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a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m h t t p : / / i n t l . e l s e v i e r h e a l t h . c o m / j o u r n a l s / c l n u Nutrition in care homes and home care: How toimplement adequate strategies (report of theBrussels Forum (22e23 November 2007)) M. Arvanitakis a, A. Beck b, P. Coppens c, F. De Man d, M. Elia e,X. Hebuterne f, S. Henry g, O. Kohl h, B. Lesourd i, H. Lochs j,T. Pepersack k, C. Pichard l, M. Planas m, K. Schindler n, J. Schols o,L. Sobotka p, A. Van Gossum a,* a Nutrition Team, Erasme University Hospital, Brussels, Belgiumb National Food Institute, Technical University of Denmark, Copenhagen, Denmarkc National Food and Health Plan, Belgiumd The European Nutrition for Health Alliancee Institute of Human Nutrition, University of Southampton, Southampton, UKf Gastroenterology and Nutrition Clinic, CHU of Nice, Nice, Franceg Ligue Nationale Alzheimer, Brussels, Belgiumh Research and Development, Schubert Unternehmensgruppe GmbH, Du¨sseldorf, Germanyi Gerontology Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, Francej Department of Gastroenterology, Hepatology and Endocrinology, Charite´ University Hospital, Berlin, Germanyk Geriatrics Department, Erasme University Hospital, Brussels, Belgiuml Clinical Nutrition Department, Geneva University Hospital, Geneva, Switzerlandm Nutritional Support Unit, General University Hospital Vall d’Hebron, Barcelona, Spainn Department of Endocrinology, Vienna Medical Institute University, Vienna, Austriao University of Maastricht and Vivre Care Group, Maastricht, The Netherlandsp Department of Metabolic Care and Gerontology, Medical Faculty of the Charles University, Hradec Kralove, CzechRepublic Received 11 March 2008; received in revised form 23 April 2008; accepted 24 April 2008 * Corresponding author. Department of Gastroenterology, Nutrition Team, Erasme University Hospital, Route de Lennik 808, Brussels 1070, E-mail address: [email protected] (A. Van Gossum).
0261-5614/$ - see front matter ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2008.04.011 Author's personal copy
Background & aims: Undernutrition in home care and care home settings is an unrecognized problem with significant consequences. The present work was edited after a forum concerning nutrition in these settings was held in Brussels in order to tackle the problem.
Methods: Various aspects of the question were addressed with the participation of scientific experts. The proceedings of the forum were edited and completed by a review of previously published material.
Results: Prevalence of undernutrition in home care and care home settings varies between 15%and 65%. Causes of undernutrition are various: medical, social, environmental, organizationaland financial. Lack of alertness of individuals, their relatives and health-care professionalsplay an important role. Undernutrition enhances the risk of infection, hospitalization, mortal-ity and alter the quality of life. Moreover, undernutrition related-disease is an economic bur-den in most countries. Nutritional assessment should be part of routine global management.
Nutritional support combined with physical training and an improved ambiance during mealsis mandatory. Awareness, information and collaboration with all the stakeholders should facil-itate implementation of nutritional strategies.
Conclusions: Undernutrition in home care and care home settings is a considerable problemand measures should be taken to prevent and treat it.
ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rightsreserved.
Improving nutrition in home care and care home settings will be a rewarding, albeit challenging task. Previous Undernutrition is a state of nutrition in which a deficiency clinical research has shown that improving nutritional of energy, protein and other nutrients causes adverse status is possible.4,5 However, there is a growing need for effects on tissue or body form (body shape, size and interest and resources. These deficiencies are confronted composition), function or clinical outcome.1 The focus of to a rising problem, considering the increasing number of the forum organized by the Belgian Food and Health Plan senior citizens. All the above reasons consisted a solid ini- tiative to organize a forum concerning this matter.
e23 in Brussels 2007 is on undernutrition, concerning seniors in home care and care home settings.
