LONG-TERM CARE AROUND THE GLOBE

Dietary and Fluid Intakes of Older Adults in Care Homes Requiring a Texture Modied Diet: The Role of Snacks
Elaine Bannerman, RD, PhD, and Karen McDermott, MSc Objective: To evaluate and compare energy, protein, non-starch polysaccharide, and uid intakes of a care home population consuming a texture modied diet (TMD) with those on a standard diet and also to evaluate the role of snacks in individuals diets. Design: Cross-sectional study. Setting: Care homes. Participants: Thirty residents (n 5 15 requiring standard diet: n 5 15 requiring TMD). Measurements: Dietary intakes were assessed using a 3-day weighed plate-wastage method. All snacks and drinks consumed were observed and recorded. Weights of standard portions and volumes were used to determine actual amounts consumed of these items. Estimated intakes were converted to energy and nutrient intakes using WinDiets Dietary analysis software. Results: Residents on a TMD had signicantly lower intakes of energy (1312 [326] kcal versus 1569 [260] kcal, P \ .024), non-starch polysaccharide (6.3 [1.7] g versus 8.3 [2.7] g, P \ .02) and uid (1196 [288] mL versus 1611 [362] mL, P \ .002) when compared with residents on a standard texture diet. Snacks provided signicantly less energy (13% or 173 kcal versus 22% or 343 kcal, P 5 .001) and non-starch polysaccharide (P \ .001) in those requiring the TMD. Conclusions: These results suggest that dietary and uid intakes of older adults in care homes requiring a TMD are signicantly less than individuals on a standard texture diet. These are unlikely to be meeting individuals dietary and nutritional needs. Strategies that maximize provision of appetizing energy and nutrient-dense foods (including snacks) and uids of suitable textures require further investigation. (J Am Med Dir Assoc 2011; 12: 234239) Keywords: Older adults; texture modied diets; care homes; undernutrition

Care homes in Scotland are currently inspected against the National Care Standards for care homes for older people in Scotland.1 Covered under these standards are elements to ensure that residents are eating well and include for example that You have . choices in courses in your midday and evening meals and You should have snacks and hot and cold drinks

Dietetics, Nutrition & Biological Sciences, School of Health Sciences, Queen Margaret University, Edinburgh, Musselburgh, UK (E.B., K.M.). The authors have declared they have no conicts of interest. Address correspondence to Elaine Bannerman, RD, PhD, Dietetics, Nutrition & Biological Sciences, School of Health Sciences, Queen Margaret University, Edinburgh, Musselburgh EH21 6UU, UK. E-mail: Ebannerman@qmu.ac.uk

Copyright 2011 American Medical Directors Association DOI:10.1016/j.jamda.2010.06.001 234 Bannerman and McDermott

whenever you like.1 These are applicable to all residents and need to consider other dietary and nutritional needs. A United Kingdomewide survey of risk of malnutrition (as dened by the malnutrition universal screening tool, MUST) in individuals admitted to care homes (n 5 75 homes; n 5 614 residents) in the previous 6 months was 42% (30% high risk, 11% medium risk).2 Over half the residents had neurological conditions (54%) with an associated malnutrition prevalence of 43%. Texture modied diets (TMD) are often prescribed for the clinical management of individuals for example with degenerative neurological conditions, dysphagia after stroke, and individuals with poor dentition. The need for a TMD may increase individuals risk of undernutrition as it often reduces food choice, may be less energy and nutrient dense owing to the need for the addition of uid to foods to achieve the desired texture, and may be
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Table 1.

Estimated Energy and Protein Intakes of Populations in Acute and Long-Stay Care Settings on Standard and Texture Modied Diets Population Standard Diet (STxD) n Energy, kcal 2153 1380 1123 1461 1569 Protein, g 88 56 49 60 50 TMD n 20 20 101 30 15 Energy, kcal 1786 1291 919 926 1281 Protein, g 78 56 44 40 43 CMS method CMS method VRS Plate wastage Plate wastage Yes Yes No Yes Yes Assessment Snacks

First author (year)

Johnson (1995)4 Johnson (1995)*,4 Nowson (2003)5 Wright (2005)6 Current study

Residential care (US) Residential care (US) Residential care (Aus) Hospitalised (UK) Care homes (UK)

