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AGENCE DE LA SANTÉ ET DES SERVICES SOCIAUX DE LA CÔTE-NORD REFERENCE GUIDE IMPROVING THE DIET OF SENIORS LIVING IN RESIDENTIAL AND LONG TERM CARE CENTRES November 25, 2013 Document produced by the Direction des affaires médicales et de la coordination des programmesservices (DAMCPS) in charge of medical affairs and program coordination in collaboration with the Direction de santé publique (DSP) responsible for public health issues. Coordination Caroline Jean, Nutritionist Ginette Fournier, Planning, Programming and Research Officer – DAMCPS Ellen Ward, Nutritionist and Planning, Programming and Research Officer – DSP Produced in collaboration with members of the Comité de travail pour l’amélioration de l’alimentation en CHSLD who work to improve the nutritional quality of food offered in residential and long-term care centres Thank you to the following people for their comments: Véronique Hamel, Nutritionist - CSSS de la Haute-Côte-Nord-Manicouagan Pierrette Leclerc, Nutritionist - CSSS de Sept-Îles Nancy Shuglo, Nutritionist - CSSS de Sept-Îles Diane Sonier, Nutritionist - CSSS de Sept-Îles Technical production Louise D’Astous, Administrative officer Guylaine Tremblay, Administrative technician Translated by: Karen P. Williamson Note Please note that the French acronym for residential and long-term care centres, CHSLD, will be used in this document on account of its widespread use. You can consult this guide on the website of the Agence: http://www.agencesante09.gouv.qc.ca Legal deposit Bibliothèque et Archives nationales du Québec, 2013 Bibliothèque de l’Assemblée nationale, 2013 ISBN: 978-2-89003-238-5 (French printed version) ISBN: 978-2-89003-239-2 (English printed version) ISBN: 978-2-89003-268-2 (French electronic PDF version) ISBN: 978-2-89003-269-9 (English electronic PDF version) © Agence de la santé et des services sociaux de la Côte-Nord, 2013 TABLE OF CONTENTS Page INTRODUCTION PART 1: UNDERNUTRITION The basics of healthy eating ....................................................................................................................... Canada’s Food Guide (CFG) ................................................................................................................. Specific needs ...................................................................................................................................... Undernutrition ............................................................................................................................................ Causes of undernutrition ..................................................................................................................... Consequences of undernutrition ......................................................................................................... Treatment for undernutrition ............................................................................................................. 3 3 3 4 4 5 5 PART 2: DEHYDRATION The basics of hydration ............................................................................................................................ The body’s water needs .................................................................................................................... Causes of dehydration ....................................................................................................................... Symptoms .......................................................................................................................................... Consequences of dehydration ........................................................................................................... Recommendations ............................................................................................................................. 11 12 12 13 13 13 PART 3: FEEDING PROCESS Recommendations .................................................................................................................................... In the kitchen ..................................................................................................................................... Before meals and snacks ................................................................................................................... During meals and snacks ................................................................................................................... After meals......................................................................................................................................... Instructions for residents requiring assistance ................................................................................. A few suggestions to improve the atmosphere ................................................................................ Questionnaire used to evaluate the feeding process ........................................................................ 15 15 15 16 16 16 17 18 ENRICHED RECIPES List of recipes ............................................................................................................................................. 19 APPENDICES Appendix 1: Appendix 2: Appendix 3: Appendix 4: Canada’s Food Guide .......................................................................................................... Mini Nutritional Assessment MNA ® (questionnaire) ......................................................... Charter for body mass index ............................................................................................... Algorithm - Nutritional Intervention: Using the MNA®, the MedPass Program and Resource® 2.0 - Results of the Mini Nutritional Assessment (MNA®) abstract ........................................................................... BIBLIOGRAPHY 35 41 42 43 ACRONYMS AND ABBREVATIONS BMI Body mass index CFG Canada’s Food Guide CHSLD* Centre d’hébergement et de soins de longue durée *The French acronym for residential and long-term care centres °C Degree Celsius °F Degree Fahrenheit g Gram in Inch kg Kilogram mg Milligram m2 Square metres ml Milliliter MNA® Mini Nutritional Assessment oz Ounce QID Four times a day tbsp Tablespoon tsp Teaspoon TID Three times a day INTRODUCTION It is difficult to apply a standard set of rules to the diet of seniors. They are part of a heterogeneous group meaning the importance lies with adapting recommendations based on their specific needs, tastes and eating habits while advocating a global approach. A number of factors may lead to the deterioration of the nutritional status and quality of life of seniors, they may be physiopathological (anemia), environmental (isolation) or psycho-socio-economic. Given the prevalence of undernutrition and dehydration in seniors, a regional project part of the program to improve the diet of seniors in residential and long-term centres (CHSLDs) was initiated. This project will serve to establish procedures to prevent undernutrition and promote hydration in residents. To support and carry out these actions, special training courses were offered along with a reference guide and practical tools. The reference guide is divided into three phases. The first phase addresses the issues surrounding undernutrition and explains the basics of healthy eating as well as the specific needs of seniors. Then the definition of undernutrition, its causes and its consequences on the health and well-being of seniors are explored. A screening questionnaire is then presented and explained along with a treatment plan and follow-up process. The second phase deals with the importance of hydration, the causes and consequences of dehydration and ends with recommendations to prevent dehydration. Finally, the last phase addresses the feeding process and covers the socio-cultural aspects of eating. Practical advice and a questionnaire to evaluate the feeding process are also presented. This reference guide is intended for health and social workers, physicians, nurses, nutritionists, orderlies, kitchen staff and others. It was developed to support them in their actions to promote healthy eating habits in residents. 