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NHDmag.com June 2016: Issue 115
IBS: THE LOW FODMAP DIET student zone
NUTRITION AND HYDRATION IN DEMENTIA: THE DMAT CARE PLAN By Lee Martin, RD
NHd-extra: COMMUNITY
Innovation in the nutritional care of dementia Lee Martin Registered Dietitian R&M Dietetics Ltd Lee Martin MSc RD is the founder of The DMAT and has a special interest in the mealtime environment in dementia. For correspondence please email info@thedmat.com.
Mealtime eating difficulties are a major contributor to malnutrition in people living with dementia, as well as a constant stress to those caring for them. This article will explain the innovative approach taken which led to the development of software to help carers identify, find solutions and create a care plan to overcome mealtime eating difficulties. Initial exposure to people living with dementia came from providing a dietetic service to a 99-bed registered dementia care home in 2011 where >90% of the residents had a form of dementia or cognitive impairment. The dietetic department would receive many referrals for malnutrition which often stated that residents were refusing to eat lunch, the main meal of the day. Very quickly, the hardest part of the dietetic role became getting people living with dementia to eat.
The loss of independence in self-feeding associated with mealtime eating difficulties can lead to weight loss, malnutrition and a poorer quality of life. When providing a dietetic assessment, all the conventional and recommended evidence-based practice approaches to improve nutritional intake were implemented. Often, these approaches would not work successfully and the person living with dementia would continue to lose weight. This led to trying a completely different approach. Mealtime observations were commenced on a particularly problematic floor in the care home to see if anything was being missed in the usual assessment approach. More was learnt in that onehour mealtime observation than in the
previous six months of discussing and planning interventions. Many mealtime eating difficulties were observed which prevented those living with dementia from consuming enough food. Eating difficulties at mealtimes have also been termed as ‘feeding difficulties’ and ‘aversive feeding behaviours’. Whatever the terms used, they describe the decline in eating abilities and behaviour associated with mealtimes in people living with dementia.1 The loss of independence in self-feeding associated with mealtime eating difficulties can lead to weight loss, malnutrition and a poorer quality of life. Problems with eating and feeding can often become a stressful time for both the carer and person with dementia.2 The difficulties observed made mealtimes a highly complex caring task. For example, some residents would struggle getting food off the plate and into their mouths, others would have difficulty chewing or swallowing and for some it seemed that they did not even recognise it was a mealtime. Those with more advanced dementia would refuse to eat or show signs of aggression. It seemed obvious that until these mealtime difficulties were resolved, dietetic advice would not be as effective as it should be. RECORDING MEALTIME EATING DIFFICULTIES
It was necessary to find a way to record these mealtime observations and, www.NHDmag.com May 2016 - Issue 114
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NHd-extra: COMMUNITY Figure 1: How to use The DMAT
importantly, also have suggestions of effective interventions to overcome them. A quick look at available research showed that there was limited information available for recording mealtime eating difficulties.3 The tool that had undergone the most rigorous testing for validity and reliability only highlighted a few of the observations witnessed and provided no suggested interventions,4 plus it was difficult to find any records of it being used in clinical practice. This prompted the creation of a more practical tool to record observations and, in addition, suggest interventions to overcome the observed eating difficulties. Initially, the tool was based on the Caroline Walker Trust practical guidelines Eating Well: Supporting Older People and Older People with Dementia (pages 25-27)5 and used elements from the Edinburgh Feeding Evaluation in Dementia Scale4 to provide a simple way of measuring the frequency of the identified eating difficulties. The tool was named the Dementia Mealtime Assessment Tool (DMAT) and with the help of a dietetic student, the DMAT was used to observe and record eating difficulties in a sample of dementia residents. The DMAT was simple to use and helped identify an individualised treatment plan to target interventions on overcoming the eating difficulties. The DMAT was useful in clinical practice and its use was continued; however, it was felt that further advancement was 54
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warranted as it provided a simple solution to a complex problem and feedback from the care home was positive. DMAT INITIAL MEASUREMENT FORM
Starting an MSc in Clinical Research (MRES) at University of Hertfordshire six months later, provided the opportunity to explore the literature on dementia and eating difficulties. Available tools for measuring mealtime eating difficulties were researched and elements from each tool aided in designing the DMAT ‘Initial Measurement Form’3,4,6,7 Most of the research was completed in long-term care settings, although the findings could be transferrable to home care and the acute setting. INTERVENTIONS FOR EATING DIFFICULTIES
The literature was researched for effective interventions for the many different types of eating difficulties, including how manipulation of the environment and social interactions at mealtimes could aid in the improvement of eating difficulties and nutritional intake. Research in this area has been neglected, with much of the research completed over a decade ago. Recently, there has been a resurgence of interest in the topic with literature or systematic reviews and guidelines published.8-14 Guidelines however are limited in their recommendations, with many potential interventions that could help
improve eating difficulties not mentioned, despite the authors suggesting assessment of eating difficulties.13 Reading and critiquing all the different interventions made one thing completely clear: one intervention alone is not going to work. Mealtimes are complex and there is a need for multi-component interventions to address this, while ensuring individualisation of the care plan. When translating the evidence into practical interventions, this was kept in mind. DMAT PILOT PROJECTS
The DMAT has been piloted by several NHS trusts and private organisations during its development. Feedback from these experiences highlighted that the DMAT needs to become more accessible with an emphasis placed on providing interventions that are simple to initiate.