31 31 114 25 15

Aus, Australia; CMS, consumption monitoring system method uses a record sheet to record the percentage (none, 25%, 50%, 75%, or all) of each menu item consumed; STxD, standard texture diet; TMD, texture modied diet; VRS, visual rating scale uses a record sheet to record the scale (none left, mouthful left, 25%, 50%, 75%, mouthful eaten, all left) of each menu item served; Plate-wastage, weighs all food offered, then all food leftovers to determine the amount of food consumed. * Results from the study4 excluding intake from supplements.

aesthetically unappealing. Also, the very nature of the TMD, in that particular food items identied as high risk are high in non-starch polysaccharide (NSP)3 also suggests that intakes of NSP are likely to be compromised in those individuals requiring this dietary prescription. However few data exist to support whether intakes of NSP and also uid are compromised in this group of individuals in the care home setting. Table 1 summarizes the ndings from studies that have looked at dietary intakes of populations in acute and longstay care settings from around the globe requiring a TMD. The methods of dietary assessment used in the long-stay care settings are subjective in nature and thus may be susceptible to reporting errors.4,5 The need for frequent small, energy- and nutrient-dense foods and uids has been proposed as necessary to optimize opportunities for individuals with impaired appetite and/or increased needs to maximize food and uid intakes.7,8 There is little known about the role that snacks play in the energy intake of older individuals in long-stay care. It is suggested that snacks are likely to be a key aspect of food and uid provision for those requiring a TMD.7e9 The Food Standards Agencys guidance on food served to older people in residential care in the United Kingdom recommends that snacks (food served between meals) should contribute 20% of total energy intake.10 Availability and choice of suitable texture snacks is anecdotally thought to be poor and thus may contribute to poor dietary intakes. The aim of this study was to evaluate and compare energy, protein, NSP, and uid intakes of a care home population consuming a TMD with those on a standard texture diet (STxD) and, with UK dietary reference values (DRVs),11 to evaluate the role of snacks in the diets of older adults consuming an STxD and TMD in care homes. METHODS This was a cross-sectional observational study of the dietary intakes of and food service practices for residents consuming a STxD and residents consuming a TMD from 3 privately managed care homes in central Scotland. Recruitment of Care Homes Three care homes were chosen at random from those care homes within the City of Edinburgh, Scotland, registered
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with the Care Commission. Each home was then approached regarding their involvement in the study. All homes were privately managed care homes in the City of Edinburgh, although all had to meet specic standards to be registered with the Scottish Commission for the regulation of care.1 Participants All residents (males and females, aged .60 years) within the 3 care homes were eligible to participate. Exclusion criteria included residents who were younger than 60 years, nil by mouth (no oral food or uid intake), were receiving articial nutritional support, had a uid restriction, were acutely unwell at the time of data collection period, or those who were receiving palliative care. National descriptors for stages of food and uid texture modication for adults in the United Kingdom have been developed jointly by the British Dietetic Association and the Royal College of Speech and Language Therapists3 and were used to categorize residents for type of diet being followed. Residents on an STxD were randomly selected from the register in each care home. The selection of residents on a TMD was not random because of the relatively small number of suitable residents available. Informed consent was obtained or for those unable to consent, carer approval was sought. Each participating residents care home notes were used to ascertain information including date of birth, sex, weight, height, body mass index (BMI), and level of cognition. Documented information on individuals dietary and uid needs, including appropriate texture, use of nutritional supplements, and assistance required with meals, were also collected. Residents were weighed using a chair scale or a sling scale (0.1 kg). Dietary Assessment Dietary intake was assessed using 3-day weighed food intake by one researcher. Data were collected on 2 midweek days and 1 weekend day for each subject to account for staffing, food provision, and differences in eating habits that may occur at weekends. The researcher was present in each care home from 8 AM until at least 8 PM during each day of data collection. Night staff were provided with a list of residents taking part in the study each evening and asked to record any uid or food intakes during this time period.
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Data were collected on a maximum of 5 residents on any 1 day. This has previously been shown to work practically to obtain accurate weighed dietary intakes.12 Food was weighed before residents received their meal using Salter electronic kitchen scales (accurate to 1 g) (Salter Housewares; Tonbridge, Kent, UK). All attempts were made by the researcher to ensure data were collected in an unobtrusive and efcient manner to avoid any effect on the timing or temperature of residents meals. All food left on the residents plate after the meal (waste) was weighed after the resident had nished eating.13 All attempts were made to weigh individual food items, both before the meal was received by the resident and when the resident was nished. If it was not possible to weigh component parts of the meal, as components had been blended together or had been mixed during the eating period, eg, milk and cereal, then details of the recipes used were noted and the relative proportions determined based on the portion size offered. When relevant, oral nutritional supplement intake was assessed and all supplement wastage was weighed. Snack provision was observed and recorded. For the purpose of this study, a snack was dened as any food or drink consumed outside the 3 main meals of the day, ie, breakfast, lunch, and the evening meal. Standard food items were not weighed, eg, biscuits, pot of yogurt. If a nonstandard food item was provided as a snack, eg, slice of cake, an average weight was used for all residents consuming that item. Any leftovers were weighed to determine amount consumed. Fluid intake was measured by determining standard weights for full cups of uid consumed along with observation of any
Table 2.

