Tài liệu Nutritional Care of the Housebound Elderly pptx

Nutritional Care of the
Housebound Elderly

Notes from the Conference held at the
University of Sydney, 4 November 2005

May 2006


The Conference was supported by the
Australian Nutrition Trust
and
Sydney University Nutrition Research Foundation
and
Gosford Hospital, Northern Sydney, Central Coast Area Health Service

If you have comments or would like to obtain further copies of this booklet,
contact:Nutrition Department
Gosford Hospital
PO Box 361,
GOSFORD NSW 2250,
E-mail:

Thanks to Rachel Moerman and
Marianne Alexander for help with this project.


Committee on Nutrition for Older Australians
Sydney University Nutrition Research Foundation
Presents:

NUTRITIONAL CARE OF THE
HOUSEBOUND ELDERLY
A One-day Conference
Friday, 4 November 2005
One-day Conference
Veterinary Science Conference Centre
University of Sydney
The Committee on Nutrition for Older Australians (CNOA) is organising a one-day conference on
Nutrition for the Housebound Elderly.
This is the first conference on this topic to be held in Australia.
Speakers include both experts and practical field workers (refer to the list on the next page for
details).
Field workers and representatives of patients’ organisations are invited to attend.
We expect to hear about the food and nutrition needs and problems of this growing section of the
community; what different organisations of field workers are achieving, what challenges they see for
the future and perhaps what research might help.
This conference may help to remind the whole community of the importance of helping our
housebound older people keep well fed and nourished.
Members of the planning committee (CNOA) have been involved in writing and popularising NH and
MRC’s Dietary Guidelines for Older Australians (1999) and researching and preparing the Best
Practice Food and Nutrition Manual for Aged Care Facilities (2004). But Australia seems at present
to lack formal guidelines for nutrition of disabled and frail old people in their own homes.
CNOA is part of the Nutrition Research Foundation of the University of Sydney. The major funding
for the Conference comes from the Australian Nutrition Trust (a small, entirely independent fund
with no commercial or political affiliation or agenda).

2
Nutritional Care of the Housebound Elderly

Program
Registration and Morning Tea 8.30 - 9.30 am
9.30 am

Chairman: Professor Stewart Truswell
Opening Remarks: Margaret Fulton
Undernutrition in housebound elderly: Dr Peter Lipski
Importance of oral hygiene in older people: Dr Peter King
Dietitians work with older people: Sally James
The meaning of food: more than nutrients: Dr Susan Quine
Economic aspects: Dr Michael Fine

12.30 – 1.30 pm

Lunch
Consumer involvement in nutrition and health: Sheila Rimmer
Nutrition: is it on your training calendar? Janette Robinson
Nutrition screening: ACAT: Nicole Vos
Case study: an incident waiting to happen: Trish Devlin
MOW: More than just meals: Debra Tape
A practical approach to food issues: Carolyn Bunney
A consumers experience: Marlene Brell
Summing Up: Rudi Bartl

3
Nutritional Care of the Housebound Elderly


Committee on Nutrition for Older Australians (CNOA)
Nutritional Care of the Housebound Elderly Conference

SPEAKERS
Stewart Truswell, AO, Emeritus Professor of Human Nutrition,
Chairman CNOA
Margaret Fulton, AM, Australia’s best known food writer
Dr Peter Lipski, MD FRACP, Staff Specialist in Geriatric Medicine,
Central Coast AHS
Dr Peter King, BDS, Staff Specialist, Special Care Dentistry, Hunter and New England AHS
Sally James, Dietician, Geriatric Ambulatory Care Service,
Westmead Hospital
Associate Professor Susan Quine, School of Public Health,
University of Sydney
Dr Michael Fine, Senior Lecturer, Department of Sociology,
Macquarie University
Sheila Rimmer, AM, Chair of NSW Home and Community Care State (HACC) Advisory Committee
Janette Robinson, HACC Training Coordinator, Lake Macquarie,
Newcastle, Hunter and Central Coast
Nicole Vos, Aged Care Community Dietician, Sydney South West AHS
Trisha Devlin, Program Coordinator, McKillop Community Care Central Coast
Debra Tape, General Manager, Meals on Wheels
Carolyn Bunney, Community Nutritionist/Home Economist,
Central Coast AHS
Marlene Brell, Consumer Advocate, Member CNOA
Rudi Bartl, Community Dietician, Central Coast AHS,
Honorary Secretary CNOA

