The Lantern Project: shining a light on food in aged care

Meet Mr B, an aged care home resident living with dementia. Mr B had a history of significant overnight agitation and presented with confusion as to time and place, poor oral intake and dysphagia.

Mr B had ill-fitting dentures which resulted in staff downgrading Mr B to a pureed diet prior to a speech pathology review. His profound vision and hearing impairment meant staff were providing Mr B with full assistance with his meals, with no ability to cue him for each mouthful due to sensory deficits. Mr B simply could not see or hear verbal cues as to when the next mouthful was coming and what food and fluid was being offered. This led to confusion, lack of mealtime engagement and a resulting poor dietary intake.

Recommendations involved replacing the batteries in Mr B’s hearing aid and ensuring his hearing aid and glasses were worn during all meals. A dental review was also recommended. Staff were prompted to guide Mr B to hold his own cup and cutlery, and offer verbal cues and assistance where required.

The result? Hearty conversation around the meal served, Mr B independently holding his own cup and drinking well in between mouthfuls of the meal, satiety at the end of the meal, resulting in Mr B having a more settled overnight sleep, engaging in conversation during mealtimes, and an upgrade to thin fluids and soft diet achieved by addressing identified sensory deficits (sight, hearing, touch), leading to an improved mealtime experience. In brief, a happier, more nourished Mr B.Mealtimes are so much more than nutrients on a plate. They are a time to connect with others, savour flavours, colours, textures and smells, trigger memories and create joy.

The Lantern Project was borne of the need to improve the quality of life of older adults through the joy of food. I started The Lantern Project in 2013 to explore and illuminate ways to further improve the food and dining experience for people in aged care settings.

The project is a national collaboration, meeting monthly on the Gold Coast with webinar linkups for participants across the country. There’s now more than 500 members across Australia and overseas including aged care managers, catering managers, dementia consultants, healthcare workers, carers, accountants, dietitians, speech pathologists, researchers, horticultural therapists, representatives from peak industry bodies, and resident advocates.

The project welcomes all aged care stakeholders to join in the monthly conversation and group brain-storming with the goal to problem solve and develop innovative solutions and inform action-based research via Bond University.

In the five years since The Lantern Project began we have learnt so much. Key successes to date include:

• Development and release of Lantern’s EXPLORE app, a story capture tool designed to identify food service priorities.
• Producing The Lantern Aged Care Food Safari ‘Little Things’ video series – short videos shared online, demonstrating innovations occurring in aged care home food service that have had a big, positive impact on the lives of residents.
• Development of The Lantern Approach, a set of evidence-based guiding principles designed to improve the dining experience for residents in aged care.
• Collaboration with key seafood industry leaders to improve access to local Australian seafood in the aged care setting.
• The project’s research arm has 11 papers currently published and under review.
• Three working groups are currently looking at ‘dining experience’, ‘legal and quality food issues’, and ‘food activities connecting generations’.

The underlying issue of malnutrition

The Lantern Project’s aim of improving mealtime and dining experiences in aged care settings is in response to the unacceptably high levels of malnutrition among older Australians. Malnutrition is a known risk for older Australians, particularly those with dementia. More than one in two aged care residents are malnourished, with figures between 10-30% for people living in the community (Watterson et al 2009).

There is a scarcity of studies into the prevalence of malnutrition in people with dementia in Australia, but it is generally accepted that the prevalence of malnutrition is significantly higher for people with dementia than those without (Milte et al 2017; Meijers et al 2014). International studies reviewed in a 2014 report, Nutrition and Dementia, indicate that up to 50% of people with dementia in residential aged care have inadequate food intake (ADI 2014).

The reasons for malnutrition are complex – Mr B’s initial experience shows just one example of a potential pathway towards malnutrition. Many factors increase malnutrition risk: disease (Gallagher et al 1996; Visser et al 2006), anorexia (Rasheed & Woods 2013), reduced sensory input associated with ageing (Huang & Shanklin 2008), reduced access to food choice (Remsburg et al 2001), lack of mealtime assistance (Hugo et al 2017b), funding issues (Hugo et al 2017a,b,c), inappropriate meal provision, inadequate nutrition support and poor dentition (Hugo et al 2016) are just a few. Dementia is typically associated with many malnutrition risk factors including dysphagia (difficulty in swallowing), impaired sensory function and an increased sensitivity to environmental factors in the dining room.

