what to eat, when and with whom, promote wellness and a sense of normality within RACSs 26. People bring a range of preferences, tastes, practices and attitudes regarding food with them on entry to long-term care settings. Food that reflects their family backgrounds can act as a powerful source of comfort that can play an important role in recovery from illness or adaptation to their new accommodation 3. Evidence suggests that responding to individual preferences, providing personal choice and variety in menu options, and perception of food service quality can all affect food consumption amongst residents 27, 28.
Infantilisation or lack of agency can be perpetuated by the absence of choice and decisions regarding meals being made on the behalf of a resident 15. Aged care residents may be less familiar or concerned with regulations associated with risk management and food services. Rather residents prefer to exercise choice and control over their meals, including timing and the environment in which they are consumed 21, 26, 29, 30. Furthermore, personal control in seating arrangements and food access can support a sense of autonomy and independence within RACSs 30.
What factors affect the dining experience within aged care services?
The ability to make decisions intentionally and independently is a basic human right. Food choice can be defined as a process whereby older adults living in RACSs are able to select from a range of options, choose one food in preference to another, or reject certain food items, with no restriction on the amount that they consume 28. To varying degrees, people living in RACSs will often relinquish their right to choose what to eat or drink each day. The loss of autonomy to make food choices is of particular concern as a lack of choice decreases motivation to eat, placing residents at risk of malnutrition and reducing their overall quality of life 31.
Choice has been reported to be one of the primary reasons for improved food and nutritional intake in residential aged care service settings 19, 32, 33. Despite its importance, choice can be challenging to fulfil in these settings for a number of reasons. An Australian study of menus supported by observations in RACSs identified a low level of choice of meals for residents on both general and texture modified diets. Those on a textured diet appeared to experience even less diversity at mealtimes or options were inconsistent with what was presented on menus prior. While residents may be able to choose certain parts of their meals, it is not often at the point of service itself 28.
Teeth and mouth problems can negatively affect food enjoyment and intake. As such changes in resident eating patterns and behaviours may be an indication of oral health deterioration 11. People in residential aged care settings are at particular risk of developing complex oral diseases and dental problems. Age related oral health issues include the maintenance and repair of natural teeth which can be further impacted by decay, gum disease and oral cancers 34. Furthermore, dysphagia is highly prevalent amongst aged care residents exacerbating risk for malnutrition and dehydration 35. Poor dentition and ill-fitting dentures or age-associated changes in taste and smell may influence food choice and limit the type and quantity of food eaten by older people. Medical conditions such as gastrointestinal disease, malabsorption syndromes, acute and chronic infections, and hypermetabolism will often result in anorexia, micronutrient deficiencies, and increased energy and protein requirements. Furthermore, multiple medications can induce malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite 36.
Mealtimes are important opportunities to support residents' personhood in care facilities. The environment in which residents dine can influence nutritional intake as well as enjoyment of mealtime more generally. Dining rooms with a home-like ambience, minimal noise, and careful furniture placement can further contribute to social interactions during meals 37. An unpleasant mealtime experience not only has negative nutritional consequences, but may also undermine a resident's dignity, self-esteem, and personhood. Feeling rushed to eat or confused by the pacing of meal service can impede nutritional intake and enjoyment of eating itself 38. Excessive noise has been reported as distracting and can hinder mealtime conversation amongst residents 15. It can also be particularly overwhelming for older adults with dementia in this setting 38. Additional factors impeding a quality dining experience can include overstimulation (multiple activities occurring whilst eating), shape and design of the room, furniture, overcrowding, uneven or poor lighting, and "institutional" ambience38. "Assembly-line" style feeding assistance for multiple residents concurrently can be dehumanising. The attitudes of staff can further add to or detract from the quality of a resident's mealtime experience. Mealtime should be viewed by staff as an opportunity to create a home-like atmosphere by their interaction with the residents. However, this can be difficult to provide in the context of pressure to meet the food and hydration needs of all residents within a timely manner 2.
What has been done to improve the dining experience for aged care residents?
Examples of efforts to improve the overall dining experience have been directed towards increasing food intake, reducing weight loss, improving nutrition and hydration, minimising behaviours associated with dementia, enhancing staff knowledge and greater resident satisfaction.
Changes are realised through revision of food service delivery, environmental modification, staff education or a combination of one or more of these. The approaches to each have been informed by the existing evidence, resident and family feedback or represent a more innovative attempt towards quality improvement. Some examples of food service interventions and their outcomes include:
Where to from here?