waste. This study focused on uid intake from beverages and also uid ingested from foods, as it was anticipated that through food texture modication this study population could consume a signicant amount of uid from food. Dietary and uid intakes were analyzed to estimate energy and nutrient intakes using WinDiets (WinDiets, 2005; Robert Gordon University, Aberdeen, UK). Dietary intakes were compared with UK Dietary Reference Values.11 The estimated average requirement (EAR) for energy, the reference nutrient intake (RNI) for protein, and the dietary reference value for NSP were compared with the dietary intakes of the 2 groups. The number of residents meeting estimated requirements was also calculated. Fluid requirements were calculated as 30 mL per kilogram body weight.14 A minimum requirement was set at 1500 mL/day.15 Data Analysis Statistical analyses were carried out using SPSS v15.0 (SPSS 2005, IBM; Chicago, IL). One-sample t tests were used to compare results with UK Dietary Reference Values11 and calculated uid requirements.14 Independent-sample t tests were used to compare results between the 2 groups. A P value less than .05 was deemed to be statistically signicant. Ethical approval for the study protocol was obtained from the University Research Ethics Committee. The manager of each care home gave consent for the study to take place within their care home.The manager or a member of staff allocated by the manager decided if each resident had capacity to give consent or if consent was required from a legal

Demographics of Residents on a Standard or Texture Modied Diet STxD (n 5 15) Mean SD 3.7 0.08 10.1 2.8 95% CI 86.7e90.7 1.56e1.66 52.5e63.6 20.5e23.7 TMD (n 5 15) Mean 87.4 1.57 46.3 18.4 9/15 0 6 9 11 4 2 3 10 0/15 k SD 7.1 0.06 8.1 2.6 95% CI 83.5e91.3 1.54e1.61 41.8e50.8 16.9e19.8 .52 .23 .001 .001 P Value*

Age, y Height, m Weight, kg BMI, kg/m2 BMI \18.5 kg/m2 Cognitive status No impairment Minimal impairment Dementia/ Alzheimer Need for TMD Texture C Texture D Need for assistance with meals No assistance Limited assistance Assistance Males/Females

88.7 1.61 58.1 22.1 1/15 7 5 3 d d 11 2 2 5/10

STxD, standard texture diet; TMD, texture modied diet; SD, standard deviation; BMI, body mass index; CI, condence interval. * Comparison of age, height, weight and BMI of residents on a STxD (n 5 15) and residents on a TMD (n 5 15), using an independentsamples t test. A P value \ .05 was considered statistically signicant. Indicates statistically signicant difference between the 2 groups. Texture C e a thick smooth uniform consistency, a food that has been pureed or sieved to remove particles, will hold its own form on the plate.3 Texture D e food that is moist with some variation in texture, has not been sieved or pureed, can be mashed with a fork, for example sh in sauce.3 k Energy from snacks, non-starch polysaccharide, and uid intake of residents requiring no assistance (n 5 13) were signicantly greater than residents requiring assistance (n 5 17) (P \ .05).

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Table 3. Mean (SD) Estimated Daily Intakes (Including Supplements) of Energy, Protein, Non-starch Polysaccharide and Fluid of Residents on a Standard Diet or Texture Modied Diet DRV STxD (n 5 15) Mean Energy, kJ Energy, kcal Protein, g NSP, g Fluid, mL EAR EAR RNI 18 30 mL per kilogram body weight14,15 6588 1569 49.6 8.3 1611 SD 1096 260 10.4 2.7 362 95% CI 5981e7194 1426e1713 44e55 6.7e9.7 1411e1812 TMD (n 5 15) Mean 5495 1312 44.4 6.3 1196 SD 1364 326 12.4 1.7 288 95% CI 4740e6250 1131e1493 37.5e51.3 5.3e 7.2 1036e1355 .02 .02 .23 .03 .002 P Value*