4
Nutritional Care of the Housebound Elderly


The conference on NUTRITIONAL CARE FOR THE HOUSEBOUND ELDERLY at the

University of Sydney on 4th November 2005 had a large enthusiastic audience and we
said we intended to send them notes from the speakers after the conference. We know
a number of other people were disappointed to miss our conference, either because they
were at another geriatric conference in Sydney the same day or for other reasons.
So Carolyn Bunney, Rudi Bartl and I have edited the notes that speakers gave us and/or
their slides and/or notes we took, to produce this impression of the main points of what
was said. These are not definitive conference proceedings. Speakers have not been
asked to re-write these notes in a more formal way.
We hope these notes will add to those our audience may have taken for themselves and
give interested people who could not attend some idea of the experiences, advice and
problems our speakers shared with us. The conference was not tape-recorded and we
have missed points that came up in Discussions.
This was the first conference on this difficult subject in Australia and we haven’t seen any
report of a comparable meeting elsewhere.
The subject is difficult because there is no available estimate of numbers of people at
risk or numerical analysis of the problems they have or how severe they are. It is difficult
too because the many thousands of housebound elderly are in private houses and flats,
often alone and widely scattered across the streets and suburbs of Australia and there is
no register of who they are.
We hope the meeting of 4 November 2005 will increase awareness of the community, of
governments, NGOs and professionals so that Nutritional Care of the Housebound
Elderly will receive increasing attention, study, planning and work. Our Committee on
Nutrition for Older Australians will try and help this along. We are sending copies of this
set of notes to all who attended and hope to have it on a Website soon as well.
Stewart Truswell, AO, MD, DSc, FRACP

1
Nutritional Care of the Housebound Elderly

NUTRITIONAL CARE OF HOUSEBOUND ELDERLY
OPENING REMARKS:
Margaret Fulton, AM
Food Writer
It seems remarkable to find myself 'The Cook' invited to be here to be heard. When I
speak of 'The Cook' I am recalling my early days when I decided on what was to be my
career simply because I realised the kitchen was the place to be with family and friends,
chopping, slicing, stirring, being frivolous but at the same time serious about the
preparation of food, soon to be a delicious meal to be shared. My career choice seemed
odd at this time and I was to be referred to as 'The Cook' with a sniff of dismissal by my
contemporaries.
From an early age I accepted that food was an important part of life. It was the perfect
way to start and finish a day, eating something good, with family and friends around a
table.
My first realisation that cooking was so important was in the early 1940's when I was
asked to give cookery lessons for the blind. Classes began, with me a sort of novice, but
I soon learned. My excited students told me of the horrors of being blind at the time;
being hidden, not allowed to touch anything, go anywhere, or do anything. This was after
baking a batch of scones, baking a cake, frying an egg. We bonded over the food we
had prepared together. They were so proud of their new skills. It may have been bedlam
but we did it together. The Royal Society for the Blind had addressed a serious problem,
things had to change, and special cookery classes were on the way. It was a brilliant
approach and had a more far-reaching affect than anyone had imagined.
Children respond enthusiastically to cooking and seeing what enjoyment there is in
making a batch of pikelets, a jacket potato, a proper hamburger. Understanding how to
make salad, soup, wash, peel, grate a carrot or just eat one, raw or cooked. It is great to
be able to look after yourself, and learn what helps you to feel better, stronger. They are
quick to realise what helps you be good at whatever outdoors activities call for - running,
jumping, catching or throwing balls they soon learn good food makes you think better.
Throughout life food plays an important role in our well being, but what happens when

things go wrong?
Today this group (CNOA) is interested in problems of the elderly and in being
housebound.
Organisations, individuals, groups - church, charity, and ethnic are responding in
different ways.

2
Nutritional Care of the Housebound Elderly


Examples:







Kosher meals on wheels, available through the Jewish centre on ageing.
Hungarian catering based on Northside.
TLC catering - tender, loving cuisine offer meals that are National Heart Foundation
approved, gluten-free, homemade dinners for diabetics and others.
Edith Models Pty Ltd offer a wide selection of dishes that could be used to compile an
international cookbook.
Auntie Beryl's Kitchen -. An elder of the Redfern community cooks and takes her
caravan to the Hurstville area.
and of course Meals on Wheels.

These are just a few examples of what is going on. Hungarians like their rather stodgy
but nonetheless delicious and comforting goulash, paprika, sour cream and cabbage

dishes. Jewish people have to have kosher foods, genuine, authentic. I appreciate my
porridge, it's the only way a Scot can start the day- with good organic oats. And so it is
with the rest of the world, we try other foods but we always return to what we call comfort
foods. Different countries, different customs, but based on good food, food that makes us
what we are.
While it is obvious that there are people and groups who are addressing the problems of
those needing care, my concern is the increasing role of machines. No matter how clever
or time and labour saving, they can't replace man. Soups, cottage pies, vegetables etc,
being whirred by those electric, clever magic wands - the trouble is everything becomes
the same. And this is only the beginning. Clever technology and inventions invite the
easy approach without giving the full human touch. Steamers, chillers, freezers,
microwaves - there's every trick in the book. Then there are powders, packets and so
many things. They are useful of course but we shouldn't let them take over, nor should
we allow anything but good foods to be used.
I know what a difference mass production makes, so do the accountants. For years we
have seen the changes, in top institutions and hospitals. Food is no longer always
cooked on the premises, much is farmed out. It makes sense to all but the sick patient or
person who has no say in the matter and often has to eat what no self-respecting
chimpanzee would choose.
I am here to speak up for the home cook, the cook in the home, hospital, and factory
kitchen. What 'The Cook' does cannot be replaced with a machine, or powder no matter
how clever the invention. The cook who chops, stirs, notices, watches and cares is
irreplaceable.
It is my aim that we should all remember the true importance of eating, the necessity of
educating our cooks, accountants, nutritionists, indeed us all in treading the paths in
which we should go, in what is the aim of this conference, the well-being and enjoyment
we can offer to the housebound elderly.