THE DMAT ONLINE SYSTEM
With the help of a software developer, the DMAT was transformed from a paper-based resource into web-based software compatible across multiple devices. The DMAT aims to help carers identify, find solutions and create a care plan for overcoming mealtime eating difficulties in dementia. The DMAT software works in three simple steps (see Figure 1). Step 1. The figure provides an overview of how to use the DMAT. First you create an account and log into the system.17 Once logged on, you can download instructions and the Initial Measurement Form in paper format to use during mealtimes if required. Based on the research literature and feedback from pilot projects, the Measurement Form helps identify 37 common eating difficulties and is split into four sections, an example of which is shown in Table 1.
Table 1: Example of common mealtime eating difficulties taken from The DMAT Initial Measurement Form Section 1 Ability to self-feed (10 items)
Not seen
Seen once
Seen repeatedly
Not seen
Seen once
Seen repeatedly
Not seen
Seen once
Seen repeatedly
Not seen
Seen once
Seen repeatedly
Difficulty identifying food from plate Falls asleep or is asleep during mealtime Incorrectly uses cutlery (spoon, fork or knife) Section 2 Preferences with food (7 items) Prefers sweet food or eats dessert/sweets first Eats very small amounts of food (or drink) Eats other people’s food (or drink) Section 3 Resistive or disruptive behaviour (12 items) Refuses to eat (verbally or physically) Stares at food without eating Shows agitated behaviour or irritability Section 4 Oral difficulties and behaviours (8 items) Bites on cutlery (spoon, fork, knife) Holds food or leaves food in the mouth Difficulty chewing www.NHDmag.com May 2016 - Issue 114
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NHd-extra: COMMUNITY Step 2. The DMAT system allows you to choose two interventions per eating difficulty and any combination of interventions can be trialled. Limiting the interventions to two should keep the care plan simple and allow more accurate outcome monitoring. Different eating difficulties require different approaches, but generally the first set of interventions are aimed at improved caring techniques. The next set of interventions aims to enhance catering and nutrition support. Further interventions are aimed at adapting the mealtime environment to make it more dementia-friendly, as provided in the example in Table 2. Finally referral to healthcare specialists may be indicated. The DMAT is not a dysphagia tool, but does highlight swallowing difficulties in the ‘Oral Difficulties and Behaviours‘ section on the Initial Measurement Form. The intervention
choices associated with these highlight to care staff the importance of patient safety in regard to certain oral difficulties and levels of risk in dysphagia.15 If any texture modified food is recommended as an intervention, users are also reminded to refer to the national descriptors.16 Step 3. The system will generate a care plan based on the identified eating difficulties and chosen interventions (see Figure 2 for example). The care plan is saved on the system and can be downloaded, printed and shared with health and social care teams. For monitoring, it is recommended to use the DMAT monthly or fortnightly if you have concerns about the individual. Comparisons of previous care plans and results can help measure improvements in eating difficulties.
Table 2: Range of interventions that could be trialled for overcoming the mealtime eating difficulty ‘Stares at food without eating’ Suggested interventions: Stares at food without eating Reassure and remind the individual where they are and what time it is and what they are doing. Check hearing aids or glasses are worn if normally used. Try verbal cues: prompt the individual to initiate eating and offer encouragement. Try manual cues, e.g. placing food or utensils into the person’s hands. Try modelling eating so individual can copy your movements and offer encouragement. Trial using hand over hand or hand under hand technique to initiate and guide self-feeding. Simplify the meal process: place only one plate and one utensil on the table, directly in front of the individual. When the individual is finished with the first dish, replace it with another. Trial sensory cues, especially those involving smell, this can let the person know it is time to eat and help stimulate appetite. Trial using plates with a simple plain design and ensure a colour contrast between the plate and the food (e.g. white food served on a white plate may cause visual problems in identifying the food). Trial a colour contrast between the table or place mat and the plate (e.g. a white plate on a white tablecloth may make identifying the food harder). Note: tablecloths make dining more attractive and may provide the colour contrast required rather than changing the plate. Trial adjusting lighting: People living with dementia tend to need increased light compared to normal; attention should be paid to lighting in rooms where people eat. Try to achieve high levels of illumination whilst still maintaining a homely feel. Note: If seated near a window the outside light may cause glare, making it harder to see the meal, therefore try moving the meal place. If the individual continues not to eat provide feeding assistance and consult with a dietitian for nutritional assessment.