NSP, non-starch polysaccharide; StxD, standard texture diet; TMD, texture modied diet; SD, standard deviation; CI, condence interval; DRV, dietary reference value; EAR, estimated average requirement; RNI, the reference nutrient intake. * Comparison of energy, protein and uid intake of residents on a STxD (n 5 15) and residents on a TMD (n 5 15), using an independentsamples t test. A P value \ .05 was considered statistically signicant. Indicates statistically signicant difference between two groups. Mean intakes were signicantly less than recommendations11 and estimated uid requirements14 using a 1-sample t test (P \ .001).

guardian/next of kin. Potential subjects were provided with written and verbal information before consent was obtained. RESULTS Thirty individuals (n 5 15 STxD: n 5 15 TMD) were recruited (response rate n 5 30/31). Table 2 provides a comparison of the nutritional health and dietary needs of the 2 groups. Individuals requiring a TMD were of poorer nutritional status, had poorer cognitive state, and had greater need for assistance with eating and drinking than individuals requiring an STxD. Table 3 presents a comparison of the estimated energy, protein, NSP, and uid intakes of the 2 groups. Residents on a TMD had signicantly lower intakes of energy (1312 [326] kcal compared with those on an STxD 1569 [260] kcal, P \ .024). There was no statistically signicant difference in protein intakes of individuals requiring a TMD or STxD. Intakes in both groups met the DRV. In terms of food service practice, menu items for main meals that needed texture modied were generally blended along with a sauce; for example, gravy, parsley sauce, and white sauce were not just diluted with water. One home added extra cream to all the desserts of residents on a TMD. Residents on the TMD were estimated to be consuming on average 35% of the DRV for NSP (6.3 [1.7] g), which was signicantly less than intakes of individuals consuming an STxD (8.3 [2.7] g, P \ .02; 46% of DRV). Not one residents intake met the DRV for NSP irrespective of which diet they were following. Two of the care homes did not modify the texture of the vegetable component of the meal, even when the meat or alternative component was blended. If vegetables were blended, they were blended along with the meat/sh component of the meal and a sauce resulting in an unrecognizable meal. Residents on a TMD were served high-risk foods, including pineapple in a blended fruit salad, tomatoes in a blended cheese and tomato quiche, mixed consistency foods, eg, soup with lumps, and crumbly items including dry biscuits. Drinks were provided at all meal and snack times (minimum of 6 occasions in each home). In each care home, these included a choice of tea, coffee, Ovaltine (Associated British
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Foods; London, UK), hot chocolate, Horlicks (GlaxoSmithKline; London, UK), or milkshake. Fluid intakes of residents (calculated from food and drinks) on a TMD (1196 [288] mL) were signicantly less than intakes of residents on a standard texture diet (1611 [362] mL, P \ .002). Only 5 residents on an STxD and 1 resident on a TMD met their estimated uid requirements. Individuals requiring a TMD on average only achieved three quarters of the estimated uid requirements. Two residents required thickened uids; analyses excluding these individuals did not provide different results. Snacks Snacks consumed provided signicantly less energy (13% [173 (110) kcal] versus 22% [343 (147) kcal], P 5 .001) and NSP (P \ .001) in those requiring the TMD. Snacks were provided in each care home 3 times per day at the following times: mid-morning 1030 to 1100 hours; midafternoon 1500 hours; evening snack1930/2030/2100 hours. Several residents were in bed when the evening snack was offered and thus missed out on this eating occasion. Snacks provided included a variety of semisweet biscuits, fun-size bars, and baked items, and sandwiches for evening snacks. None of the care homes provided snacks suitable for residents requiring either a texture C or texture D diet. Soaking solutions were not used to make snacks a suitable texture, although biscuits were dipped in hot drinks. Assistance with Eating and Drinking Thirteen of 15 individuals requiring a TMD required assistance with eating and drinking (compared with 4 of 15 requiring a standard diet) (Table 2). Intakes of energy, NSP, and uid were signicantly less in individuals requiring assistance with eating and drinking compared with those who were independent. Observational assessments revealed that some residents who required assistance to eat and drink missed some meals, as there was insufcient staff available to provide assistance. DISCUSSION The ndings of the study suggest that dietary and uid intakes of older adults in care homes requiring a TMD are