1 2 PART 1: UNDERNUTRITION Undernutrition has been observed in many hospital settings over the last few years. The prevalence of protein-energy undernutrition is particularly high in this environment, ranging from 25% to 65%1. A study conducted by Chevalier et al. established the prevalence of undernutrition in seniors at 80% at the time of their admission into a CHSLD2. Added to the normal physiological changes associated with ageing or illness, undernutrition increases the fragility of individuals, decreases autonomy and increases the risks of morbidity and mortality. What is more, undernutrition is known to reduce immunocompetence and has often been associated with decreased resistance to infections, delayed wound healing and a higher incidence of pressure sores. THE BASICS OF HEALTHY EATING CANADA’S FOOD GUIDE (CFG) With age, the human body goes through changes that influence its nutritional needs. To maintain good overall health, seniors should eat a variety of foods contained in the CFG (Appendix 1). This document takes the science of nutrition and makes it into a model of healthy eating. In it we find the quantities of food that people need and the types of food that are part of healthy eating practices for every age group. It contains food from the 4 major food groups: vegetables and fruit, grain products, milk and alternatives, and meat and alternatives. For persons aged 51 years or more, the CFG recommends a daily allowance of: Vegetables and Fruit: Grain products: Milk and alternatives: Meat and alternatives: 7 servings 6 to 7 servings 3 servings 2 to 3 servings Each food group offers a wide variety of choices in order to take into account personal preferences. Eating different foods from each group makes it easier for everyone to get the nutrients they need. CHSLDs must be able to offer diverse foods in order to meet the tastes and needs of every resident. SPECIFIC NEEDS All persons of 50 years of age or more should follow the CFG but also take a 10 µg (400 UI) supplement of vitamin D3. The diet of seniors is affected by the natural ageing of the digestive system. These age-related changes affect the sense of smell and taste as well as all the organs of the digestive tract. The changes in taste 1. 2. ORDRE PROFESSIONNEL DES DIÉTÉTISTES DU QUÉBEC. Approche nutritionnelle de la personne âgée - Manuel de nutrition clinique en ligne. CHEVALIER, Stéphanie, Isabelle DESJARDINS and Dominique MAINVILLE. « Dépistage de la dénutrition et impact d’une intervention nutritionnelle chez les personnes âgées en soins de longue durée », Revue Nutrition - Science en évolution, volume 6, numéro 1, Spring 2008, p. 17-20. 3. HEALTH CANADA, Eating Well with Canada’s Food Guide – A Resource for Educators and Communicators, Ottawa, 2007. 3 and smell, attributable to many factors, influence the interest and motivation of seniors in eating and hydrating themselves. Major changes involve a decrease in: Taste and olfactory (smell) sensitivity Salivary secretions Perception of flavours such as salty, acid and bitter Chewing force As regards chewing force, studies on the effects of dentition on the diet of seniors indicate that edentulous persons (without teeth) can reduce their consumption of fruit, vegetables, fibre, protein and calcium, among others. Another study conducted in the province of Quebec in the 1990s observed that seniors aged 60 years or more with mastication problems reduced their consumption of fruit and vegetables which increased the prevalence of gastro-intestinal4 problems. UNDERNUTRITION Undernutrition is a pathological condition that arises from insufficient nutritional or energy intake in order to satisfy the needs of the human body. This condition may have multiple origins. We have distinguished two physiopathological mechanisms: nutrient deficiency (lack of appetite) and hypermetabolism (increased needs due to illness). Other nutritional deficiencies are often reported in seniors and relate to: calcium, zinc, magnesium, vitamins D, B1, C, B6, folic acid and fibre: hence the importance of eating a wide variety of foods in the proper quantities5. Since undernutrition is avoidable and potentially reversible, it should remain a core issue for persons providing personal care. Nursing staff is in a perfect position to observe, screen and prevent diet-related problems as well as question residents on these matters and take appropriate action. CAUSES OF UNDERNUTRITION There are many reasons that can lead a person to be undernourished; they can be physical, social, economic or psychological. Here are some of the factors: chronic illnesses (Parkinson’s, arthritis, renal failure, obstructive pulmonary disease) on account of their physical limitations; these residents run a higher risk of undernutrition; gastro-intestinal diseases: stomach aches, gastro-oesophagian reflux, diarrhea, constipation, cancer, inflammatory bowel disease, celiac disease, etc.; medications: some medications may cause nutritional deficiencies due to malabsorption (anti-acids, anti-inflammatories, anti-convulsants, laxatives, diuretics, psychotropics, etc.); dysphagia: decreased nutrients due to difficulty swallowing food based on texture and consistency; ill-fitting dental prostheses: pain or injury to the gums can lead to decreased food intake and cause inadequate mastication; 4. 5. 