The forum included participants from medical, nutri- There is an increase interest regarding adequate nutrition tional, political and commercial settings, as well as repre- at a scientific but also at a political level. As an example, the sentatives from patients associations. Topics included an Council of Europe published a report and a resolution on food overview of the prevalence, causes and consequences of and nutritional care in hospitals in 2002/2003, which con- undernutrition in home care and care homes, as well as tained over 100 recommendations for improvement of nutri- strategies to optimize and implement adequate nutrition in tional strategy.2 This resolution focused on the importance of nutritional risk screening in hospital care, identifying causes Finally, the objectives of this forum were to update of undernutrition, offering nutritional support, the distribu- scientific knowledge, to share experience between persons tion of responsibilities for nutritional care in hospitals, food involved in this topic, and to increase awareness. Obvi- service practice, and continuous education regarding clinical ously, the final goal of this brain-storming process will be in nutrition. In the same line, implementing nutritional strate- the next future to formulate recommendations, and to gies in home care and home care settings is also of significant encourage implementation of nutritional strategies at interest because there is also growing attention for improving quality of care in care homes all over Europe.
On a national level, when the Belgian National Food and Health Plan (NFHP-B) was initiated in 2003 as a multidisci- Prevalence and causes of undernutrition in plinary multistake holders platform to address nutrition and health, undernutrition was recognized as a significant issueto tackle.3 A working group with leading experts from soci- In The Netherlands, since 1998, a National Prevalence ety, academia and authorities was created to identify the Measurement of Care Problems is conducted annually in main causes of undernutrition and develop an action plan home care organizations, care homes and hospitals.6 This to improve the situation. Three distinct settings were stud- measurement is called LPZ and provides insight in the prev- ied: hospitals, care homes and home care.
alence, prevention, management and quality indicators of Moreover, hospital caregivers are concerned by under- relevant care problems, including undernutrition. According nutrition in home care and care homes. Indeed, as the to the LPZ, undernutrition was defined as: (1) a BMI <18.5 (or length of hospital stay becomes shorter, the need to <24 if age 85); (2) unintentional weight loss (6 kg/ improve the interaction between hospitals and home care 3 months or 3 kg/1 month); or (3) a BMI between 18.5 settings in order to assure an optimal nutrition plan and 20 (24e29 if age 85) in combination with no nutritional intake for minimum 3 days or possibility of less intake for Author's personal copy
more than a week. According to this definition, in 2007, the chronic disability, decline in physical, cognitive and social prevalence of undernutrition varied from 18 to 28% in differ- function, increased health care cost and death.12 Once es- ent home care and care home settings. The prevalence in- tablished, the nutritional deficits, mainly protein-calorie un- creases according to co-morbidity and care dependency. In dernutrition place the hospitalized old patient at increased support of this, studies from all over Europe have docu- risk of developing subsequent in hospital complications, the mented a high prevalence of ‘‘nutritional risk factors’’, in- likelihood of developing a complication increasing in direct adequate dietary intake and decreased nutritional status relation to the severity of the nutritional deficits. In approx- among home care clients and nursing home residents.7e9 imately one third of cases, this risk becomes substantial.
The most important causes of undernutrition are: in- These severely undernourished patients often enter a cycle sufficient intake of nutrients and loss of nutrients, dyspha- of progressive clinical deterioration. Their hospital stay may gia, swallowing disorders, and dementia. Depression, excess be up to twice as long, and they experience two to 20 times of medications, lack of financial resources may also contrib- higher complication and death rates compared to patients ute to a poor nutritional intake. Chronic disease and with the same pathologies, but who are well nourished.12 disabilities have been identified as underlying problems, as Because of their severe nutritional deficits, patients are of- well as a general decrease in food intake, sensation of ten unable to recover from one pathophysiologic insult prior hunger and thirst. The problem is aggravated due to a lack of to developing a second. For those who survive the hospital- alertness in patients and their families themselves, as well ization and do not receive adequate nutritional support, the as in health care professionals, leading to insufficient nutritional deficits often persist for variable periods subse- attention for systemic screening and nutritional care, of quent to discharge. Patients who remain undernourished education and formation of the caregivers, and of criteria at discharge have substantially increased rates of early hos- and quality standards for the food offered to the residents.
pital readmission and 1-year mortality.13 Moreover, environmental and social aspects play an impor- Another major consequence of undernutrition in old tant role, especially in home care and care home settings.
people is the loss of muscle mass (sarcopenia). Further Especially in the home care setting, many factors can complex factors, which intervene in this procedure and can contribute to the gradual decline of the nutritional status.