3
Nutritional Care of the Housebound Elderly

UNDERNUTRITION IN HOUSEBOUND ELDERLY:
Dr Peter Lipski
Staff Specialist
Department of Geriatric Medicine
Gosford Hospital
Conjoint Associate Professor Newcastle University
Summary:
Undernutrition is very common in the elderly. The ageing process is not a cause of
malnutrition.
Over two-thirds of acute Geriatric Medical admissions to hospital and over 50% of
housebound, hostel and nursing home residents have some form of significant
undernutrition. At least 30% of independent community living elderly are
undernourished. 80% of undernutrition goes unrecognised.
The causes of undernutrition are multifactorial with common risk factors being
 housebound,
 social isolation,
 dementia,
 stroke,
 Parkinson’s disease,
 gait and balance disorders,
 adverse drug reactions,
 chronic pain, depression,
 swallowing disorders,
 fractured hip, and
 recent hospitalisation.
People with Alzheimer’s disease have a reduced sense of smell and taste and this can
reduce desire to eat.
Many older people eat food of low nutrient density. Most critical nutrients include

Calcium, Iron, Zinc, Vitamin B12, B1, D, Folate.
The complications of undernutrition include 30% increase in mortality within 1 year,
recurrent infections, falls, pressure sores, adverse drug reactions, dehydration, early
hospitalisation and nursing home entry, prolonged and complicated hospital stay and
increased health care costs. Many elderly people lose weight in hospital.
“It is quite a paradox of modern medicine that most doctors pay little attention to the
nutritional status of the elderly when it is such a common problem, leading to potentially
catastrophic outcomes yet is potentially reversible” – Lipski 1997. Nutrition is regarded
as a non-core medical subject and most doctors pay little attention to it. Nutrition needs
to be incorporated into medical student’s training.
4
Nutritional Care of the Housebound Elderly


Early screening of high-risk groups is important for early intervention. Screening tests
include a good history, and screening tool such as the Mini-Nutritional Assessment.
Treatment includes:
 a holistic general medical assessment,
 diagnosis and treatment of underlying conditions, including managing chronic pain
and depression,
 appropriate time to consume meals,
 safe swallowing techniques,
 medication reviews and drug holidays,
 early mobilisation and weight bearing exercises with rehabilitation where appropriate
(Increased physical activity increases appetite)
 nutritional supplements including fortified milk and fruit drinks,
 eating at least 3 meals per day,
 avoiding restrictive diets,
 adequate fluid intake, and
 improved social contact.

Better nutritional care has clearly been shown to improve health outcomes and quality of
life for housebound, institutionalised and hospitalised undernourished elderly, and also
reduces health care costs. For every dollar spent on better nutrition care for the elderly,
$5 is saved in health care costs.

5
Nutritional Care of the Housebound Elderly


ORAL DISEASE, A HIDDEN DISEASE OF THE FRAIL ELDERLY:
Peter Lloyd King BDS MDS FICD
Staff Specialist
Special Care Dentistry
Hunter and New England Area Health Service
There is a trend away from edentulousness (no remaining natural teeth) in the elderly. In
1979, 60% of elderly Australians were edentulous. By 1989 this figure had dropped to
44% and it is projected that by 2019 about 20% of Australians will be edentulous. The
combination of an ageing population that are retaining more natural teeth has created a
phenomenon that has been effectively portrayed as growth in the pool of teeth requiring
treatment.
Predominant oral health problems of the elderly include dental caries, periodontal
disease, dry mouth and oral cancer. The prevalence of periodontal disease appears to
increase with age. This may reflect an accumulation of disease over time rather than
enhanced susceptibility. The number of teeth that need to be extracted due to
periodontal disease increases with age.
Dry mouth is a common complaint of elderly people, however, age does not significantly
effect the salivary flow rate. Medications commonly prescribed to elderly persons are the
strongest influence on reducing salivary flow rates. The progressive impact of smoking
and drinking on the development of soft tissue lesions is more apparent in older adults.
The prevalence of oral cancer increases with age.