4 ALLINGTON, Chris, Paul ALLISON and Judiann STERN. Access to Dental Care for Under-privileged People in Quebec, Montréal, McGill University, Faculty of Dentistry, May 2004. Ibid., note 1. psychological problems: depression and cognitive disorders often lead to loss of appetite and lead residents to require stimulation to eat; increased needs necessary to the healing process (ex.: pneumonia, hip fracture, etc.); isolation and solitude: even if they live with other people, seniors living in CHSLDs can suffer from solitude and miss their family and friends; this often leads to loss of appetite; as for persons living at home, they may deal with other issues, such as: insufficient income and problems with the planning, purchase and preparation of meals. CONSEQUENCES OF UNDERNUTRITION Here are some of the consequences of undernutrition in seniors: fatigue, asthenia, pallor, lack of endurance, apathy, occasional irritability; reduced mobility, tendency to stay in bed or in a chair; decreased muscle mass and strength, which leads to functional deficiencies and reduces their autonomy when performing the activities of daily living; peripheral edema with or without evidence of heart failure; bone fragility that could lead to fractures: high risk of falling; dependent on others to perform the activities of daily living (requires assistance from nursing staff to get around, for care, etc.); weakened immune response; delay in the healing of certain illnesses or wounds, susceptibility to infections; anemia, hypoalbuminemia, lymphopenia; neurological disorders and confusion. All these health problems increase the risk of morbidity and greatly reduce the quality of life and overall health of seniors. Being proactive about these issues by addressing undernutrition through preventive action can strengthen the autonomy of seniors. TREATMENT FOR UNDERNUTRITION As the effectiveness of nutritional interventions is higher in the early stages of undernutrition, a screening process should be implemented in order to identify the persons at risk and reduce the consequences on their health. A 3-stage process is suggested to accomplish this goal: evaluation, taking action and monitoring. First stage: Evaluation The first stage consists in implementing a systematic undernutrition screening procedure for residents. The Mini Nutritional Assessment MNA® can be quite useful because it is validated and it is easy and quick to use (Appendix 2). Nursing assistants or any other appointed persons can fill out the questionnaire by collecting information from the residents or their family or directly from their file. Used within the month following their arrival and every three months for monitoring purposes, this tool helps evaluate undernutrition risks by using a point system. 5 Here is some useful information to help you fill out the MNA® questionnaire. Calculating the body mass index (BMI) BMI is used to indicate the ideal weight/height ratio. It is calculated by dividing weight in kilograms by height in metres². BMI = weight in kilograms (height in metres)2 The resident needs to be weighed at the same time of day with the same scale to get an accurate weighin. The weight of the resident will be the indicator that will help us verify the results of the various interventions. Convert the weight of the resident into kg: 2.2 lbs = 1 kg Convert the height of the resident into centimetres (cm): 1 inch = 2.54 cm If you cannot measure the resident’s height, base yourself on what you have been told or on former information to calculate the BMI. Height that is provided verbally is less accurate, especially for residents who are bedridden or those who have lost a few centimetres over the years. You can use a chart to determine the BMI of residents based on their height and weight (see Appendix 3). Calculating the BMI of amputees Here are the steps to follow to determine the total weight of amputees. 1. Using the chart entitled Weight of different limbs, determine the percentage that the amputated limb represents. 2. Multiply the weight of the individual by this percentage to determine the estimated weight of said limb. 3. Add the weight of the missing limb to the weight of the individual to determine the weight of the resident prior to amputation. 4. Divide the estimated weight by the estimated height in square metres to determine the BMI. Example: 80-year-old man with lower part of left leg amputated: 1.72 m, 58 kg: 1. 2. 3. 4. 6 See “lower leg with foot” in chart = 0.059 58 kg X 0.059 = 3.4 kg 3.4 kg + 58 kg = 61.4 kg (estimated weight) 61.4 kg = 20.8 (1.72)2 WEIGHT OF DIFFERENT LIMBS LIMB Body without limbs Hand Forearm with hand Forearm without hand Upper arm Entire arm Foot Lower leg with foot Lower leg without foot Thigh Entire leg PERCENTAGE 50.0 0.7 2.3 1.6 2.7 5.0 1.5 5.9 4.4 10.1 16.0 Measuring the circumference of the shin If it is not possible for you to measure some persons or calculate their BMI, you must measure the circumference of their shin to complete the MNA® questionnaire (question F2). Residents must be seated and let their left leg hang down or remain standing and distribute their weight evenly on both feet. Roll up pant leg to uncover the shin. Wrap the measuring tape around the shin at the largest point and write down the measurement. Be attentive to weight Weight change is a basic parameter that is used to evaluate the nutritional status of persons. The speed with which weight is lost must also be considered. Nutritional consequences generally occur with rapid weight loss, regardless of the initial weight. For instance: persons who have always had a stable weight and lose weight in a short period of time even though they are overweight or of normal weight. These types of occurrences should lead us to question their condition. Some health problems may cause oedema (ex.: heart failure, presence of malnutrition, nephritic syndrome, etc.) and must be taken into account because they have an important incidence on weight. Second stage: Taking action Based on the score obtained in the short version of the MNA® questionnaire, you can now take appropriate action. Final screening score using the MNA® 12 to 14 points: 8 to 11 points: 0 to 7 points: normal nutritional status risk of undernutrition confirmed undernutrition 7 1. Consult a nutritionist to receive a more in-depth evaluation of the resident’s nutritional status. 2. Start Resource® 2.0 three times a day (TID) or four times a day (QID) with 60-80 ml taken at the same time as medications, for a period of 1 month or until the results of the next blood work (with albumin or pre-albumin given at the request of the physician or nutritionist). 3. Weigh the resident on a regular basis (once a month). 4. Re-evaluate every 6 months using the MNA®. 1. Start Resource® 2.0 TID or QID with 60 ml taken at the same time as medications, for a period of 1 month or until the results of the next blood work (with albumin or pre-albumin given at the request of the physician or nutritionist). 2. Weigh the resident on a regular basis (once a month). 3. Re-evaluate every 6 months using the MNA®. 4. Please consult the nutritionist if you have any questions. Fill out the questionnaire every 3 months or following a serious illness or situation. Resource 2.0 nutritional supplement Resource® 2.0 is a liquid nutritional supplement that is vanilla flavoured and rich in protein and calories. It can be used to manage weight loss and improve the nutritional status of persons who run the risk of suffering from undernutrition or of those who already do. Nutritional supplements must be considered as medication and not as food that you chose to eat for its taste. Ideal for persons who have difficulty eating large quantities of food. Easy to add 480 calories and 20 grams of protein daily. Easy to integrate into daily routine without significantly increasing the workload of health care staff; serve 60-80 ml cold at the same time as medications (TID or QID). For comparison purposes only: 480 cal = 2 slices of whole wheat toast + 2 eggs + 1 cup of orange juice. 