Nutritional Care of the
Housebound Elderly
Notes from the Conference held at the
University of Sydney, 4 November 2005
May 2006The 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:-

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.


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

Nutritional Care of the Housebound Elderly

4 Committee on Nutrition for Older Australians (CNOA)

Nutritional Care of the Housebound Elderly Conference

SPEAKERS

Stewart Truswell, AO, Emeritus Professor of Human Nutrition,

Central Coast AHS

Marlene Brell, Consumer Advocate, Member CNOA

Rudi Bartl, Community Dietician, Central Coast AHS,
Honorary Secretary CNOA
Nutritional Care of the Housebound Elderly

1

The conference on NUTRITIONAL CARE FOR THE HOUSEBOUND ELDERLY at the
University of Sydney on 4
th
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.
Nutritional Care of the Housebound Elderly

2

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;


3

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

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

 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.
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


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.



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.

Nutritional Care of the Housebound Elderly

9

GOOD NUTRITION FOR THE HOUSEBOUND ELDERLY:

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 Nutritional Care of the Housebound Elderly

10 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.

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.

Nutritional Care of the Housebound Elderly

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.” Nutritional Care of the Housebound Elderly

13

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

Nutritional Care of the Housebound Elderly

14

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.

year

Volunteers
Cost
Per
meal
NSW
202
22,000
4.5 m
30,000
$5.50
Australia
751
53,150
14.7m
73,750
$3.60- $6.50
Meals on Wheels, Australia 2004

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


Expenditures on Community Care

FUNDING
2002-2003
INCREASE
1996-2004
HACC
$1,200 m
70%
CACPs
$307 m
83%
Dementia
programs
$138 m
128%
NRCP (respite)
$99 m

ACAP
$47 m

EACH
$32 m

Carelink
$14 m

All community

This has been the early, foundation period.
The coming period of one of challenge and uncertainty.


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?

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 underweight-
frailty, 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).

Nutritional Care of the Housebound Elderly


Nutritional Care of the Housebound Elderly

20

AN INCIDENT WAITING TO HAPPEN CASE STUDY – CACP RECIPIENT:

Trish Devlin
Program Co-Ordinator

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