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The DMAT was simple to use and helped identify an individualised treatment plan to target interventions on overcoming the eating difficulties. Figure 2: Example of the DMAT Care Plan
SUMMARY
Maintaining independence at mealtimes by preventing and overcoming mealtime eating difficulties should be a more prominent feature of nutritional care for people living with dementia. A recent systematic review on supporting improved nutrition and hydration in dementia concluded that there was ‘no specific evidence or lack of effectiveness of specific interventions’. The authors also stated, with good judgement, ‘people with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence’.8
The DMAT has not undergone psychometric evaluation for validity or reliability, but provides a much needed resource to quickly and easily capture common eating difficulties that people with dementia may present with. Perhaps more importantly, it provides carers with evidenced-based simple, practical and cost effective interventions to create a care plan to overcome them. The DMAT will continue to be developed and is in the process of becoming involved in research trials. You can try the DMAT yourself with a seven-day trial by signing up on the website www.thedmat.com
References 1 Chang CC, Roberts BL. Feeding difficulty in older adults with dementia. J Clin Nurs. 2008; 17(17): 2266-2274. doi:10.1111/j.1365-2702.2007.02275.x 2 Prince M, Emiliano A, Maëlenn G, Matthew P. Nutrition and Dementia A Review of Available Research.; 2014. doi:10.1155/2012/926082 3 Aselage MB. Measuring mealtime difficulties: Eating, feeding and meal behaviours in older adults with dementia. J Clin Nurs. 2010;19(5-6): 621-631. doi:10.1111/j.1365-2702.2009.03129.x 4 Watson R. The Mokken scaling procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia. Int J Nurs Stud. 1996;33(4):385-393. doi:10.1016/0020-7489(95)00058-5 5 Crawley H, Hocking E. Eating Well : Supporting Older People and Older People with Dementia.; 2011 6 Durnbaugh T, Haley B, Roberts S. Assessing problem feeding behaviors in mid-stage Alzheimer’s disease. Geriatr Nurs (Minneap). 1996;17(2):63-67. http:// search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=1996018245&site=ehost-live&scope=site 7 Rivière S, Gillette-Guyonnet S, Andrieu S, et al. Cognitive function and caregiver burden: Predictive factors for eating behaviour disorders in Alzheimer’s disease. Int J Geriatr Psychiatry. 2002;17(10): 950-955. doi:10.1002/gps.724 8 Abdelhamid A, Bunn DK, Dickinson A, et al. Effectiveness of interventions to improve, maintain or facilitate oral food and/or drink intake in people with dementia: systematic review. BMC Health Serv Res. 2016;14(Suppl 2): P1. doi:10.1186/1472-6963-14-S2-P1 9 Whear R, Abbott R, Thompson-Coon J, et al. Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review. J Am Med Dir Assoc. 2014;15(3): 185-193. doi:10.1016/j.jamda.2013.10.016 10 Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: Systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013;32(6): 950-957. doi:10.1016/j.clnu.2013.03.015 11 Chaudhury H, Hung L, Badger M. The role of physical environment in supporting person-centered dining in long-term care: a review of the literature. Am J Alzheimers Dis Other Demen. 2013;28(5): 491-500. doi:10.1177/1533317513488923 12 Vucea V, Keller HH, Ducak K. Interventions for Improving Mealtime Experiences in Long-Term Care. J Nutr Gerontol Geriatr. 2014;33(4):249-324 76p. doi:10. 1080/21551197.2014.960339 13 Volkert D, Chourdakis M, Faxen-Irving G, et al. ESPEN guidelines on nutrition in dementia. Clin Nutr. 2015;34(6): 1052-1073. doi:10.1016/j.clnu.2015.09.004 14 Abbott RA, Whear R, Thompson-Coon J, et al. Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: A systematic review and meta-analysis. Ageing Res Rev. 2013;12(4): 967-981. doi:10.1016/j.arr.2013.06.002 15 Joliffe J, Chadwick D. Guide to Levels of Risk of Negative Health Consequences from Dysphagia.; 2006 16 NPSA. Dysphagia Diet Food Texture Descriptors.; 2011. www.hospitalcaterers.org/publications/downloads/dysphagia-descriptors.pdf 17 The Dementia Mealtime Assessment Tool Software: https://app.thedmat.com/
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NHD-extra: CONDITIONS & DISORDERS
Joe Alvarez Student, Nutrition and Dietetics, University of Chester Joe is currently studying MSc Nutrition and Dietetics at the University of Chester, with a particular interest in gastroenterology, especially allergies. He is passionate about Paediatrics and hopes to work in an acute setting in London after completing his course.