coexist with undernutrition are immobility, ongoing chronic A Belgian study from 1997 in the Flanders region showed diseases, hormonal changes, oxidative stress, etc. The loss that 50% of elderly people are completely dependent for of muscle mass contributes to limitations in physical activity preparation of hot meals; however, only 17% have house- and decreases a capacity for rehabilitation especially in old delivered hot meals. Moreover, financial problems account people, which reflects the long-term consequences of un- for undernutrition in 10% of old people.10 dernutrition, following the hospital stay. Even small loss of In general, home delivered meals and food prepared in muscle mass (which occurs during acute illness) significantly large scale kitchens are important nutritional services to decreases capacity for the basic activities. Whereas in young home care clients and nursing home residents in many and so far healthy persons the loss of muscle mass decreases countries. However, despite the size and the important role capability for some extra activities (sport, climbing the of the meal service, little is known about its ability to meet stairs, running, etc.), the loss of muscle mass in depleted or the nutritional needs of the old consumers. Several problems even healthy old people leads to the loss of very basic exist, e.g., (1) lack of recommendations regarding the meal activities.14 This leads to loss of autonomy and can even service provision, i.e., the nutritive value of meals provided cause significant problems with keeping the upright position and the responsibilities, and duties and tasks of different food and cough. Multiple aspirations and fatal pneumonia are fre- service operators and health care personnel. (2) Lack of quent consequences of such development.15 Alterations of control with portion sizes and knowledge about the percent- the nutritional status may occur during a hospitalization age of meal consumed. (3) Lack of ambience (mealtime care).
for acute illness. An assessment of the nutritional status (4) Lack of knowledge about consumer acceptability and should be repeated at the discharge for providing adequate satisfaction of provided meals. (5) Lack of flexibility and recommendations to favor a prompt recovery at home.
individuality (e.g. with regard to culture, ethnical and re-ligious background). (6) Lack of nutritional screening and provision of nutritional support and advice to the consumers.
Undernutrition is common in nursing homes.16e18 Protein- (7) Lack of nutrition education of the providers of meal energy undernutrition is endemic in institutions, with service including the health care personnel. (8) Lack of a prevalence ranging from 17% to 65%.16 In community nurs- knowledge about the optimal larger scale food production ing homes, nutritional deficiencies have been associated technologies. (9) Lack of quality control to prevent microbial with increased hospitalizations,19 and, in Veterans Affairs growth and secure optimal serving temperature and (10) lack intermediate care (Geriatric Evaluation and Management of common guidelines for out-sourcing meal service.11 Units) and nursing homes, protein-energy undernutritionhas been associated with increased infections, hospitaliza-tions, and mortality.20e23 Residents often have low blood Consequences of undernutrition for old people levels of water-soluble vitamins of which folate and pyridox-ine deficiencies are the most common.24,25 Protein-calorie undernutrition and low vitamin C levels and have beenassociated with decubitus ulcers.26 Protein-calorie undernu- trition and deficiency of the liposoluble vitamin D are impor- Low BMI and weight loss has been shown to have serious tant factors in the pathogenesis of hip fractures, a frequent consequences and can result in compromised quality of life, cause of morbidity and mortality in residents.27e30 Residents Author's personal copy
are also at high risk for trace mineral deficiencies, and both because of premature death and the years of ‘‘healthy’’ life zinc and selenium deficiency can aggravate immune defi- lost by virtue of being in states of disability. The years lost ciency and delay wound healing.16,31 The most common nu- due to disability are estimated by multiplying the average tritional problems in nursing home residents are weight loss duration of the disease and a weight factor reflecting the se- and concomitant protein-energy undernutrition. Although verity of the disease on a scale from 0 (perfect health) to 1 the causes of weight loss in these patients can usually be (dead). On the other hand, QALY is the sum of years added treated, they are rarely identified in the nursing home. De- to the life span after an intervention. Despite some method- pression and adverse drug effects are the most common ological limitations mainly due to the difficulties to define causes of weight loss. Inadequate fluid intake leads to dehy- precisely the weight factors for each health state, QALYs dration, hypotension, and, in persons with diabetes melli- and DALYs are reliable tools, which are increasingly used tus, hyperosmolarity. Finally, food intake itself can cause postprandial hypotension (which in turn may precipitate A low cost QUALY (<£20,000) is more easily accepted falls), produce electrolyte shifts, and result in aspiration from public health services than a higher cost QUALY.