20 grams of protein = 2 ounces of meat. 8 Important Position: if the position of certain residents seems to adversely affect their food intake (person confined to bed or a wheel chair, weak muscle tone, etc.), it is recommended to refer them to occupational therapy. Deglutition: persons who eat very slowly, who chew or swallow with difficulty, who regularly choke during a meal or who store food residues in their mouth for long periods of time could suffer from deglutition (dysphagia). In these cases, it is advised to refer them to the person in charge of dysphagia. Mastication: persons who experience mastication difficulties or pain during mastication could suffer from dental health problems such as ill-fitting dental prostheses, periodontal problems, carious lesions, aphthous lesions or other problems. It is recommended to refer them to a dental health professional. Given the high prevalence of undernutrition among seniors living in CHSLDs, the preparation of enriched meals in the kitchen can be an interesting avenue to explore as it would benefit all CHSLD residents. You will find a list of enriched recipes on page 19 of this document. First, here are a few useful tips for nursing and kitchen staffs to increase the nutritional intake of residents. Divide daily intake into 3 small meals and add nutritional snacks. Avoid clear soups that fill up the stomach too much with respect to the energy they provide. Choose thick or cream soups. Avoid giving beverages during meals but think about keeping residents hydrated throughout the day, such as serving liquids every time you come into contact with a senior. Here are some ideas to increase the protein intake in commonly offered foods. SUGGESTIONS FOR INCREASING PROTEIN INTAKE Add THIS to THAT Powdered skim milk (30 à 60 ml) Cooked cereal, scrambled eggs, mashes potatoes, soups, cream sauces, milk, milk shakes, cream-based deserts and puddings Eggs Sandwiches, salads, sauces and soups Cheese (melted, cream or cottage, brick) Pasta, thick soups, sauces and casserole dishes, sandwiches, crackers, bagels, muffins, fruit and vegetables Plain or fruit yogourt Fresh or canned fruit, vegetables, potatoes, rice, pancakes, casserole dishes, stews, soups, vegetable or fruit dips Peanut butter Cookies, milk shakes, sandwiches, crackers and muffins Tofu Milk shakes, soups, casserole or stir fry dishes and salads Dried peas or beans Casserole dishes, soups, stews and salads Seeds and nuts Salads, cereal, ice cream and yogourt 9 Third stage: Monitoring In order to ensure that each person receives a follow-up, it is recommended to perform the MNA® screening test every three months. It is common for residents undergoing nutritional treatment to refuse to continue taking nutritional supplements or to no longer be able to eat 3 meals and several snacks a day. In these cases, it is extremely important to refer them to a nutrition specialist. As we mentioned earlier, undernutrition occurs for different reasons and it is important to find the source of the problem. It is also crucial to determine the best nutritional treatment for a resident with the consent of the resident or of his/her family. The nutritionist will determine the adapted care plan in collaboration with the attending physician, the health care staff and food services. As health care staff members are in constant contact with residents, they must keep an eye out for changes in food intake, weight or any other factor that may lead to undernutrition. If you have any questions regarding the application of the treatment plan devised to improve the resident’s diet, please address them to the nutritionist. End-of-life nutrition End-of-life nutrition does not require dietary supplements but revolves around taste. The significant decrease in food intake and appetite is a common and expected phenomenon at the end of one’s life. Family members may be frightened or even embarrassed to see their loved one deteriorate. It may also be the case for health care staff. To them, feeding someone is a way to love and take care of them. To successfully feed someone can be reassuring. It leaves the impression of having contributed to their well-being and comfort. It is important to explain to family members that at this stage of life food plays the role of satisfying a basic need often associated with pleasure, satisfaction or togetherness. As a result, the resident or his/her family is asked to make food choices. However, force feeding can aggravate some symptoms and cause discomfort. It is very important to offer small quantities of food that the person likes and to serve it as needed. 10 PART 2: DEHYDRATION Dehydration is defined as a disorder affecting fluid and electrolyte balance and is characterized by a reduction in the volume of body water. A water loss of 1 to 2% in body weight is already considered dehydration. Physical capacity and concentration decrease as dehydration increases. Dehydration is often under-diagnosed and goes unnoticed due to the absence of acute symptoms. It sets in insidiously and symptomology is unspecific. Water needs depend on renal, respiratory, digestive and thermoregulating functions which vary from one person to another according to ambient conditions (humidity, temperature). Since dehydration sets in silently and is often avoidable, it is important to anticipate and recognize the risk factors in order to act early. It must remain a core issue for persons providing personal care. The nursing staff is in a perfect position to observe, identify and anticipate hydration problems. Staff members can question residents about hydration and act accordingly. THE BASICS OF HYDRATION Water does not contain any proteins, carbohydrates or lipids and is not considered a food item. However, water is an essential element to life. At birth, the body is composed of approximately 75% water and looses it progressively with age. The body of an elderly person only contains about 55% water. In point of fact, the quantity of body water is directly proportionate to the quantity of lean mass, namely muscles, and since persons lose muscle mass as they age, it constitutes another loss. Water is essential to vital needs which means that it helps the body: Use the energy in food Maintain blood volume and lymph volume (liquid that nourishes and cleans the body’s cells) Provide saliva which helps swallow food Work as a lubricant for joints and eyes Maintain body temperature Provoke chemical reactions between cells Facilitate the absorption and transportation of nutrients found in food Promote neurological activity in the brain Keep skin hydrated Eliminate waste from digestive and other metabolic processes 11 THE BODY’S WATER NEEDS It is clear that water is essential to survival and that the human body cannot store it. During a typical day at rest (without activity), the body loses approximately 2 to 3 litres of water. As a result, it is important to replace it as the day progresses. Urine = 1 to 1.5 litre Evaporation though skin and lungs (without sweating) = 0.9 to 1.3 litre TOTAL = 2 to 3 litres Stools = 100 to 200 ml It is generally recognized that the liquid intake (water and drinks) of seniors should be superior to 1,500 ml per day6. Here are a few methods that can be used to calculate a person’s daily fluid needs. Example of a woman weighing 55 kg: Method 1 30 to 40 ml per kg of body weight 40 ml X 55 kg = 2,200 ml of fluids per day Method 2 1,500 ml for the first 20 kg of body weight + 15 ml per kg for remaining body weight 1,500 ml + (15 ml X 35 kg) = 2,025 ml of fluids per day The purpose of this demonstration is to emphasize the importance of daily hydration, especially in seniors. CAUSES OF DEHYDRATION Seniors become dehydrated for several reasons. 