Quality improvement specific to food services within RACS settings will be multidimensional and involve organisational leadership, staff, residents and their families. Evidence suggests that effective interventions are likely to be multifaceted, including staff development, creating small and homelike environments and underpinned by organisational policies that promote good practice specific to food services 15.
As with any other domain of care in this setting, the design and delivery of food services are opportunities to promote resident wellbeing and personhood 15.
A summary of activities or points of focus is presented below.
- Pankhurst, M., A. Yaxley, and M. Miller, Identification and Critical Appraisal of Food Service Satisfaction Questionnaires for Use in Nursing Homes: A Systematic Review. Journal of the Academy of Nutrition and Dietetics, 2021. 121(9): p. 1793-1812.e1.
- Abbey, K.L., Australian Residential Aged Care Foodservices. Menu design, quality and standards – A time for action, in School of Human Movements and Nutrition Studies 2015, University of Queensland.
- Evans, B.C., N.L. Crogan, and J.A. Shultz, The meaning of mealtimes: connection to the social world of the nursing home. J Gerontol Nurs, 2005. 31(2): p. 11-7.
- Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect. Volume 1 Summary and recommendations. 2021: Commonwealth Government.
- DoH. Basic daily fee supplements for aged care. 2021; Available from: https://www.health.gov.au/health-topics/aged-care/providing-aged-care-s….
- Hugo, C., et al., What does it cost to feed aged care residents in Australia? Nutrition & Dietetics, 2018. 75(1): p. 6-10.
- Iuliano, S., et al., Dairy food supplementation may reduce malnutrition risk in institutionalised elderly. The British journal of nutrition, 2017. 117(1): p. 142-147.
- Dietitians Australia, Menu Planning and Innovation in Aged Care- Position Statement. 2020: Dieticians Australia.
- Tamura, B.K., et al., Factors Associated With Weight Loss, Low BMI, and Malnutrition Among Nursing Home Patients: A Systematic Review of the Literature. Journal of the American Medical Directors Association, 2013. 14(9): p. 649-655.
- Greenwood, C.E., et al., Behavioral disturbances, not cognitive deterioration, are associated with altered food selection in seniors with Alzheimer's disease. J Gerontol A Biol Sci Med Sci, 2005. 60(4): p. 499-505.
- Bartl, R. and C. Bunney, Best Practice Food and Nutrition Manual for Aged Care Homes Edition 2.2. 2015: Central Coast Local Health District: NSW Government.
- Dietitians Australia, Oral Health, Swallowing & Hydration in Aged Care- Position Statement. 2020: Dieticians Australia.
- Vic Health, Healthy and high-quality food in public hospitals and aged care facilities: Audit overview. 2021: Department of Health, Victoria.
- Watkins, R., et al., Exploring residents' experiences of mealtimes in care homes: A qualitative interview study. BMC geriatrics, 2017. 17(1): p. 141-141.
- Hung, L. and H. Chaudhury, Exploring personhood in dining experiences of residents with dementia in long-term care facilities. Journal of Aging Studies, 2011. 25(1): p. 1-12.
- Curtis, M.P., et al., Satisfaction with care among community residential care residents. J Aging Health, 2005. 17(1): p. 3-27.
- Joung, H.-W., E.-K. Choi, and B.K. Goh, The Impact of Perceived Service and Food Quality on Behavioral Intentions in Continuing Care Retirement Communities: A Mediating Effect of Satisfaction. Journal of Quality Assurance in Hospitality & Tourism, 2015. 16(3): p. 221-234.
- Goh, B.K., et al., Residents' Satisfaction with Foodservice at a Continuing Care Retirement Community: A Pilot Study. Journal of Quality Assurance in Hospitality & Tourism, 2013. 14(2): p. 185-199.
- Crogan, N.L., et al., Food choice can improve nursing home resident meal service satisfaction and nutritional status. J Gerontol Nurs, 2013. 39(5): p. 38-45.
- Chaulagain, S., J. Li, and A. Pizam, What matters, and what matters most? Exploring resident satisfaction in continuing care retirement communities. International Journal of Contemporary Hospitality Management, 2022. ahead-of-print(ahead-of-print).
- Wright, O.R.L., et al., Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care. Health Expectations, 2013. 16(3): p. 251-265.
- Seo, S. and C.W. Shanklin, Important Food and Service Quality Attributes of Dining Service in Continuing Care Retirement Communities. Journal of Foodservice Business Research, 2005. 8(4): p. 69-86.
- O'Hara, P.A., et al., Taste, Temperature, and Presentation Predict Satisfaction with Foodservices in a Canadian Continuing-Care Hospital. Journal of the American Dietetic Association, 1997. 97(4): p. 401-405.