The impact of oral health on the well being of elderly persons in Australia has been
investigated in both the institutionalised elderly and functionally independent elderly.
Stockwell's study of 238 geriatric patients at the Mount Olivet Complex revealed that oral
pain was a problem for 12 % of the group. Functional problems including chewing,
swallowing and speaking were identified in 49% of the patients. Loss of chewing
mechanisms can lead to the preference of soft bland food, which may be nutritionally
dilute compared to the vitamins and fibre obtained from harder fruit and vegetables.
Undernutrition in the elderly is a significant problem and has a variety of effects ranging
from the development of pressure sores to an increase in the incidence of fractured
femurs.
In South Australia, 1217 non-institutionalised persons aged 60 years and over completed
a questionnaire containing 49 questions about the effect of oral conditions on discomfort,
dysfunction and disability. Impacts such as difficulty chewing discomfort during eating
and avoidance of foods 'fairly often 'or very often' was reported by over 5% of dentate
persons and 10% of edentulous persons. 5% of persons reported that their oral health
had significant impact on their interpersonal relationships. The correlation between oral
disease and aspiration pneumonia is also well documented. A correlation between oral
disease and diabetes management as well as cardiovascular disease is under
investigation.
Strategies need to be implemented to address the oral health needs of frail and
functionally dependent elderly people. Carer education should focus on how to provide
6
Nutritional Care of the Housebound Elderly


oral hygiene in residents with challenging behaviours. What products are available to
address dry mouth and will prevent dental caries and periodontal disease? How diet
effects oral disease and what sugar substitutes are available to reduce the risk of dental
caries? Dental professionals require education in the oral health needs of the frail and
functionally dependent elderly. Finally, resources need to be allocated to public health

facilities to manage complex needs of elderly patients requiring hospital admissions for
dental care.
Natural teeth for optimum health
In a Nutritional Status Survey at Tufts University which looked at 691 subjects aged 60 to
98, the three factors that were significantly associated with nutritional status were
income, education and denture status.
For denture wearers males had significantly reduced levels of Vitamin A, C, B6, folate,
proteins and calories. Female denture wearers had significantly reduced levels of
calcium and protein. As we would expect, there appears to be good evidence that the
older adult with teeth is more likely to maintain a nutritious diet than an edentulous older
adult.
Ettinger (1998) explored the question: Does improvements in the quality of prosthesis
effect nutrition? He found that while the masticatory function improves with improvement
in the quality of prosthesis, in the absence of dietary counselling significant changes in
the choice of foods does not.
Broken down dentitions
While there is little doubt that a healthy natural dentition is ideal to maintain optimum
nutrition, for a functionally dependent older adult, this ideal may no longer be an option.
Patients with dementia frequently present with dentitions that are broken down and they
require multiple extractions to stabilise their oral disease.
Poor oral health is a known risk factor for undernutrition, chest infections, upper
respiratory tract infections, management of diabetes and possibly heart disease.
If a broken down dentition is contributing to a patient's poor general health, an
appropriate treatment plan to remove painful stimuli from the mouth is essential.
However, if the patient is undernourished and postoperative complications occur that
prevent the patient from eating, there is a risk of "protein energy undernutrition". This
syndrome occurs when an undernourished patient fails to eat well for four to five days
and results in weight loss, peripheral oedema, and ultimately organ failure.
Hence, the dentist managing a patient with a broken down dentition with risk factors of
undernutrition should use the mini nutritional assessment to determine the nutritional

status of the patient before treatment proceeds. If the patient is undernourished or at risk
of undernutrition the dentist should arrange for the patient to be monitored by a dietitian
over the course of treatment to ensure that dietary changes are implemented pre
operatively and that the patient's nutritional status is monitored postoperatively.
7
Nutritional Care of the Housebound Elderly


Maintaining oral health in patients with dementia
The key areas to be addressed are:
Use of fluoride
Clients should be using a high fluoride regime. Use a high fluoride toothpaste.
Minimise sugary between meals snacks and drinks
Consider the use of sugar substitutes and reducing between meal snacks. Nutritional
requirements may over ride this objective. If the client needs to snack throughout the
day, more frequent use of fluoride is required. Atomising a fluoride mouthrinse can
effectively deliver a small dose of fluoride regularly throughout the day.
Manage Xerostomia (dry mouth)
Reduce caffeine intake and consider the use of saliva substitutes for dry mouth
Train Staff
Direct care staff requires training in oral health care practices.
Access dental services
Consider the use of the enhanced primary care program to access private services.
Make use of DVA privileges; understand the limitations and abilities of public health
dentistry.
Bibliography
Australian Bureau of Statistics 1999 Year book
NHMRC 1994 A Report of the Health Care Committee. Oral health care for older adults.
NHS National Health Strategy 1992 Improving Dental Health in Australia, Background paper No. 9, NHS,
Melbourne

Gift HC. Issues of ageing and oral health promotion. Gerodontics 1988, 4: 194-206.
Katz RV, Stanley PH, Neal WC, Muma RD. Prevalence and intraoral distribution of root caries in an adult
population. Caries Res 1982, 16:265-271.
Pajukowski H. Salivary flow and composition in elderly patients referred to an acute care geriatric ward.
Oral Surg Oral Med Oral Path Oral Radiol and Endo 1997, Sept: 84(3) 256-7.
Stockwell Al. Survey of the oral health needs of institutionalized elderly patients in
Western Australia. Community Dent Oral Epidemiol 1987, 15:273-6.
Mc Cormack P. Undernutrition in the elderly population living at home in the community: a Review of the
literature. Journal of Advanced Nursing, 1997,26:856-863
Slade G Spencer AI, Social impact of oral conditions among older adults. Australian Dental Journal 1994,
39(6):358-64.
DSRU 1993 Dental Statistics and Research Unit, Australian Institute of Health and Welfare, A research
data base on dental care in Australia, Adelaide
FDI Technical Report No.43 1986 Commission on Dental Education and Practice
Working group 10. Delivery of oral health care to the elderly patient. London: Federation Dentaire
International.
King PL A dental health education program for carers of elderly people. MDS thesis in press, University of
Sydney, 1992
Maguire M. Implementing a staff development program. Geriaction 1991, 10(2):8-10.