6. 12 Decreased lean mass Liquid restriction for fear of incontinence Anorexia due to depression Cognitive disorders Insufficient stimulation to hydrate themselves Being confined to bed (less access to liquids): persons who are bedridden do not always have a glass of water at hand. They never ask for water for fear of disturbing the staff. Decreased sense of thirst (thirst mechanisms become less effective with age) High ambient temperature: it is worse in summertime Use of diuretics or laxatives: some medical conditions require the use of diuretics or laxatives which cause a loss of body fluids Diarrhea, vomiting, fever MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX DU QUÉBEC. Approche adaptée à la personne âgée en milieu hospitalier - cadre de référence, 2011. Inefficiency of kidneys to concentrate urine leading to polyurea (ex.: diabetes insipidus) Liquid dysphagia SYMPTOMS Concentrated (dark yellow) and foul-smelling urine Dry tongue and mouth (hyposalivation) Loss of turgidity (skin’s elasticity) Sunken eyes Confusion Urinary flow rate lower than 500 ml per day Weight loss CONSEQUENCES OF DEHYDRATION Here are some of the complications that appear when dehydration increases. Constipation Loss of appetite Exacerbation of pressure sores (delayed healing) Nausea Headache Reduced concentration Drowsiness Coordination problems Increased risk of falls Medication toxicity risk due to increased concentration Increased risk of bladder and lung infections Delirium Reduced arterial blood pressure Electrolyte imbalance Hyperthermia A vicious circle is created as the person eats less and moves less increasing undernutrition and dehydration risks as well as medical care needs (hospitalization). RECOMMENDATIONS Many liquids and foods can be used to meet daily needs. Water, mineral water, milk, fruit or vegetable juice, nutritional supplements (Resource, Boost, Ensure, etc.) Soup Coffee, tea and soft drinks Oatmeal, yogourt, ice cream, milk pudding and Jell-O Based on a study conducted by Robinson and Rosher in 2002, more than 80% of residents accepted beverages that were offered by an orderly. As the sense of thirst tends to decrease in seniors, staff must not wait for a person to express thirst before offering a beverage. It is important to write down a low consumption of liquids or foods in a person’s file if such consumption represents less than three quarters of the beverages and foods served. 13 Here are a few useful tips to promote good hydration in seniors. Seniors must always have liquids at their disposal. They must be able to see them and have them close at hand. They must receive the requested beverages in sufficient quantity. Liquids must be served at the appropriate temperature: cold water and juice, etc. Recreational activity periods are the perfect time to serve beverages. Beverages or water should always be offered to residents at each contact. Medications must be offered with a higher volume of liquids, respecting the basic rule of 125-250 ml each time. The distribution of beverages should be scheduled for each work shift. Water rich snacks should be favoured: fruit, fruit compotes, pudding. An estimate of the quantity of liquid intake over a 24-hour period can be requested by a physician or nutritionist. In the summertime (June to September) and especially during heat waves, it is important to be attentive to hydration by offering beverages more often than usual. Attention Dysphagia: some persons suffer from dysphagia. In these cases, it is important to take into account the consistency of liquids that is recommended in the resident’s medical file. Liquid restrictions: it is crucial to check medical prescriptions that restrict water intake (heart failure). Undernutrition: for persons who suffer from undernutrition, it is essential to understand that each sip and each bite counts when dealing with nutrients. As mentioned earlier, water does not contain any nutrients. It would be advisable to also offer juice, milk and water rich foods (fruit, fruit compotes, ice cream, etc.) in order to increase the intake of calories and nutrients on a daily basis. 14 PART 3: FEEDING PROCESS The aim of the feeding process is to meet a person’s needs for food and drink but it also performs an important social role. It is during this process that people supply their bodies with the necessary nutrients for them to function but the role of food intake is not limited to satisfying physical needs. In point of fact, one must not forget the social and cultural aspects of eating... It can be symbolic, social or simply pleasurable. This means that it is important to take the time to perform the activities linked to food; location and atmosphere also play a role in healthy eating habits as they help create the feeling of well-being that people get from a meal. In order to improve food intake, it is essential to consider the dynamics of mealtime, from meal preparation to the clearing of food. It is also important to recognize the role of the general environment in which people live. The atmosphere, the environment and the surrounding people can create conditions that are either favourable to good eating practices or not. The emotions felt by seniors at mealtime such as: feeling confident or reassured, or quite the opposite, feeling anxious and angry, can significantly influence their food intake. It is important to recognize that personal factors such as education, knowledge and individual taste also play a role in the choice of food. RECOMMENDATIONS IN THE KITCHEN Be attentive to: how food is presented on the plate the textures the smells the shape the colours the temperature of the food BEFORE MEALS AND SNACKS Announce the menu and the time at which the meal will be served to whet the appetite. Create a calm atmosphere. Make sure the resident is alert. Have them put on eyeglasses and hearing prostheses. Make sure dental prostheses are worn. However, wearing prostheses at mealtime depends on how they are adjusted and on the person’s ability to wear them. Make sure the resident is comfortable and seated straight with feet on the ground. Make sure the table is at the appropriate height (example: wheelchair). 