- Simmons, S.F., P. Cleeton, and T. Porchak, Resident Complaints About the Nursing Home Food Service: Relationship to Cognitive Status. The Journals of Gerontology: Series B, 2009. 64B(3): p. 324-327.
- Lopez, K.J. and S.L. Dupuis, Exploring meanings and experiences of wellness from residents living in long-term care homes. World Leisure Journal, 2014. 56(2): p. 141-150.
- Bailey, A., S. Bailey, and M. Bernoth, 'I'd rather die happy': residents' experiences with food regulations, risk and food choice in residential aged care. A qualitative study. Contemporary Nurse : a Journal for the Australian Nursing Profession, 2017. 53(6): p. 597-606.
- Shahar, S., K.Y. Chee, and W.C.P. Wan Chik, Food intakes and preferences of hospitalised geriatric patients. BMC Geriatrics, 2002. 2(1): p. 3.
- Abbey, K.L., O.R. Wright, and S. Capra, Menu Planning in Residential Aged Care-The Level of Choice and Quality of Planning of Meals Available to Residents. Nutrients, 2015. 7(9): p. 7580-92.
- Boelsma, F., et al., "Small" things matter: Residents' involvement in practice improvements in long-term care facilities. Journal of Aging Studies, 2014. 31: p. 45-53.
- Reimer, H., Providing person-centred mealtime care for long term care residents with dementia. 2012, University of Guelph.
- Winterburn, S., Residents' choice of and control over food in care homes. Nurs Older People, 2009. 21(3): p. 34-7; quiz 38.
- Desai, J., et al., Changes in Type of Foodservice and Dining Room Environment Preferentially Benefit Institutionalized Seniors with Low Body Mass Indexes. Journal of the American Dietetic Association, 2007. 107(5): p. 808-814.
- Vincent, E., Ongoing nutrition assessment, menu modification, and personal service improve food consumption in assisted-living facilities. J Am Diet Assoc, 2008. 108(5): p. 792-3.
- Lewis, A., A. Kitson, and G. Harvey, Improving oral health for older people in the home care setting: An exploratory implementation study. Australasian Journal on Ageing, 2016. 35(4): p. 273-280.
- Malhi, H., Dysphagia: warning signs and management. Br J Nurs, 2016. 25(10): p. 546-9.
- Donini, L.M., C. Savina, and C. Cannella, Eating Habits and Appetite Control in the Elderly: The Anorexia of Aging. International Psychogeriatrics, 2003. 15(1): p. 73-87.
- Chaudhury, H., L. Hung, and M. Badger, The Role of Physical Environment in Supporting Person-centered Dining in Long-Term Care: A Review of the Literature. American Journal of Alzheimer's Disease & Other Dementias®, 2013. 28(5): p. 491-500.
- Hung, L., The dining experience of residents with dementia in long-term care facilities. 2008, Simon Fraser University (Canada): Ann Arbor. p. 152.
- Cartwright, J., et al., Montessori mealtimes for dementia: A pathway to person-centred care. Dementia, 2022. 21(4): p. 1098-1119.
- Young, K.W.H., et al., A Randomized, Crossover Trial of High-Carbohydrate Foods in Nursing Home Residents With Alzheimer's Disease: Associations Among Intervention Response, Body Mass Index, and Behavioral and Cognitive Function. The Journals of Gerontology: Series A, 2005. 60(8): p. 1039-1045.
- Remsburg, R.E., et al., Impact of a buffet-style dinning program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. American Dietetic Association. Journal of the American Dietetic Association, 2001. 101(12): p. 1460-3.
- Shatenstein, B. and G. Ferland, Absence of Nutritional or Clinical Consequences of Decentralized Bulk Food Portioning in Elderly Nursing Home Residents with Dementia in Montreal. Journal of the American Dietetic Association, 2000. 100(11): p. 1354-1360.
- Brush, J.A., R.A. MEEHAN, and M.P. CALKINS, Using the environment to improve intake for people with dementia. Alzheimer's Care Today, 2002. 3(4): p. 330-338.
- Altus, D.E., K.K. Engelman PhD, and R.M. Mathews, Using family-style meals to increase participation and communication in persons with dementia. 2002, SLACK Incorporated Thorofare, NJ. p. 47-53.
- Bhat, C.J., A. Wagle, and S. Ousey, Culture Change: Improving Quality of Life by Enhancing Dining Experience. Journal of the American Dietetic Association, 2011. 111(9, Supplement): p. A109.