8
Nutritional Care of the Housebound Elderly


GOOD NUTRITION FOR THE HOUSEBOUND ELDERLY:
Sally James APD
Dietitian, Geriatric Ambulatory Care Service,
Westmead Hospital
Summary:
Weight loss and lack of appetite are common among older people who are housebound.

This frequently causes anxiety for family and carers. It should not be regarded as an
inevitable part of ageing.
Why does this happen?
 Physiological changes eg; taste, constipation diarrhoea, decreased thirst sensation,
swallowing difficulties
 Early cognitive impairment. This affects planning, making shopping and cooking
difficult. Later cognitive changes impact on remembering how, when and what to eat
 Depression is common, often unrecognised, and is treatable.
 Dental problems. People need to be encouraged to seek dental care earlier rather
than later
What can be done?
 Treat the treatable
 Medical review by general practitioner or geriatrician. Diagnosis and treatment of
depression, medication review, diagnosis and treatment of early Alzheimer’s disease
as appropriate can improve appetite.
 Dental review and regular oral care
 A speech pathologist can recommend appropriate consistency of meals for those with
swallowing disorders
 Exercise – a physiotherapist can prescribe exercises which can be done at home. Tai
chi or seniors’ exercise group for those who can access these.
 Regular exposure to sunlight for 10-20 minutes daily – without sunscreen and not
through glass. Avoid the middle of the day in summer. This is essential to maintain
vitamin D levels and can enhance mood.
 Bowel care – fluid, fibre, exercise, regular habit. Those on painkillers may need
laxatives.
Assistance with meals
 Shopping
 Meal provision – Meals on Wheels, Tender Loving Cuisine, frozen supermarket
meals, in home preparation
 Take-aways

 Day Centres, clubs
 Ensure good food hygiene

9
Nutritional Care of the Housebound Elderly


Ways to encourage eating
 Offer a variety of attractive, tasty, good-smelling meals and snacks. Use garnishes
and sauces to enhance appearance.
 Ensure meals are of appropriate consistency and that meat and vegetables can be
easily chewed.
 Meals should be culturally appropriate.
 Small meals with snacks between meals usually result in better overall intake.
 Guided choice – offer a choice of two or three foods rather than asking, “what would
you like?”
 Relaxed environment – turn off the TV!
 Use plain plates & tablecloth for those who are confused.
 Finger food for those having difficulty manipulating cutlery. Eg. mini quiche,
sandwiches, cut-up fruit, ice cream in cone, mug of nourishing soup.
Make every mouthful count
No restrictive diets.
Add extra energy (calories/kilojoules) – Oil, margarine, butter, powdered milk, cheese,
avocado, and peanut butter.
Offer small amounts of food and drinks often.
Tea, coffee, salads are filling but low in energy.
Vitamin-mineral supplements
Make up for lack of balanced diet.
Do not provide energy (kilojoules) or help weight gain.
May improve appetite.

Nourishing snacks
Yoghurt, custard, Fruche®, rice desserts.
Muffins, scones, pikelets, raisin bread.
Muesli bars, breakfast bars, breakfast cereal – at any time!
Dried fruit, nuts, fruit snacks.
Flavoured milk, Milo®, ice cream, smoothies
Baked beans, spaghetti, tuna, sardines
Sandwiches, biscuits and cheese, dips
Nutritional supplements
Used to help gain weight or as meal replacement.
Most contain vitamins and minerals – e.g.Sustagen®, Ensure®, Fortisip®, Resource®.
Others are additives eg: Promod®, Polyjoule®, Polycose®, and Calogen®.
Can use Milo®, malted milk, powdered milk, cream etc instead or in addition.

10
Nutritional Care of the Housebound Elderly


A dietitian can
Assess nutritional status
Estimate nutritional needs
Recommend foods which are practical and enjoyable
Advise on supplements
There are few dietitians working in the community
Carers are often in a better position to make well-informed changes
Refer early for best results!
Conclusion
Weight loss is not an inevitable part of ageing
Management is challenging for all those involved in the care of the individual
Requires time and resources

Early intervention will be most effective – it is difficult to regain a significant amount of
lost weight