15 DURING MEALS AND SNACKS Establish eye contact, crouch down if necessary. Never put a plate down on the table without addressing yourself to the resident. Wish them an enjoyable meal: “Enjoy your meal”. Encourage the person to chew properly, to take small bites and slow their eating pace. Insist on foods with high nutrient content (such as meat, enriched foods, milk-based deserts, etc.). Adopt a respectful and attentive attitude. Respect the person’s pace. Use prescribed technical aids properly, such as plates with higher rims, glasses with wide mouths; consult the occupational therapist as needed. Create a calm atmosphere by reducing noise (music, television, etc.); some types of discussions between health care workers can also disrupt the atmosphere. Offer food with a positive attitude, without regard to your personal tastes. Serve one dish at a time. Avoid mixing food together in order to keep the flavour of each food separate. The position of the worker is very important to persons who require assistance to eat. It is advisable to be at the same height as the resident. Interaction is more pleasurable and it stimulates the person’s appetite. Avoid overstimulation by wiping the person’s mouth too often; use a moist cloth if necessary. Avoid clearing plates too quickly; some persons like to take a break between bites. Plan enough time for meals. AFTER MEALS Offer moist facecloths to residents. It is recommended to brush residents’ teeth after each meal using a toothbrush and fluoride toothpaste. Should this prove to be too difficult, make sure that they rinse their mouths after each meal to remove as many residues as possible. Candies are not recommended because they lower salivary hydrogen (pH) which promotes the development of dental cavities. However, we encourage gum and mints with xylitol because it uses a natural sugar that is known for its antibacterial properties. It is also safe for diabetics and helps increase salivary flow. INSTRUCTIONS FOR RESIDENTS REQUIRING ASSISTANCE7 Being fed by another person can bring about shyness, frustration, impatience and powerlessness. Helping someone to eat is an ‘‘intimate’’ activity that must be performed while respecting the dignity and safety of the resident. That is why careful attention must be paid to the following instructions. Seat yourself in front of the person or slightly to the side to establish eye and auditory contact. Seat yourself at the same height as the person to prevent him/her from raising their head (choking risk) Place small quantities of food in the person’s mouth. Do not start a conversation with the person while they have food in their mouth. 7. 16 CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DE SEPT-ÎLES, Procédure sur l’acte alimentaire en CHSLD - brouillon. Make sure the person’s mouth is empty before offering the next bite; if there are residues, ask the person to swallow again. Give the resident a break between deglutitions to reduce stress. For dysphagic residents: Give simple verbal instructions: chew, swallow, cough, etc.; Never give liquids when there are solids in a person’s mouth; Never give liquids or solids when a person is coughing, encourage them to continue coughing; Serve foods with the recommended texture and consistency. A FEW SUGGESTIONS TO IMPROVE THE ATMOSPHERE Seeing and smelling food increases the appetite. It is worthwhile for CHSLDs to have a hot table and serve meals in the dining room when the facility is able to do so rather than portioning the food in the kitchen on platters. Residents benefit from more personalized service. Why not set the table with a tablecloth, as if you were at home? Encourage meals to be taken in the dining room rather than in the person’s bedroom. If the meal must be taken in their bedroom, it is preferable to seat them in an armchair. If the resident must eat in bed, make sure that their body and pelvis are centered and straight, knees are slightly bent and the body is raised between a 45 and 90 degree angle. Setting tables up in small groups encourages intimacy and makes mealtime peaceful. Pair up people with the same interests. Reserve a special section for persons with cognitive impairments to create a better environment at mealtime. You can set up a small dining room in a more quiet section of the facility. Use brightly coloured plates, glasses and cups to create a warm atmosphere. Some residents still have the ability to provide assistance; ask them to give you a hand to maintain their autonomy as long as possible. 17 QUESTIONNAIRE USED TO EVALUATE THE FEEDING PROCESS This questionnaire can help guide your actions. OTHERS RESIDENTS STAFF FOOD SERVICE QUESTION 1 Fill out a questionnaire on the tastes of the resident upon admission in order to respect their preferences. 2 Present appetizing and eye-pleasing foods. 3 Offer more than one menu choice to residents. 4 Serve foods at the proper temperature. 5 Use a hot table to serve meals. 6 Set up a food complaint or comment procedure for residents. 7 Use an identification system for residents with specific diet needs. 8 Speak with other staff members in a manner which residents find respectful and do not call over to each other. 9 Adapt the way you communicate with residents based on their needs. 10 Say ‘’Hello’’ and ‘’Enjoy your meal’’. 11 Offer food in a positive manner regardless of your own tastes. 12 Offer choices to residents. 13 Respect prescribed textures, consistency and diet. 14 Offer full meal service. 15 Serve the meal safely. 16 Serve the meal dish by dish. 17 Adapt the speed and the order of the service to residents’ needs. 18 Set up and use equipment to encourage the autonomy of residents. 19 Position yourself adequately when feeding a resident. 20 Use good practices to feed a resident. 21 Use technical aids as recommended by the occupational therapist (plates with higher edges, ergonomic utensils, etc.). 22 Offer a moist facecloth to residents as needed. 23 Provide oral hygiene care after meals. 24 Inform nursing staff of any changes in the resident’s eating habits (loss of appetite, choking, mouth pain, allergies, dysphagia, etc.). 25 Are seated or positioned properly. 26 Are wearing their hearing prostheses and eye glasses. 27 Are wearing their dental prostheses (prostheses are only worn at mealtime if they are well adjusted and if the person is able to wear them). 28 Can take the time they need to eat. 29 Are placed in small groups based on the type of help they need and their affinities. 30 The physical environment of the dining room and kitchenette is safe. 31 There is little noise and distraction in the dining room at mealtimes. 32 Volunteers and family members respect the dietary recommendations advocated for the residents, whether it regards the contents of their plate or the technical aids used to eat. 18 YES NO DO NOT KNOW COMMENT ENRICHED RECIPES LIST OF RECIPES NUMBER Sources: RECIPE PAGE 1 Berry Banana Shake 20 2 Latte 20 3 Rice and Broccoli Casserole 21 4 Ham and Cheese Morning Casserole 22 5 Pancakes 23 6 Morning Delight 24 7 Californian Cake 25 8 Enriched Porridge 26 9 Enriched Milk 26 10 Banana Nut Muffins 27 11 Bread Pudding 28 12 Rice Pudding 29 13 Enriched Pudding 29 14 Chicken Stroganoff 30 15 Baked Sweet Potato Purée 31 16 Carrot Ginger Soup 32 17 Split Pea Soup 33 18 Streusel 34 http://abbottnutrition.ca http://www.nutrition.nestle.ca 19 RECIPE 1 Berry Banana Shake Portions: 2 x 1 cup Carbohydrate: 50 g Calories: 235 Sodium: 127 mg Protein: 18 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 235 ml of vanilla flavoured nutritional supplement, refrigerated 250 ml (1 cup) of frozen berries (raspberries, strawberries, etc.) 1 small banana 15 ml (1 tbsp) of sugar Pour all the ingredients in the blender. Blend until smooth. Serve. RECIPE 2 Latte Portion: 1 cup Carbohydrate: 41 g Calories: 240 Sodium: 250 mg Protein: 10 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 250 ml (1 cup) of vanilla flavoured nutritional supplement 5 to 10 ml (1 to 2 tsp) of instant coffee 30 to 45 ml (2 to 3 tbsp) of boiling water Dissolve coffee in boiling water. Mix coffee and nutritional supplement. Serve immediately or refrigerate up to 24 hours. 