However, another parameter which must be taken underconsideration is private coverage of costs. Moreover, quality of life and cost to caregivers is ignored in manymodels of cost-effectiveness analysis. Finally, cost-effec- Nutrition deficits results into major body dysfunctions such tiveness does not coincide with equity. Nevertheless, equal as muscle function altering daily activities and conse- health distribution is just as important as maximizing quently limiting autonomy. Studies have shown a close health, meaning that there is a need to establish an relationship between undernutrition and decreased quality appropriate equity-efficiency trade-off.
of life in elderly institutionalized patients.32 Quality of life In conclusion, undernutrition-related disease is an eco- is a based on the patient’s perception of well-being. A de- nomic burden in most countries, although limited data are creased quality of life can be related to depression, which available. Measures are required to be taken, however, may limit social interactions and further deepen isolation there are clinical and ethical concerns associated with the and alienation, thus aggravating undernutrition.33 use of cost-effectiveness analysis alone as a method ofsocial justice (for distributing limited financial resources).
Impact of undernutrition on health care costs Assessing and treating undernutrition in carehomes and home care On an international level, health care costs are continu-ously increasing. However, preventive public health mea-sures concern only 0.5 Nutritional risk screening and assessment There is little information on the national cost of In the USA, an expert panel of interdisciplinary opinion leaders undernutrition. Nevertheless, a recent report published in representing academia and the medical community joined 2005 regarding the cost of disease-related undernutrition in together to form the Council for Nutritional Clinical Strategies the UK reveals some interesting facts, which underline the in Long-Term Care. The purpose of this panel was to evaluate urgency to take measures against this problem.34 First of the current literature on the treatment of undernutrition and all, the number of annual GP and hospital visits, along involuntary weight loss and to formulate clinical guidelines with hospital admissions, is increased in elderly patients that may be used by physicians, dietitians, and nurses in (65 years) with undernutrition. It is estimated that public a long-term care setting.36 The council formulated algorithms expenditure on disease-related undernutrition in 2003 was for the diagnosis and treatment of involuntary weight loss.
>7.3 billion £/year, or 10% of public expenditure on These algorithms, which are supported by the American Die- health. Most of the expenditure on disease-related under- tetic Association and the Gerontological Society of America, nutrition involves people >65 years, who account for only are presented under the title, ‘‘Clinical guide to prevent and ~15% of the general population. About half the cost of un- manage malnutrition in long-term care’’.
dernutrition occurs outside hospitals, mainly for long-term The guidelines are based on three ‘‘trigger conditions’’: residential care for the elderly. Finally, there are major in-equalities concerning undernutrition prevalence, between  Involuntary 5% weight loss in 30 days or 10% in 180 days and within countries, as well as within the same region.
But how can public health services determine where to put the money? Cost-effectiveness analysis is a form of  Resident leaves 25% or more food uneaten at two thirds of economic analysis that compares the relative expenditure meals (assessed over 7 days, based on 2000 kcal per day) (costs) and outcomes (effects) of two or more courses ofaction. The cost-effectiveness of a therapeutic or preven- These triggers are based on two Congressional acts, the tive intervention is the ratio of the cost of the intervention Omnibus Budget Reconciliation Act of 1987 and the Bal- to a relevant measure of its effect. A special case is cost- anced Budget Act of 1997, which dictate that a facility must utility analysis, where the effects are measured in terms of ensure that a resident maintains acceptable parameters of years of full health lived, using measures such as disability- nutritional status, such as body weight and protein levels, adjusted life years (DALY) or quality-adjusted life years unless the resident’s condition is such that this is not (QUALY).35 DALY is the arithmetic sum of the years of life lost possible. The regulations also dictate that a resident should Author's personal copy
receive a therapeutic diet when there is a nutritional include more routinely nutritional assessments and inter- problem. However, the council guidelines use a BMI of ventions in comprehensive geriatric assessment; and (c) to 21 kg/m2 rather than the BMI of 19 kg/m2 outlined in the assess the impact of nutritional recommendations on Congressional acts. The Council thought that using a higher nutritional status and on the length of hospitalization.
trigger BMI would result in earlier intervention, and a BMI of Results revealed that hospitalization stay was significantly 21 kg/m2 has been associated with increased mortality.36 lower during the interventional period than during the The algorithm, which was designed to identify and treat observational period. A higher mean serum prealbumin reversible causes of protein-calorie undernutrition, is di- concentration variation was observed during the interven- vided into two parts. One has been designed for physicians, tional period as compared to the observational period.
pharmacists, and dietitians, and a second algorithm has Finally, in The Netherlands, two country wide projects been designed for nurses, dietary staff, and dietitians.