11
Nutritional Care of the Housebound Elderly


THE MEANING OF FOOD; MORE THAN NUTRIENTS:
Associate Professor Susan Quine
School Of Public Health
Faculty of Medicine, University of Sydney
My presentation is not specific to the housebound elderly, although it includes them, as
this has not been the main focus of the research projects in which I have been involved.
It presents findings, both quantitative and qualitative, from studies of older Australians
(65+). These studies are based on older people living in the community (including the
'homeless), and does not include those older people living in institutional care. The
studies, publications from which are listed below, are those in which I was a researcher
and therefore about which I have first hand knowledge.
The purpose of this presentation is to show that while it is important to identify the
quantity and nutritional quality of food eaten by older people, other aspects of nutrition
should also be taken into consideration if we are to understand consumption patterns,
and improve the nutritional status of older people. Disability may reduce an individual's
ability to shop for groceries and to prepare food, but older people who have no major
disability may still not eat well. Reasons for this are numerous. Inadequate income is a
major cause of food insecurity and poor nutrition. Findings from the NSW state wide
quantitative study (n=8,881) identified the characteristics of those older Australians who
could not afford to purchase food. They were four times as likely to be renters as home
owners, five times less likely to have private health insurance, and 85 times more likely
to report that they ‘could not make ends meet’.
Quantity rather than quality of food was emphasised in the qualitative studies. Healthy

food was recognised as important by some low socioeconomic participants: “I love fish,
but I can’t afford it. I have tinned fish, sardines, but it’s not the same as fresh fish” , while
other participants were not concerned with quality as long as they had enough to eat:
“Healthy food is not important to me…as long as you get enough tucker into you, that’s
all you worry about.”
The quantitative study also identified that older Australians who were food insecure were
twice as likely to be living alone. Findings from the qualitative studies emphasised the
importance of motivation to shop for ingredients and to prepare a meal. Older people
living alone are less likely to cook for themselves, and this is particularly true of older
men - many of whom have not learnt the skill of cooking. “Because I live alone I don’t
care what I eat. If you’re cooking for others it’s different”. Eating is a social activity, a way
of interacting with other human beings .Findings from the study of soup kitchen clients
emphasised the social component of eating. While many came out of necessity to obtain
food which they otherwise could not afford, the social component of visiting the soup
kitchen was strongly emphasised. “I come here for lunch every day. Good meals, Get out
of my room for a couple of hours. I’ve got lots of mates here. We have a good yarn.”

12
Nutritional Care of the Housebound Elderly


Findings from both the quantitative and qualitative studies identified the impact of poor
oral health on nutrition. Oral health problems may reduce the range of foods eaten and
the enjoyment of food, so while poorly fitting dentures and sore gums may not be
classified as a 'disability', such problems can severely impact on the quality of food
eaten, reducing the intake of healthy foods such as raw fruit and vegetables.
Publications:
Quine S., Morrell S. Food insecurity in community dwelling older
Australians. Journal of Public Health Nutrition 2006; 9(2): 219-224.
Wicks R., Trevena L., Quine S. Experiences of food insecurity amongst

urban soup kitchen consumers: insights for improving nutrition and
well-being. Journal of the American Dietetic Association. (Accepted
2005, to be published late 2006/early 2007).
Quine S., Kendig H., Russell C., Touchard D.
Health promotion for socially disadvantaged groups: the case of homeless older men in Australia.
Health Promotion International, 2004, 19(2): 157-165.
Russell C., Touchard D., Kendig H., Quine S.
Foodways of disadvantaged men growing old in the inner city:
policy issues from ethnographic research
Chapter 12, International Library of Ethics, Law and the New Medicine. Kluwer, Netherlands, 2001,
ppI91-215,

13
Nutritional Care of the Housebound Elderly


ECONOMIC AND SOCIAL ASPECTS:
Dr Michael Fine,
Department of Sociology,
Macquarie University
Care doesn’t feature in economics
Care is an essential aspect of social life.
Without care none of us would exist
Food is a real embodiment of care.
Food Services
Delivered meals organisations
Meals on wheels. Other meals services (frozen meals)
Other home based meals
Help provided through Community Aged Care Packages (CACPs)
Other social food services

Care based meals (eg senior citizens centres)
Food clubs/groups (eg Balmain gourmets)
History of Meals on Wheels
MOW was established in Britain I World War II for old people who needed help. In
Australia the first service was set up in Melbourne in 1952. It was soon taken over by
the Red Cross. MOW started in Sydney in 1957, provided by the Sydney City Council
and prepared in their own kitchens. In 1968 the Federal Meals on Wheels Act was
passed and in 1985 the Home & Community Care Program (HACC) was set up.
Average
Organisation clients
s
per day
NSW
202
22,000
Australia 751
53,150
Meals on Wheels, Australia 2004

Meals
per
year
4.5 m
14.7m

Volunteers
30,000
73,750

Cost

Per
meal
$5.50
$3.60- $6.50

Key Elements of MOW
Delivery is staffed by volunteers or ‘expenses paid’ volunteers. They are both female
and male, runners and drivers. Organisations (2002 in NSW) are generally small, local
community-based organisations, linked to local government.
There used to be a hidden subsidy. The food was prepared in hospital kitchens. Now
typically organisations have their own kitchens and paid kitchen staff. The organisations
provide care and social capital as well as meals. The members are caring for strangers.
MOW is based on the Welfare model. For volunteers it may be ‘clubby’. For clients
there may be some feeling of shame in accepting charity. How can MOW adapt to
multicultural meals?

