Refusal to eat and drink is a common precursor to malnutrition for residents in long-term care, especially for older adults. Malnutrition from lack of food intake is responsible for 40 out of every 100,000 deaths in adults over age 85 years of age. Food and dining are components of quality of life and quality of care in long-term care facilities. Approximately 50-70% of residents leave 25% or more of food uneaten at most meals and 60-80% of residents have a physician or dietitian order to receive dietary supplements. The American Academy of Nutrition and Dietetics reports that undernutrition adversely affects quality and length of life. Prevalence of protein energy intake for residents’ ranges from 23% to 85%, making malnutrition one of the most serious problems facing health professionals in long-term care. Residents with pressure injuries will need a higher calorie and protein intake to facilitate the healing process.
There are many factors affecting long-term care residents’ desire to eat. These include issues with chewing or swallowing, lack of strength to cut food properly or use utensils, poorly fitting dentures or oral pain, depression, the disease process (dementia or Alzheimer’s disease), and constipation. Lifestyle habits may also affect desire to eat. For example, a resident that does not eat pork for cultural reasons may benefit from family bringing in food that has cultural or traditional significance. Residents with Parkinson’s disease or ALS (Lou Gehrig’s disease) may need a plate guard or weighted utensils due to hand tremors. “Finger foods” that are easy to grasp may also be indicated for these residents. The speech language pathologist can be instrumental in evaluating the least restrictive diet for the resident with chewing or swallowing issues. Some residents may need to be manually fed or supervised one on one at meals. Long-term care residents sometimes snack on available in-house snacks or from the vending machine throughout the day. These between-meal snacks may diminish appetite at meals.
There are several causes of refusal to eat and drink in the elderly population. These include physiologic changes including dementia, depression, medical, social and environmental factors. Many older adults in long-term care experience decrease in body weight as a result of aging combined with decreased energy intake, basal metabolic rate, lean body mass and decreased appetite, satiety and sense of taste and smell.
There are several ways to encourage increased food and drink consumption in long-term residents.
- Serve smaller meal portions on smaller plates.
- Ensure food is soft enough for the resident to comfortably chew and swallow.
- Many individuals have a favorite meal of the day. If you can determine which meal is the individual’s favorite, you can add additional nutritionally dense foods at that meal such as fortified foods, avocado, finely chopped meats, cheeses, egg, and peanut butter and other nut butters.
- Have a regular meal and snack schedule and serve foods at the same time each day. Easy-to-eat snacks such as string cheese, full-fat yogurt or cottage cheese, cheese and crackers, and diced fruit (fresh or packaged) are healthy and delicious choices. This helps the resident be ready to eat at these times. For some older adults, the ability to feel hunger and thirst decreases with age.
- Offer a liberalized diet to improve quality of life and avoid unintended weight loss.
- Appetite stimulants such as Megestrol acetate and Remeron can be ordered by the physician to help improve intake at meals.
- Digestive aids for conditions such as gastroesophageal reflux disease may be ordered by the physician.
- Nutritional supplements can be recommended by the dietitian to help with residents’ nutritional needs and weight loss/weight stability.
- The dining atmosphere should be a pleasant one for all residents. Flavor, palatability, texture and color should all play a role in the menu development.
Getting long-term residents, especially elderly residents to eat can be a challenge. Be patient and creative and keep experimenting with different foods and beverages. Keeping track lets you experiment with things that work and avoiding those that do not work.
Consult Geri, Refusing to Eat/Drink, A Clinical Website of the Hartford Institute for Geriatric Nursing.
Dietitians on Demand, 3 Ways Food Keeps Residents Engaged in Long-term Care, Deirdre Carlson, RD, May 15, 2018.
Eldercare Link, An Elder Refuses to Eat: What Should a Caregiver Do? Isabel Fawcett, SPHR.
Excelas, 10 Nutritional Considerations for Long-term Care Residents, September 2, 2017.
Pioneer Network Food and Dining Standards Task Force, New Dining Practice Standards, August 2011.