The introduction of finger foods will potentially:
- increase the opportunity to encourage or enable self-feeding
- improve quality of life
- increase oral intake and promote weight stabilization while in hospital
- improve the nutritional intake of patients admitted to the dementia and delirium ward.
To study the effect of having a finger food menu available for oral intake, and to measure this across energy and protein levels, and by tracking the weight of patients with dementia and delirium in ward 2D.
For the individual
- Improved independence particularly with self feeding
- Improved nutritional intake and status
- Promotion of weight stabilisation
- Reduced risk of malnutrition
- Improved quality of life.
For the clinical staff
- Reduced time spent feeding patients
- Improved work satisfaction as patients become more independent.
For the health system
- Potential reduction in length of stay
- Potential reduction in staff time spent per patient during mealtimes
- Potential reduction in rates of readmission.
Malnutrition (undernutrition) is a serious and debilitating condition that is highly prevalent in the hospital setting. Literature indicates that malnutrition, or the risk of malnutrition, is likely to exist at a rate of 30-60%. Allen, Methven and Gosney and others have shown that approximately 44% of those with dementia are malnourished.1
The Hornsby Ku-ring-gai Hospital malnutrition point prevalence audit, conducted in May 2017 (ethic approved - LNR/17/HAWKE/78) showed that 43% of those admitted to ward 2D were malnourished on the day of review.
Albanese E. et al have shown that weight loss during hospital admission is a significant concern with some patients losing between 6% and 24% of their body weight during their stay.2 Poor nutritional status is reported to be associated with worse cognitive, functional and behavioural profiles, as well as increased morbidity and mortality in those with dementia.
The introduction of finger food menu to ward 2D provides increased opportunities for independence and self-esteem at mealtimes, as the patient is less reliant on assistance from staff. Patients also maintain control of what they eat and the time it takes to eat. Finger foods are easy to eat either at, or away from, a table. This can be helpful for those who wander or tend to leave the table in the middle of mealtimes.
A pilot study looking at the implementation of a finger food menu, with data collection being gathered over a 12-month period across November 2018 to November 2019.
The study consisted of many steps including the following.
- Study protocol and ethics submission were designed.
- The menu was designed to comply with the ACI Nutrition Standards for Adults Inpatients in NSW Hospitals.3
- Finger food menu was built in the local data base by Health Share food services.
- Finger food taste tests were run with stakeholders including the nurse unit manager, nursing and other allied health clinicians, acute care of the elderly (ACE) staff specialist, the ACE registrar and ACE team, which consisted of an occupational therapist, physiotherapist and dietitians.
- A two-week pre-implementation audit consisting of:
- main meal intake audit (breakfast, lunch, dinner), using a food consumption form and food service collected intake data
- meal time environment observation, including time taken to eat main meal and whether assistance was required
- weight and dietitian assessment of malnutrition status, using a Subjective Global Assessment to allow for diagnosis of malnutrition.
- Pre implementation staff surveys were distributed and collected, to gather information from staff to understand the consequences of malnutrition in those with dementia, as well as what is currently working with current menu options.
- Education sessions for all clinical staff who work on the dementia and delirium ward; including nursing, allied health and medical staff.
- Start of trial on 29 November 2018.
Implementation – the initiative is ready for implementation, is currently being implemented, piloted or tested.
- Late 2016: the concept of implementing a finger food menu on the dementia and delirium ward began.
- March 2017: first project meeting with Hornsby and Northern Beaches Hospital nutrition department heads.
- January 2017 to May 2018: design of finger food menu, in conjunction with Health Share, food services and dietetic manager.
- March 2018: ethics proposal submitted.
- June 2018: finger food menu taste test, inviting medical staff, nurse unit manager, nursing staff, food service staff and allied health staff including occupational therapists, speech pathologists, physiotherapists, social workers and dietitians.
- July 2018: first of three, two-week meal time observation audits on ward 2D.
- November 2018: finger food menu trial began and was due for completion on 31 November 2019.
- November 2018: presented at the Northern Sydney Local Health District Patient Centre Care Showcase to present the ‘Implementation of Finger Food Diet on Ward 2D’.
- April 2019: presented at the NSLHD Frailty Forum on the ‘Implementation of finger food menu on the dementia and delirium ward at the Hornsby-Ku-ring-gai Hospital’.