14
Nutritional Care of the Housebound Elderly


It is easy to forget the newness of community care
 Home nursing started in Australia in 1954
 Nursing homes started in 1962
 The Meals on Wheels Act in 1968
 1970 came Home Care
 1985 saw HACC and Aged Care Assessment Program and ‘Balance of Care’
 (Aged Care reform strategy) and residential care benchmarks
 1989 Case management: community options programs
 1991 CACPs (Community aged care packages)
 1996 Howard government – Aged Care

 1997 The Aged Care Act – user pays approach
 2004 ‘The Way Forward’
There has been over 50 years of Aged Care, 20 years of HACC.
Carers are identified as a target group. There is now a ‘hybrid’
approach of ‘shared care’.
There have been 15 years of Case Management: ‘integrated’ and individualised’
care.
Home and Community Care (HACC) has these characters. It is a small-scale, service
model with localised service, community governance. It has possibilities of innovation,
eg home visiting, shopping, transport. The problems for HACC seem to be task
specialisation, lack of standardisation and regional variations.
Expenditures on Community Care
FUNDING
INCREASE
2002-2003
1996-2004
HACC
$1,200 m
70%
CACPs
$307 m
83%
Dementia
$138 m
128%
programs
NRCP (respite)
$99 m
ACAP
$47 m

EACH
$32 m
Carelink
$14 m
All community
$2,600 m
128%
care
The Way Forward (2004) discusses
Assessing need and eligibility; access to services
A common approach determining ‘consumer’ fees; accountability and quality assurance
Information management and data collection; planning.
The Hogan report (2004) recommends that aged care is no more a cottage industry. A
‘mature market’ has developed. Corporates now provide 80% of child care. Will they
move into aged care? HACC federal/state partnership doesn’t work well. Work for profit
is permitted but it’s marginal. Will HACC become attractive to corporations?

15
Nutritional Care of the Housebound Elderly


Dilemmas now and into the future for aged care
Threat of loss of democratic local control.
Will there be increased importance of residential care providers?
Networks and partnerships are underdeveloped.
Existing models are largely historical, built in response to policy.
In my opinion Community Care remains the future.
Both HACC and CACPs have been shown to be effective, popular and efficient.
This has been the early, foundation period.
The coming period of one of challenge and uncertainty.

16
Nutritional Care of the Housebound Elderly


CONSUMER INVOLVEMENT IN NUTRITION AND HEALTH:
Sheila Rimmer – Consumer
AM, Chair of NSW Home and Community Care (HACC)
State Advisory Committee
I am a very passionate advocate for good nutrition. After retiring, I became involved in
ageing issues. In time, I became president of Council on the Ageing (COTA) (NSW) and
then national president.
As a COTA representative, I was involved with the development of the Australian
Nutrition Screening Initiative (ANSI)
My personal interest in nutrition is also related to the death of my husband from cancer
of the pancreas. Since then I have read a great deal about cancer. Learning that certain
foods eg; green vegetables could provide some protection to cancer. Vegetables, fruit
and nuts have become an important part of my diet.
In 1999, International Year of Older People, the National Health & Medical Research
Council (NH&MRC) developed the Dietary Guidelines for Older Australians. Consumer
involvement led to a booklet and pamphlet, “plain English” shorter version of these
guidelines, ”Eat Well for Life”
One group I have been involved with is the National Prescribing Services (NPS) in
partnership with COTA National Seniors and the Consumers Health Forum (CHF). They
are spreading a message about Community Quality Use of Medicine, using a strategy of
older people peer education. Older people are trained to deliver the message to other
older people about the safe use of medicines. Could this older people peer education be
used on a food and nutrition front?

17

Nutritional Care of the Housebound Elderly


NUTRITION SCREENING IN THE COMMUNITY:
Nicole Vos
Aged Care Community Dietitian
Sydney South West Area Health Service,
Eastern Zone
Studies conducted between 1997 and 2002 by the Community Health Nutrition Service
in Sydney South West Area Health Service (SSWAHS), Eastern Zone have identified 2030% of elderly clients (>65 years) living in the community are malnourished (1). In
addition, Aged Care Assessment Teams (ACAT), Community Nursing and Home Care
also identified malnutrition as the major nutrition problem in their clientele. Contributing to
this problem was the lack of aged care community nutritionists in the area (2, 3, 4, 5).
The growing level of malnutrition amongst the elderly population living in the community
and lack of Community Nutrition services has led to the development of the HACC
Community Nutrition Project within SSWAHS, Eastern Zone, funded by Home and
Community Care (HACC). The project has focused predominantly on a preventative
model of care. Prevention is about targeting the problem BEFORE it becomes an issue,
as malnutrition is much harder to treat than to prevent.
To establish a preventative model requires educating HACC service providers of nutrition
issues amongst the elderly and introducing the use of a Nutrition Risk Screening Tool.
Nutrition Screening identifies individuals at high risk of food and nutrition issues as well
as individuals who already have a poor nutritional status. Once a client is identified as at
risk, an appropriate nutrition intervention can be established.
The screening tool used by the SSWAHS, HACC Community Nutrition Project, was
developed in Victoria specifically for use on HACC clients. It involves ten checklist
questions relating to factors that affect nutritional status. They are Obvious underweightfrailty, Unintentional weight loss, Reduced appetite or reduced food and fluid intake,
Mouth or teeth or swallowing problems, Follows a special diet, Unable to shop for food,
Unable to prepare food, Unable to feed self, Obvious overweight affecting life quality and
Unintentional weight gain (6). Answering yes to one or more questions on the Nutrition