have been started on behalf of the Ministry of Health. In The algorithm facilitates the careful analysis of the home care and care homes the National program Care for potential causes of weight loss. It provides suggestions for Better has been initiated, which also focuses on reducing the family, food and environmental considerations, guide- undernutrition amongst the residents of nursing homes.41 lines for laboratory assessment; and consideration of Nutritional assessment should be part of routine clinical factors such as acute illness, pain, and depression.
practice in elderly patients. A comprehensive screening tool For example, the clinical trigger will result in a careful for assessment of nutritional status is needed that is clinically analysis of the potential causes of the weight loss. If the patient relevant and cost effective to perform. If undernutrition is has anorexia, the solution may be as simple as scheduling suggested by such screening tests, then a supplemental a mealtime visit from a staff person or arranging for help in conventional nutritional assessment should be performed feeding. Perhaps the patient does not like the food being before treatment is planned. Such a quality program could be offered, or perhaps the patient is dehydrated. If these issues applied among care homes and home cares.
are not present, a new set of options should be considered. Atthis point, the team of professionals should consider laboratory testing to determine if the weight loss has resulted in abnormalvalues. If values are abnormal (the definition in the algorithm is It is certain that nutritional risk assessment is of major serum albumin <3.4 g/dL, cholesterol <160 mg/dL, and hemo- importance, but what tools are the most appropriate? In globin <12 g/dL), aggressive treatment options should be con- Europe, the European Society for Clinical Nutrition and sidered. Certainly delirium, acute illness, or pain may also Metabolism (ESPEN) published in 2002 the ‘‘ESPEN Guide- result in anorexia and rapid weight loss.
lines for Nutrition Screening’’.42 It was the purpose of this One useful feature of the algorithm is a mnemonic, document to give simple guidelines as to how undernutri- MEALS ON WHEELS, for the reversible causes of protein- tion, or risk for development of undernutrition, can be de- energy undernutrition in nursing homes36e39: Medications tected, by proposing a set of standards which are (e.g., digoxin, theophylline, antipsychotics), Emotional practicable for general use in patients and clients within problems (e.g., depression), Anorexia, Late-life paranoia, present healthcare resources. The screening tools proposed Swallowing disorders, Oral problems, Nosocomial infections were: (A) the ‘‘malnutrition universal screening tool’’ (e.g., tuberculosis, Helicobacter pylori, Clostridium diffi- (MUST) for the community (Malnutrition Advisory Group cile), Wandering and other dementia-related behaviors, 2000); (B) the NSR-2002 for the hospital35; and (C) the Hyperthyroidism/hypercalcemia/hypoadrenalism, Enteric ‘‘mini nutritional assessment’’ (MNA) for the elderly.17,43e45 problems (e.g., malabsorption), Eating problems, Low- In Belgium, a scientific expert group in undernutrition salt, low-cholesterol diets, Stones (cholelithiasis).
was created in the framework of the National Food and The consideration of the many factors that may be Health Plan to identify the most appropriate and validated related to decreased appetite and/or involuntary weight tools for screening and management of undernutrition in loss along with the algorithm presents a systematic ap- different settings.6 They concluded that, in care homes and proach to this problem. All health professionals who deal home care, the mini nutritional assessment (MNA) is the with elderly residents of long-term care facilities should be first choice for screening.45 The malnutrition universal made aware of the dangers of involuntary weight loss and screening tool (MUST) can be utilized as a second choice.46 the fact that early interventions greatly improve the The subjective global assessment is considered the optimal tool for further nutritional assessment.47 The choice of In Belgium, the College for Geriatrics associated with a tool for nutritional screening and assessment can be the Belgian Society for Gerontology and Geriatrics sup- adapted regarding the local human resources and settings.
ported by the Belgian Ministry of Social Affairs, PublicHealth and the Environment conducted a quality program inorder to sensitize the teams to nutritional assessment and intervention.40 All patients underwent a comprehensive ge-riatric assessment. For the first 3 months, the nutritional status of the patients on admission and at discharge was as- According to the French Guidelines,48 the objective of nutri- sessed without particular recommendations for nutritional tional support in malnourished elderly subjects is to achieve intervention. A standardized nutritional intervention was an energy intake ranging from 30 to 35 kcal/kg per day and a protein intake ranging from 1.2 to 1.5 g of protein/kg per The aims were to: (a) assess the quality of care day. Nutritional requirements vary among subjects and concerning nutrition among Belgian geriatric units; (b) to must be adapted to co-morbidities. Indeed, nutritional Author's personal copy
intake should take into consideration the physical activity of e Special training for the health care-givers.