20 RECIPE 3 Rice and Broccoli Casserole (Respects food policy) Portions: 4 x 1 cup (approx.) Carbohydrate: 59 g Calories: 430 Sodium: 600 mg Protein: 16 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 15 ml (1 tbsp) of margarine 1 small onion, chopped 125 ml (½ cup) of celery, cut into pieces 1 - 30 g (10 oz) package of frozen broccoli, cut into pieces and drained 4 oz of Velveeta cheese or other cheese spread, cut into cubes 235 ml of vanilla flavoured nutritional supplement 1 ml (¼ tsp) of black pepper 250 ml (1 cup) of long grain rice, uncooked Preheat oven at 180 °C (350 °F). Take out a large casserole dish and melt margarine over medium heat. Fry onion, celery and broccoli lightly for 5 minutes. Add cheese, supplement and pepper. Stir until cheese is melted. Add rice. Pour mixture into a greased 23 cm (9 in) square dish. Cover dish and bake 45 minutes in the oven. Uncover dish and continue cooking for 15 minutes or until the rice is cooked and the mixture is hot and bubbly. Serve. 21 RECIPE 4 Ham and Cheese Morning Casserole Portions: 8 Calories: 441 Protein: 22 g Carbohydrate: 31 g Sodium: 1 040 mg Ingredients 8 slices of wheat bread, crusts removed and cut into cubes 375 ml (1½ cups) of grated cheddar cheese 310 ml (1¼ cups) of cooked ham, diced 125 ml (½ cup) of finely chopped onions 60 ml (¼ cup) of finely chopped green peppers 6 eggs 500 ml (2 cups) of vanilla flavoured nutritional supplement 250 ml (1 cup) of milk 2.5 ml (½ tsp) of pepper 5 ml (1 tsp) of salt Grease a 9 x 13 inch dish. Cover the bottom of the dish with bread cubes. Place ham, cheese, chopped onions and peppers on the bread. In a bowl, beat the eggs, supplement, milk, salt and pepper together. Pour into the dish. Cover and refrigerate for 8 hours or overnight. Preheat oven at 180 °C (350 °F), take out mixture from refrigerator and let stand 30 minutes. Cook 40 to 50 minutes without a cover or until eggs are cooked. A knife inserted in center must come out clean. Cool 5 minutes before cutting and serving. 22 RECIPE 5 Pancakes (Respects food policy) Portions: 6 to 7 pancakes of 10 cm (4 in) Carbohydrate: 20 g Calories: 158 Sodium: 140 mg Protein: 12 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 200 ml (⅔ cup) of flour 7 ml (1½ tsp) of baking powder 250 ml (1 cup) of vanilla flavoured nutritional supplement 1 egg 30 ml (2 tbsp) of canola oil Take out a large bowl and mix flour and baking powder together. Add nutritional supplement and egg. Mix well. Pour oil into a fry pan and place under medium heat. Pour 60 ml (¼ cup) of mixture into pan. Flip pancake over when slightly brown underneath. Repeat until mixture is finished. 23 RECIPE 6 Morning Delight (Respects food policy) Portions: 6 Carbohydrate: 44 g Calories: 346 Sodium: 483 mg Protein: 16 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 250 ml (1 cup) of strawberries, fresh or frozen, thawed and drained 250 ml (1 cup) of blueberries fresh or frozen, thawed and drained 8 slices of wheat bread, cut into cubes 30 ml (2 tbsp) of sugar 2.5 ml (½ tsp) of cinnamon (optional) 1 - 225g (8 oz) package of cream cheese, cut into cubes 8 eggs 5 ml (1 tsp) of vanilla 1½ cans or 375 ml (1½ cups) of vanilla flavoured nutritional supplement Grease a 2-litre pan. Place half of the bread cubes at the bottom of the pan. Using a bowl, mix the fruit, sugar and cinnamon until the fruit is coated. Pour the fruit mixture on top of the bread. Place the cheese cubes on top of the fruit and cover with the rest of the bread. Using a bowl, mix the eggs, the nutritional supplement and the vanilla. Pour mixture on top of bread, cover with a sheet of aluminium foil and refrigerate 8 hours or overnight. Bake at 180 °C (350 °F) for 30 minutes and continue cooking, uncovered, for 30 to 35 minutes or until the mixture has set. Cool 5 minutes before cutting. Serve warm with maple syrup. 24 RECIPE 7 Californian Cake Portions: 16 Carbohydrate: 37 g Calories: 305 Sodium: 101 mg Protein: 4.1 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 375 ml (1½ cups) of sugar 250 ml (1 cup) of canola oil 3 eggs 550 ml (2¼ cups) of all-purpose or wheat flour 5 ml (1 tsp) of baking soda 5 ml (1 tsp) each of cinnamon, nutmeg and Jamaica pepper 250 ml (1 cup) of vanilla flavoured nutritional supplement 10 ml (2 tsp) of vanilla extract 128 ml (4½ oz) prune sauce for babies Lemon zest from 1 lemon Take out a large bowl and mix the sugar and oil until smooth. Beat in one egg at a time. Take out a small bowl and mix flour, baking soda and spices. Add both mixtures by alternating flour mixture with sugar mixture. Start and end with flour mixture. Add vanilla, prune sauce and lemon zest. Mix well. Pour into one greased pan (34 x 22 cm/13 in x 9 in) or two 8-inch (20 cm) pans. Bake at 150 °C (300 °F) for 45 to 55 minutes or until a toothpick comes out clean from the centre. Cool and add icing if desired. Icing Mix 125 ml (½ cup) of icing sugar, 30 ml (2 tbsp) of plain yogourt and 5 ml (1 tsp) each of lemon juice and lemon zest. Spread icing over cooled cake. 25 RECIPE 8 Enriched Porridge (Respects food policy) Portion: 1 Calories: 538 Protein: 15 g Carbohydrate: 75 g Sodium: 417 mg Ingredients Packets of instant porridge 250 ml (1 cup) of enriched milk (see Recipe 9) 30 ml (2 tbsp) of 35% cream 10 ml (2 tsp) of canola oil 30 ml (2 tbsp) of oat bran Prepare according to instructions on the porridge box. Add cream, oil and oat bran. You can add some fruit if you wish. You can put it in the blender to make it smoother. RECIPE 9 Enriched Milk (Respects food policy) Portions: 4 x 250 ml Calories: 230 Protein: 15 g Ingredients 1 litre (4 cups) of 3.25% milk 250 ml (1 cup) of powdered milk Mix ingredients in the blender. Prepare 24 hours ahead of time. Refrigerate. 26 Carbohydrate: 24 g Sodium: 223 mg RECIPE 10 Banana Nut Muffins Portions: 12 large Carbohydrate: 55 g Calories: 393 Sodium: 333 mg Protein: 9 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 500 ml (2 cups) of flour 250 ml (1 cup) of brown sugar 30 ml (2 tbsp) of baking powder 5 ml (1 tsp) of salt 2.5 ml (½ tsp) of baking soda 375 ml (1½ cup) of oatmeal 2 eggs 80 ml (⅓ cup) of canola oil 250 ml (1 cup) of vanilla flavoured nutritional supplement 250 ml (1 cup) of mashed bananas 125 ml (½ cup) of chopped nuts (optional) Preheat oven at 200 °C (400 °F). Mix dry ingredients in a bowl. Make a funnel in the centre, put in eggs, oil, nutritional supplement, bananas and nuts. Mix with a fork until humid. Use a greased muffin tin and fill to ¾. Bake for 18 to 20 minutes or until a toothpick inserted in the centre comes out clean. 27 RECIPE 11 Bread Pudding Portions: 4 Carbohydrate: 52 g Calories: 311 Sodium: 448 mg Protein: 12.9 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 1 litre (4 cups) of small bread cubes 125 ml (½ cup) of raisins or dried cranberries 250 ml (1 cup) of milk 250 ml (1 cup) of vanilla flavoured nutritional supplement 30 ml (2 tbsp) of brown sugar 2 eggs 1 ml (¼ tsp) of nutmeg (optional) Mix bread cubes with raisins or cranberries in a 1-litre (4-cup) baking dish or a 22-cm (9-in) cake pan. Bring milk, nutritional supplement and brown sugar to a boil over medium heat or in the microwave. Take out a small bowl and beat eggs and nutmeg together, add a bit of hot milk and beat to warm up eggs. Beat in egg mixture with the warm milk. Pour mixture over bread cubes making sure to cover all cubes. Bake at 160 °C (325 °F) for 30 minutes or until a knife inserted in the centre comes out clean. Serve warm or cold with maple syrup or apple sauce. 