Risk Screening Tool indicates a risk of malnutrition exists.
The SSWAHS, HACC Community Nutrition Project has provided nutrition training and
incorporated the Nutrition Risk Screening tool into the ACAT and Community Nursing
General Assessment process. Guidelines on how to use the Nutrition Risk Screening
tool have been developed and provide ACAT workers and community nurses with simple
nutrition interventions for at risk clients. ACAT workers and community nurses also have
access to a dietitian for complex clients.
In conclusion, the use of a Nutrition Risk Screening tool on the elderly population living in
the community along with the establishment of simple nutrition interventions for at risk
clients can begin to eliminate complications experienced with this population. These
include falls and fractures, need for more assistance, support and care, complications
such as infections, pressure sores, skin ulcers, risk of not being able to live
independently and frequent hospital admissions, all which are due to poor nutrition (7).
18
Nutritional Care of the Housebound Elderly


References
1. Barnes R. Needs Assessment of Home Care Service staff and their frail elderly clients living in the
Central Sydney Area.
CSAHS; 1997.

Human Nutrition Unit, University of Sydney and Community Health Services,

2. McCormick M. Needs Assessment of Community Nurses in Central Sydney Community Nursing Service
in providing nutritional support to their older clients living in the Central Sydney Area Health Service.
Masters of Public Health thesis. University of NSW and Community Health Services, CSAHS; 2000.
3. Abbott S. An assessment of the community nutrition support services available for frail older people
within CSAHS. Masters thesis. Human Nutrition Unit, Sydney University and Community Health Services,
CSAHS; 2000.

4. Pfeiffer H. A needs assessment for a clinical nutrition outreach counselling service in Central Sydney.
Masters thesis. Human Nutrition Unit, Sydney University and Community Health Services, CSAHS; 1998.
5. Weber D. A summary of Nutrition Services targeting the frail aged, disabled and their cares. General
Geriatrics and Rehabilitation Medicine, CSAHS; 2002.
6. Wood B, Bacon J, Stewart A, Race S (eds). Nutrition Risk Screening and Monitoring Tool For HomeBased Adults, www.health.vic.gov.au/agedcare/hacc/nutrition/index.htm , 2001.
7. Wood B, Bacon J, Stewart A, Race S (eds). Identifying and assisting home based adults who are
nutritionally at risk. A Resource Manual. Melbourne: Department of Human Services. Aged Community
and Mental Health; 2001.

19
Nutritional Care of the Housebound Elderly


AN INCIDENT WAITING TO HAPPEN CASE STUDY – CACP RECIPIENT:
Trish Devlin
Program Co-Ordinator
Mackillop Community Care
Central Coast NSW
Many of our clients have dementia. This is an account of the service provided to one
such client and while we don’t have all the answers, the following may help other carers
deal with similar challenges.
Moyna is 85, unsteady on her feet, very impaired hearing, with moderate dementia. She
reads the daily paper in an attempt to know the day and date. Moyna sometimes walked
to the butchers, brought meat home but could no longer remember what to do with it. To
reduce Moyna’s wandering a large STOP sign was put on the inside of the front door,
and it worked! (Initially)
Living alone, Moyna has a supportive neighbour and a caring niece who lives a couple of
hours away.
At first, Moyna was resistant to help so two visits a week were organised. As trust grew,
this became one visit per day, six days a week. Eventually it was two visits each

weekday and one weekend visit.
At the commencement of service, Moyna weighed only 5 ½ stone (35kg). She would say
she wasn’t hungry or had just eaten even though the only evidence of food consumption
was several open jars of sweet and sour sauce and some milk. Moyna said she didn’t
like pies but, put a hot pie in front of her then pull your hands away quickly.
Staff prepared easy nutritious meals (salad or sandwich) that always included a dessert.
These were left in the fridge and were always gone the next day. It should be noted that
food had to be carefully chosen as crunchy food such as celery and apple were difficult
for Moyna to chew and swallow. Even soft bread seemed to get “stuck”. By following
this eating pattern of at least one meal a day, Moyna gained 1 ½ stone (9.5kg) within the
first eight months of service and her cognition improved. It was decided to purchase
frozen meals, which could be heated by Moyna or staff.
As Moyna was unable to “handle” her finances, the niece, who had Power of Attorney,
established a workable system and as long as Moyna had $20.00 in her purse she was
happy.
Other challenging behaviours included:
1. Door locks – Three locks on the front door and two on the back. With Moyna being
hearing impaired and despite a neighbour with keys, it was decided to install a key
safe
20
Nutritional Care of the Housebound Elderly