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THE LOW FODMAP DIET IN THE TREATMENT OF IRRITABLE BOWEL SYNDROME
student zone
Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal tract.1-12 It affects around 11% of the global population10 and is more common in women than men.1,2,11 Studies show that a diet low in FODMAPs (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides and Polyols) can be used to treat IBS. Pooled data estimates that the prevalence in the UK is at 10% using the Rome I or II criteria and up to 19% using the Manning criteria. However, it differs greatly between regions and prevalence is 12% in Northern Europe compared to 21% in South America and 7% in South East Asia.10 Its causes are poorly understood and, therefore, it can be difficult to manage in practice. Clinical trials are also often difficult to draw conclusions from due to the placebo effect.1-2 However, it is thought that there may be increased innervation to the intestine and altered gut motility and symptoms can be triggered by psychosocial factors, but diet can also worsen the effect.8-9 IBS can reduce quality of life dramatically (QOL) with patients reporting symptoms such as; bloating, flatulence, burping, abdominal pain, diarrhoea and constipation (amongst others).1-8 Patients can be subtyped into four categories: constipationpredominant, diarrhoea predominant, mixed IBS or un-subtyped.8 A diet low in FODMAPs has been shown to decrease these symptoms in some patients2-4 and has been shown to be more effective than traditional dietary advice for IBS patients.3,11 NICE guidelines currently state that this diet should be recommended if symptoms continue after following traditional dietary and lifestyle advice for IBS.12
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FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine. When undigested, they can enter the distal small bowel and colon where they increase the osmotic load and provide substrate for bacterial fermentation.3-4 This then causes luminal distension and elicits the effects seen in IBS, such as gas production, change in bowel motility and bacterial population alterations. A diet low in these can be used to treat IBS, with some studies showing 80% of patients seeing an improvement in their symptoms.3,4,5 WHAT DOES THE DIET INVOLVE?
The diet involves global restriction of foods containing moderate to high FODMAPs (exemplified in Table 1) in the diet for a set period of time (from six to eight weeks), and then reintroducing each one at varying amounts to test a patient’s tolerance.5 Only one food should be reintroduced each week. Patients can be tested for lactose and fructose malabsorption using hydrogen/methane breath testing, as not all sufferers will be intolerant to these.4 Onions and garlic are major triggers of gastrointestinal symptoms in a large proportion of those who suffer with IBS. Therefore, those following the FODMAP diet should initially omit these completely. Although it is impossible to completely avoid all FODMAPs, choosing foods low in FODMAPs is the most important aspect when following this diet.9
Figure 1: Prevalence of IBS according to country10
WHAT DOES THE EVIDENCE SHOW?
The majority of studies demonstrate that avoiding FODMAPs can provide significant symptomatic relief to the majority of IBS patients. However, different studies have generated varying degrees of improvement, with some studies demonstrating an improvement in over 70% of patients3,4,11 and others showing improvements in around 50%.3 The differences may be due to varying symptom criteria used in different studies. The sample size also differs and is sometimes too small to make generalised conclusions and, therefore, these studies lack clinical significance. A recent prospective study of 90 IBS patients confirmed that adherence to the diet significantly decreased the symptoms of IBS in patients. 72% of participants stated that they were satisfied
with the improvement in symptoms, with 62% saying that they had reduced abdominal pain and discomfort. They found that strict adherence to the diet was paramount to ensure success. Adherent participants stated that they saw improvement in an average of 17/20 symptoms compared to just 7/20 in less adherent participants. However, this study found that burping, passage of mucus and the feeling of satiety did not improve after trialling a low FODMAP diet. The study stated that due to proposed mechanism of this diet (as described earlier), this finding was unsurprising.4 The cohort was small and 84% female. Also, the mean age of participants was 47, so overall the study is not generalizable, but is an indication that the diet could possibly provide some symptomatic relief to sufferers.