28 RECIPE 12 Rice Pudding Portions: 4 Carbohydrate: 39 g Calories: 221 Sodium: 97 mg Protein: 9.5 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 2 eggs 250 ml (1 cup) of vanilla flavoured nutritional supplement 5 ml (1 tsp) of vanilla extract 2.5 ml (½ tsp) of cinnamon (optional) 375 ml (1½ cup) of cooked rice 125 ml (½ cup) of raisins or dried cranberries Preheat oven at 180 °C (350 °F). Take out a 1-litre (4-cup) dish and beat in eggs, nutritional supplement, vanilla and cinnamon. Add rice and raisins or cranberries and mix well. Pour into a 22-cm (9-in) square pan. Pour very hot water half way up the pan. Bake 1 hour or until a knife inserted in the centre comes out clean. Serve warm or cold. RECIPE 13 Enriched Pudding Portions: 4 x 125 ml (½ cup) Carbohydrate: 41 g Calories: 255 Sodium: 481 mg Protein: 7.5 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 250 ml (1 cup) of vanilla flavoured nutritional supplement 250 ml (1 cup) of 2% milk 113 g (1 small packet) of instant pudding, any flavour Take out a bowl and mix all ingredients until smooth. Refrigerate until thickened, approximately 1 hour. 29 RECIPE 14 Chicken Stroganoff Portions: 2 Carbohydrate: 35 g Calories: 347 Sodium: 896 mg Protein: 29 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 5 ml (1 tsp) of olive oil 2 chicken breasts of 90 grams (3 oz), boned, without skin, cut into 4 strips 2.5 ml (½ tsp) of salt Black pepper to taste 2 green onions, finely chopped 2.5 ml (½ tsp) of paprika 500 ml (2 cups) of fresh mushrooms, finely chopped 125 ml (½ cup) of chicken broth 2.5 ml (½ tsp) of Dijon mustard 30 ml (2 tbsp) of fresh parsley, chopped 5 ml (1 tsp) of corn starch 125 ml (½ cup) of vanilla flavoured nutritional supplement 30 ml (2 tbsp) of sour cream 150 ml (⅔ cup) of cooked egg noodles, hot Heat olive oil over medium heat in a medium-size non-stick pan. Sprinkle salt and pepper over chicken and brown 2 to 3 minutes on each side. Place chicken on a plate and keep warm. Use the same pan and heat up the green onions and 30 ml (2 tbsp) of water and fry lightly for 2 minutes. Add paprika and mushrooms to pan, continue to fry until mushrooms are golden brown. Add chicken broth, mustard and parsley and cook until liquid has reduced by half. Take out a small bowl and mix 15 ml (1 tbsp) of cold water and corn starch, add the mixture to the pan. Cook for another 2 to 3 minutes while stirring constantly. Bring heat down to minimum and stir in nutritional supplement. Add cooked chicken and continue to cook for 2 to 3 minutes. Cook chicken well. Do not bring to a boil. Serve over cooked noodles. Garnish with parsley and sour cream. 30 RECIPE 15 Baked Sweet Potato Purée (Served as a side dish, respects food policy) Portions: 6 x ⅓ cup Carbohydrate: 29 g Calories: 135 Sodium: 166 mg Protein: 3 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 680 g (1½ lb) of sweet potatoes, peeled and chopped into 1-in cubes 1 large cooking apple, peeled, cored and cut into 8 pieces 10 ml (2 tsp) of ground cinnamon (optional) ½ ml (⅛ tsp) of ground cardamom 2.5 ml (½ tsp) of salt 5 ml (1 tsp) of olive oil 125 ml (½ cup) of vanilla flavoured nutritional supplement Preheat oven at 200 °C (400 °F). Place sweet potatoes, apple pieces, ginger, cinnamon, cardamom, salt and oil in a baking pan and stir. Bake 20 minutes, stirring from time to time. Bake for another 15 to 20 minutes or until sweet potatoes are tender. Place mixture in a bowl, add nutritional supplement and mash together. Serve. 31 RECIPE 16 Carrot Ginger Soup (Respects food policy) Portions: 4 x 1 cup Carbohydrate: 37 g Calories: 237 Sodium: 391 mg Protein: 6 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 454 g (1 lb) of carrots 25 ml (1½ tbsp) of margarine 250 ml (1 cup) of chopped onions 7 ml (1½ tsp) of chicken soup mix 500 ml (2 cups) of vanilla flavoured nutritional supplement 125 ml (½ cup) of water 7 ml (1½ tsp) of ginger root, peeled and chopped 3.75 ml (¾ tsp) of coriander 2.5 ml (½ tsp) of grated orange zest 1 ml (¼ tsp) of black pepper Cook carrots until tender, drain. Melt margarine in a medium-size pan. Add onions and chicken to soup mixture. Lightly fry onions until tender without browning them. Take out a blender, put in carrots, onions, nutritional supplement, water, ginger, coriander, orange zest and pepper. Blend until smooth. Reheat and bring to serving temperature. Do not boil. 32 RECIPE 17 Split Pea Soup (Respects food policy) Portions: 4 Calories: 224 Protein: 20 g Carbohydrate: 33 g Sodium: 320 mg Ingredients 250 ml (1 cup) of split peas 1 litre (4 cups) of water 90 grams (3 oz) of diced ham 125 ml (½ cup) of celery 50 ml (3 tbsp) of chopped onions Cover peas with water, bring to a boil and simmer for 2 minutes. Remove from heat, cover and let stand for one hour. Add other ingredients, cover and simmer for 1 hour or until peas are tender. 33 RECIPE 18 Streusel Portions: 8 x 80 g Carbohydrate: 46 g Calories: 283 Sodium: 253 mg Protein: 5.6 g (Calculated with nutritional supplement: 1 calorie/ml) Ingredients 375 ml (1½ cup) of all purpose flour 15 ml (1 tbsp) of baking powder 1 ml (¼ tsp) of ground nutmeg 125 ml (½ cup) of sugar 1 egg 175 ml (⅔ cup) of vanilla flavoured nutritional supplement 45 ml (3 tbsp) of melted butter Topping 60 ml (¼ cup) of melted butter 125 ml (½ cup) of all purpose flour 30 ml (2 tbsp) of brown sugar 2.5 ml (½ tsp) of cinnamon (optional) Preheat oven at 200 °C (400 °F). Sift the first 5 ingredients into a large bowl. Add the egg, nutritional supplement and melted butter. Mix ingredients in a blender until smooth. Place batter into a greased 20-cm (8-in) pan. Even off the top with a spatula. Mix the ingredients for the topping in a small bowl. Sprinkle evenly over batter. Bake 30 minutes or until a toothpick inserted in the centre comes out clean. 34 APPENDIX 1 35 36 37 38 39 40 APPENDIX 2 To print questionnaire: http://www.mna-elderly.com/mna_forms.html 41 APPENDIX 3 42 APPENDIX 4 ALGORITHM 43 BIBLIOGRAPHY ALLINGTON, Chris, Paul ALLISON and Judiann STERN. Access to Dental Care for Under-privileged People in Quebec, Montréal, McGill University, Faculty of Dentistry, May 2004. CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DE SEPT-ÎLES. Procédure sur l’acte alimentaire en CHSLD - brouillon. CENTRE HOSPITALIER UNIVERSITAIRE HÔTEL-DIEU DE QUÉBEC. Recueil de recettes enrichies, 2001. CHEVALIER, Stéphanie, Isabelle DESJARDINS and Dominique MAINVILLE. « Dépistage de la dénutrition et impact d’une intervention nutritionnelle chez les personnes âgées en soins de longue durée », Revue Nutrition Science en évolution, volume 6, numéro 1, Spring 2008, p. 17-20. CROOK, J. 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Dépistage nutritionnel des aînés en perte d’autonomie à Montréal, Québec, Santé Canada, Spring 2003. 44