- August 2019: research student started.
- December 2019: post implementation staff survey.
- December 2020: expected completion of data analysis.
Hornsby Ku-ring-gai Hospital Ward 2D, which is a specialised 10-bed dementia and delirium ward.
From 18 August 2018, 34 patients admitted to ward 2D were referred to the finger food trial, with 31 meeting eligibility criteria.
Data collection was ongoing until 31 November 2019, which marks the completion of the 12-month study period. Statistical tests to be collected and analysed will include:
- descriptive statistics such as estimated energy and protein consumption, weight and percentage weight loss, total number of patients diagnosed with malnutrition and overall percentage of patients malnourished.
- the nutritional intake of those on the finger food diet.
Data will be collated and coded using Microsoft Excel and then analysed using Statistical Package for the Social Sciences (SPSS). A chi-squared test and one way Analysis of Variance (ANOVA) test will be performed to explore if there is significance between data sets.
A qualitative data analysis software package will be used for the qualitative analysis of the staff and family surveys. Further statistical tests may be used in consultation with a statistician.
A Master of Nutrition and Dietetics student from the University of Sydney completed a 12 week placement from 6 August 2019 to begin entering and analysing data already collected.
Challenges included the following.
- Menu design planning was difficult, to ensure protein requirements met the ACI Nutrition Standards for Adults Inpatients in NSW Hospitals.
- Sourcing new compliant food items, which meet the finger food specifications. The hospital menu should meet the daily requirements of protein and energy on a daily basis, according to the ACI Nutrition Standards for Adults Inpatients in NSW Hospitals.
- Completion of food intake charts was inconsistent and variable.
- Weight of patients was often not completed at the start and end of the finger food diet.
- The introduction of an additional diet code meant staff were unsure of when to use it.
- Patients on the finger food diet were not always given adequate time by staff to feed themselves and so staff would intervene.
- Low completion and return rate of family surveys.
- Allen J, Methven L and Gosney M. Use of nutritional complete supplements in older adults with dementia: Systematic review of clinical outcomes. Clinical Nutrition. 2013; 32: 950-957.
- Albanese E. et al. Dementia severity and weight loss: A comparison across eight cohorts. The 10/66 study. Alzheimer’s & Dementia. 2013; 9: 649–656
- Agency for Clinical Innovation. Nutrition Standards and Diet Specifications. Sydney: ACI; 2017.
- Abdelhamid A, Bunn D, Copley M, et al. Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis. BMC Geriatrics. 2016;16(1):26.
- Agency for Clinical Innovation. Therapeutic diet specifications for adult inpatients in NSW Hospitals. Sydney: ACI Nutrition Network 2011.
- Malerba G, Pop A, Rivasseau-Jonveaux T, et al. Feeding a patient with neurocognitive impairment in hospital and at home? Convenience of finger-food. Nutrition Clinique et Metabolisme. 2015;29(3):197-201.
- Moore K, O'Shea M, Hughes C, et al. Current evidence linking nutrition with brain health in ageing. Nutrition Bulletin. 2017;42:61-8.
- Pouyet V, Giboreau A, Benattar L, Cuvelier G. Attractiveness and consumption of finger foods in elderly Alzheimer’s disease patients. Food Quality and Preference. 2014;34:62-9.
- Smith K, Greenwood C. Weight loss and nutritional considerations in Alzheimer disease. Nutrition for the elderly. 2008;27.
- Tapsell Le. Evidenced Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care. Nutrition & Dietetics. 2009;66(3):S1S34.
- Watson R. Weight increase in patients with dementia, and alteration in meal routines and meal environment after integrity promoting care: Commentary. Clinical Nursing. 2008;17(9):1246-47.
- Watts V, Turnpenny B, Brown A. Feeding problems in dementia. Neurology. 2007;15.
- Wen L, Jooyoung C, Thomas S. Interventions on mealtime difficulties in older adults with dementia: A systematic review. International Journal of Nursing Studies. 2014;51(1):14-27.
Clinical Dietitian, Nutrition and Dietetics Department
Hornsby Ku-ring-gai Hospital
Northern Sydney Local Health District
Manager, Nutrition and Dietetics Department
Hornsby Ku-ring-gai Hospital
Northern Sydney Local Health District