Table 1: FODMAPs - Examples of food ingredients and commonly consumed foods with that ingredient.9 FODMAP
Example ingredient
Example food
Oligosaccharides
Fructans and galacto-oligosaccharides
Pasta, couscous, bread (all wheat based products), barley and rye based products, onions and garlic
Disaccharides
Lactose
Dairy products: milk, yoghurt, cream, soft cheese
Monosaccharides
Fructose
Fruit, fruit juice, honey, table sugar
Polyols
Sorbitol, mannitol, xylitol, erythritol, lactitol, maltitol, isomalt and hydrogenated starch hydrolysates
Food additives (commonly found in confectionery)
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NHD-extra: CONDITIONS & DISORDERS Another study compared patients on a low FODMAP diet with those who were given standard dietary advice as recommended by NICE. They found that 76% of those on the low FODMAP diet saw an improvement in symptoms compared to 54% of those on the standard diet. 85% felt an improvement in abdominal pain or discomfort compare to 61% who were given NICE advice.11 This consists of limiting fruit intake to three per day, limiting consumption of resistant starch and sugar-free foods (which tend to be high in additives) and controlling insoluble fibre intake.12 IS IT PRACTICAL TO ADVISE IN PRACTICE?
Studies show that patient adherence to the diet is good. Although this is difficult to measure, food diaries and interviewing can be used. One study showed that 75% of participants adhered to the diet for the full period of time. As they saw improvements in symptoms, patients deemed the adherence worthwhile.4 It is vital that patients only remove potential triggers from their diet. They should also receive sufficient information and advice from a registered dietitian about a healthy, balanced diet before initiation. Using breath hydrogen tests to identify lactose or fructose malabsorption can reduce restrictiveness of the diet in the absence of this.5 Fructose malabsorption has been shown to
be present in approximately 40% of IBS sufferers6 with a higher prevalence in those of Northern European ethnicity, whilst lactose intolerance exists in 15-100%6 with a higher prevalence in Hispanic and Black populations.7 It is important to recognise that diet is not the only trigger of symptoms in IBS. Stress and emotions also play a significant role in causing gastrointestinal dysfunction.7 Patients with this disorder tend to have higher levels of depression and anxiety. Therefore, psychotherapy may also play a role in the treatment of IBS. Pharmacological interventions are sometimes required for pain relief in many patients, this may include anti-spasmodics, laxatives (for those with constipation-dominant IBS), tricyclic antidepressants or anti-diarrheal agents (for those with diarrhoea-dominant).8 CONCLUSION
Research suggests that the FODMAP diet is effective in improving symptoms of IBS in some people. Adherence to the diet is generally good and can be measured using food diaries. Hydrogen or methane breath testing could be used to determine if patients are fructose or lactose intolerant to reduce the restrictiveness of the diet for those who are not. Advice and guidance from a dietitian is paramount to ensure that patients are eating a varied, balanced diet.
References 1 Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). Functional bowel disorders. Gastroenterology, 130, pp 148091 2 Heizer W, Southern S and McGovern S (2009). The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review. Journal of the American Dietetic Association, 109(7), pp 1204-1214 3 Böhn L, Störsrud S, Liljebo T, Collin L, Lindfors P, Törnblom H and Simrén M (2015). Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as well as Traditional Dietary Advice: A Randomised Controlled Trial. Gastroenterology, 149(6), pp 1399-1407.e2 4 de Roest R, Dobbs B, Chapman B, Batman B, O’Brien L, Leeper J, Hebblethwaite C and Gearry R (2013). The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. International Journal of Clinical Practice, 67(9), pp 895903 5 Gibson P and Shepherd S (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology, 25(2), pp 252-258 6 Shepherd S, Parker F, Muir J and Gibson P (2008). Dietary Triggers of Abdominal Symptoms in Patients with Irritable Bowel Syndrome: Randomised Placebo-Controlled Evidence. Clinical Gastroenterology and Hepatology, 6(7), pp 765-771 7 Rumessen J and Gudmand-Høyer E (1987). Malabsorption of Fructose-Sorbitol Mixtures Interactions Causing Abdominal Distress. Scandinavian Journal of Gastroenterology, 22(4), pp 431-436 8 Hayes P, Fraher M and Quigley E (2009). Irritable bowel syndrome: Role of food in pathogenesis and management. Gastroenterology and Hepatology, 10(3), pp 164-174 9 Shepherd S and Gibson P (2013). The complete low-FODMAP diet. United States, New York. Experiment 10 Lovell R and Ford A (2012). Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis. Clinical Gastroenterology and Hepatology, 10(7), pp 712-721.e4 11 Staudacher H, Whelan K, Irving P and Lomer M (2011). Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. Journal of Human Nutrition and Dietetics, 24(5), pp 487-495 12 NICE (2008). Irritable bowel syndrome in adults: diagnosis and management, Recommendations (CG61)
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