Targeting malnutrition

Malnutrition directly affects quality of life. A malnourished person experiences muscle wasting which increases risks of falls, reduces stamina and limits independence. It hampers skin integrity and immune function, a common catalyst for pressure areas and impaired wound healing. Hospital readmissions are increased, mood is negatively impacted and morbidity and mortality sharply rise with decreasing nutritional status. For people with dementia, accessing a dietitian and speech pathologist regularly to optimise oral intake can prevent detrimental and costly consequences related to malnutrition.

Lantern Project research

The Lantern Project research began in 2014 with my PhD research project into Quantifying the Value of Nutrition in Aged Care, through Bond University, and has been looking at the complexity of the mealtime experience to highlight strategies that improve quality of life. Cost-benefits of nutrition, staff training, food-first approaches* along with the connection between oral health, malnutrition and quality of life (Hugo et al 2017a,b,c; Hugo et al 2016) have been explored.

One example of innovation through our research is the creation and piloting of The Lantern Project’s SenseMaker© EXPLORE app, a story capture tool to gain real-time food service insights from residents, family, staff and visiting health professionals and guide innovations to improve food satisfaction, intake and quality of life. The app is explained in more detail later in this article.

The Bond University-led research studies have been conducted in conjunction with the monthly Lantern collaboration meetings, culminating in the development of The Lantern Approach, a framework that aged care facilities can use to support quality improvement and accreditation around the food and dining experience. This framework offers an evidence-based guide to improve the quality of life of older Australians through improving the mealtime experience. The guide will be available on The Lantern Project website in 2018.

Lantern Project learning

In this article we share a few key learning points from The Lantern Approach.

Further information as to how organisations can integrate this approach is available via The Lantern Project website at www.thelanternproject.com.au.

Food is a safe investment

In collaboration with the StewartBrown financial benchmarking survey**, The Lantern Project research identified the current Australian average raw food spend in aged care as $6.08 per resident per day with downward trends of $0.31 per resident per day over the 2015-2016 period (Hugo et al 2017a). Diet quality can be adversely impacted by limiting the food budget and figures tend to support this fact with supplement trends increasing over the same period by $0.50 per resident per day (Hugo et al 2017a).

As well as increasing the overall cost of food, studies have highlighted poor long-term acceptance of nutritional supplements among aged care residents with dementia (Milne et al 2009). So spending more on supplements is false economy, especially if they are not consumed. Research also highlights a reduced oral intake among residents with dementia when prescribed supplements (Simmons et al 2010). Supplements can act as a meal replacement rather than a supplement if appropriate nutrition input and mealtime strategies are not in place.

A Lantern Project research study (Hugo et al 2017c) involving malnourished aged care residents, including people with dementia, looked at the implementation of Lantern Approach food-first strategies. Food strategies, combined with staff training sessions, improved nutritional status, average weight and quality of life while also offering cost savings of 5%.

Tip for practice

Consider food-first strategies and involve an accredited practising dietitian to ensure nutritional adequacy. If supplements are considered/prescribed, keep a detailed food/fluid chart for two days prior to and then for two days following to monitor impacts on actual intake.

Increased staffing to assist with supplement provision and monitoring of effectiveness is required – but with this increased staffing, food-first approaches may be as effective or more effective than supplements (Simmons et al 2010). Short-term use of supplements can be both positive and negative in terms of a person’s nutritional intake and weight, but is unlikely to have longer term weight and functional impacts.

Mealtime enjoyment is key

Meals are an opportunity for people to experience joy, recall memories, promote connection and enhance communication. A great meal and dining environment encourages this, whereas a poor meal and dining experience thwarts conversation, dampens mood and affects food intake. Mealtime experiences can make up 70% of the waking hours of an aged care resident’s day and the majority of their social interaction. They directly influence the person’s quality of life.