the senior residents. In semi- or immobile persons, providing e If necessary, nutritional supplements should be used in 20 kcal/kg per day should be enough according a recent study that compared the results from the HarriseBenedictequation and those from indirect calorimetry obtained in The hospital-care homeehome care continuum normal weight care-dependent seniors.49 Moreover, bodyweight may vary because of body composition (water reten- During hospitalization, undernutrition aggravates mostly be- tion or sarcopenia). Therefore, these recommendations cause pre-existing undernutrition is unrecognized, food intake must be reconsidered according to every patient.50 is chronically insufficient and nutrition support, if prescribed, Nutritional support should, as a priority, be initiated by is too delayed to be efficient. As a rule, at hospital discharge, providing dietary device and/or fortified foods, in collab- older patients already suffer undernutrition or are at risk to oration with a dietician. Fortified foods are used to increase develop undernutrition due to disease and functional or the energy and protein intake of a meal without increasing cognitive deficits. Further aggravation of their malnutrition its volume. They are obtained by enriching traditional foods promotes complications and increases their risk for re- with high-energy and fat products (milk powder, grated hospitalization. This vicious circle can be broken by a ‘‘con- cheese, eggs, fresh cream). If these support measures are tinuum of nutrition care’’ at home and in the hospital.
insufficient, oral nutritional supplementation may be given.
An information campaign on the risks related to malnu- Enteral nutrition may be attempted if adequate oral trition is mandatory to increase the awareness of patients nutrition support is impossible. Parenteral nutrition should and their relatives. Its counterpart is needed in the be limited in certain indications when the digestive tract curriculum of all the health care personals. Global rise of cannot be used. Both enteral and parenteral feeding should awareness is the best option to promote a continuum of be considered after a cautious benefit-risks analysis cen- nutrition care at home and in the hospital.
tered on the patient expectation and medical needs.
However, it should be stressed that pharmacological seda- Strategies to tackle undernutrition in care tion or physical restraining of the patient to make enteralor parenteral nutrition possible is not justified. Calcium and vitamin D must be administered along with nutritionalsupport and other micronutrient (iron, C and B group Awareness, information and implementation are the key vitamins) elements must be corrected if necessary.51 words to prevent and to treat undernutrition in home care Physical activity programs are an important component and care homes. Scientific experts in collaboration with all of nursing home care that may have an effect on nutritional the stakeholders who are involved in this field must sensitize status, and simple, cost-effective programs may be as the political authorities about the magnitude and the impor- beneficial as high-technology programs.52 tance of the problem. Undernutrition is a silent or unrecog-nized problem which substantially decreases quality of lifeand increases morbidity. To provide an adequate nutrition in home care and care home settings should be included in the Follow up is mainly based on the weekly measurement of global management of individuals. Recommendations for body weight, estimation of food intake and daily activity.
nutritional assistance at an European level should take into Serum albumin and transthyretin are useful tools to evaluate consideration various aspects: first, care homes and home the efficacy of nutritional intervention.53 The second is use- care differ in structure considerably within Europe. A prior ful for short-term management and the first for long-term.
mapping of these structures should be helpful for identifyingthe different needs and potentials. We may hope that the results of the Nutrition Day54 which has been extended toHome Care will provide some enlighting data; second, demog-raphy, social conditions and medical development will lead to e It is advised to increase eating frequency during the day by splitting up meals and by adding snacks.
a four-fold increase of care-dependent old citizens until 2050.
European recommendations need to consider these develop- ments otherwise they will become unrealistic; third, ethicalissues will be a major and integrated aspect of nutritional sup- e It is possible to modify food texture according to chew- port in elderly people and especially in those suffering fromdementia. After this meeting, actions are ongoing for imple- e Assistance for feeding should be provided if required and time for it should be sufficient.
e Good oral health through routine mouth and dental care can help in maintain the pleasure of oral feeding.
e Physical training of moderate intensity twice per week along with nutritional support may improve nutritionalstatus and preserve muscle function.
e Special training of the cooks may help in providing e An improved ambiance during meals (setting a table, This Forum was financed and organized by the Federal Public eating in company) can help in improving oral intake.
Service of Health, Food Chain Safety and Environment Author's personal copy
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