Engaging the five senses is essential for mealtime enjoyment:

Taste: Taste changes as we age, specifically reduced taste acuity. Dry mouth problems are common too, and both issues can hamper mealtime enjoyment. Amplifying flavours, particularly sweet choices, can improve food intake.

Smell: Enhancing mealtime aromas before a meal provides physiological cues to the body to prepare to eat. Increased salivary flow, increased appetite and focus on mealtimes improves the chances of a successful mealtime. Making popcorn, using a bread-making machine and brewing coffee are other simple ways to infuse aroma into the environment in preparation for mealtimes.

Touch: Be mindful of dexterity changes – some people may find it challenging to use cutlery effectively and to pick up cups, making it harder to eat and drink independently. The comfort of the dining chairs can also be the difference between the person having a settled and an unsettled mealtime experience.

Sound: Background noise, such as televisions being left on, rattling medication trolleys, vacuum cleaners and the loud scraping of plates within the dining area can negatively impact food intake and should be avoided. Soothing music may be helpful.

Sight: Adequate lighting can be a game-changer at mealtimes for those struggling with impaired vision. Reducing visual distractions, such as televisions and activities such as medication rounds, and improving dining ambience help to improve focus on the meal. One study demonstrated the benefits, including enhanced food intake, of the calming effect of aquariums in the shared dining room of aged care homes (Edwards & Beck 2002). Choosing table settings that contrast with the table/tablecloth and with the food can also assist with mealtime focus by making it easier to see the plate and food.

Care around the presentation of meals – particularly for those requiring a pureed meal – reduces food wastage, can increase enjoyment and restores dignity for residents dining with others consuming normal texture meals (see tips from Peter Morgan-Jones for examples).

Overcoming food challenges through observation, engagement and stories

Dementia presents a series of challenges that can have an effect on a person’s food intake and enjoyment of mealtimes, including:

• changes in food preferences
• communication of food likes and dislikes may become more difficult
• changes in hunger/satiety cues
• reduced ability to prepare and access foods independently
• dexterity issues reducing mealtime independence
• reduced focus on meal event
• extended time consuming meals
• hoarding or playing with foods
• agitation and difficulty sitting for the entire mealtime
• spitting out food, biting cutlery or refusing to open mouth.

Understanding an individual’s views and values around the dining experience can be easier through use of the SenseMaker© EXPLORE app – a tool developed through Lantern Project research to capture and analyse food stories with the purpose of highlighting resident-informed food priorities and the resulting areas to focus on within an organisation’s food and dining environment. Aged care residents, including those with early to mid-stage dementia, are encouraged to share a food memory around a food experience – be it distant or recent – and respond to a series of questions around how they felt about the memory.The tool informs mealtime priorities to guide targeted changes in response to these priorities. One example of a site-specific priority from the pilot testing was around the language used to describe the meals in a new menu introduced by one aged care organisation across all its facilities. Residents’ stories related to their being unfamiliar with the menu items and, as a result, they perceived the food choice was reduced. In response, staff held a workshop with residents to rename the menu items. Stories collected three months after this change demonstrated that residents felt they now had more choice. However, the food items were exactly the same, they were just labelled with more familiar names.

Education and awareness

Knowledge is key and appropriate training for health care staff can lead to significant improvements in those residents needing assistance during meals. The Lantern Project, along with individual members of the project, provide specific targeted training for aged care staff and organisations to improve food intake among older Australians on topics related to food and dining experiences specific to dementia, malnutrition and dysphagia. Consulting services to improve the dining experience, upskill catering staff and maximise nutritional intake are available.

For further information on The Lantern Project, resources and consultancy, email Cherie Hugo at cherie@mynutritionclinic.com or visit www.thelanternproject.com.au

FootNotes

*A food-first approach means prioritising food, mealtime ambience and staff support (training and adequate staffing during mealtime periods) in preference to commercial nutrition supplements for residents.

**The StewartBrown Aged Care Financial Performance Survey incorporates detailed financial and supporting data from over 950 residential aged care facilities and 500 Home Care programs across Australia. The quarterly survey is the largest benchmark within the aged care sector and provides an insight into the trends and drivers of financial performance at the sector, facility or program level.