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signicantly less than individuals on an STxD and are unlikely to be meeting individuals dietary and nutritional needs, in particular energy, NSP, and uid requirements. These ndings are in agreement with ndings of the study of hospitalized patients in the United Kingdom6 and also ndings in residential care in Australia.5 Wright et al6 showed that hospitalized individuals requiring a TMD consumed signicantly less energy and protein compared with those on a normal-textured hospital diet. The poor dietary intakes reported in hospitalized patients (acute care) and also older adults in long-stay care in the current study may be contributing to the high prevalence of undernutrition (BMI \18.5 kg/m2)2 that is seen in these populations (Table 2). Consequences of undernutrition are well documented and include vulnerability to infection, delayed wound healing, decreased muscle strength, and depression.16 Positive practices in terms of food fortication and avoidance of high-risk foods varied signicantly. Training is required to ensure standardized food fortication and provision of suitable foods that carry minimal health risks for the resident. There are a number of different methods proposed for estimating uid requirements.17,18 The method used in the current study has previously been used19e21 and shown to be adequate for preventing dehydration in the elderly population.20 As such, the poor uid intakes reported in this study are a cause for concern. Poor uid intakes along with poor NSP intakes suggest residents, in particular those on the TMD diet, are at increased risk of constipation. Constipation is a common problem in older adults; laxative use increases with age and at times multiple agents are used to relieve symptoms of constipation.22 Dietary factors that may contribute to this can include reduced ber (insoluble NSPs) and uid intakes. Age-related changes in thirst sensations make older adults more vulnerable to developing dehydration, which in turn can lead to alterations in both physical and psychological functioning.23 Whelan19 highlighted that uid intakes were insufcient in a group of hospital patients that required thickened drinks (mean [SD] intake 1197 [485] mL, n 5 24). Constipation could further compromise already reduced appetites. Thus, further assessment of bowel function along with assessment of medication usage and activity levels is warranted. The Royal College of Nursing and the National Patient Safety Agency have created a Hospital Hydration Best Practice Toolkit,17 which provides practical advice on how to minimize the risk and potential harm that dehydration can cause, and offers solutions to improving the provision of water to patients in hospitals. Water UK had previously produced the resource Water for Healthy Ageing Hydration Best Practice Toolkit for Care Homes.24 Both of these resources can be used to develop practices that encourage the elderly to increase their uid intake. The provision and choice of appropriate textured snacks for individuals requiring a TMD is signicantly limited in care homes studied and is likely to be compromising overall dietary and nutrient intakes. This study has shown that individuals requiring a TMD have signicantly lower energy intakes from snacks and subsequently poorer overall energy
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intake. This study reports that a group of residents requiring a TMD consumed signicantly less energy from snacks (mean 173 kcal, SD 110 kcal) than residents on an STxD (mean 343 kcal, SD 147 kcal, P 5 .001). Observational ndings regarding the provision of snacks to residents in the 3 care homes in this study showed that some of the possible reasons for this reduced intake include lack of assistance at snack times, provision of inappropriate snacks, and timing of snack provision. Although snacks, like meals, were provided as set times throughout the day in all 3 care homes, in 2 of the 3 care homes staff did not dedicate this time to assisting residents who required assistance. A member of staff was assigned to the provision of snacks but if another member of staff was not in the room or the area of a resident requiring assistance, that resident did not receive anything from the snack trolley. On occasion, a member of staff would approach the trolley and indicate that he or she was going to assist a resident with a snack. The lack of sufcient numbers of individuals to assist with eating and drinking at snack and mealtimes is likely to have a negative impact on energy intakes from snacks. Wright et al25 showed that targeted feeding assistance resulted in higher energy and protein intakes from meals and supplements. If residents appetites are poor and intakes are compromised, then the role of snacks in terms of meeting nutritional requirements becomes very important. The provision of a choice of snacks of suitable textures along with assistance to consume these would be key areas to improve intakes. In the current study, snacks provided included a range of biscuits, shortbreads, fruit cakes, cream cakes, sponge cakes, and white or wholemeal bread sandwiches with a range of llings along with drinks that included tea, coffee, milk, Horlicks, Ovaltine, hot chocolate, water, and sugar-free diluted squash (a low-calorie diluting fruit drink). Snacks provided were in general not suitable for residents following texture C or texture D diets. A soaking solution can transform nonsuitable items, eg, bread and crackers, into an appropriate texture but these were never used. Biscuits were on occasion dipped into tea but this was the only adaptation made and it is likely that individuals would end up with mixed textures that are not suitable if they should be following a texture C diet. Two of the 3 care homes had yogurts, but these were available only at breakfast and not used for mid-meal snacks throughout the day. Both positive and negative care home practices were observed during the study period. Safety issues were highlighted in relation to residents receiving high-risk foods that could cause choking, lack of choice of snacks of suitable texture, and not all meal components being texture modied or to the appropriate level. There appear to be gaps in the dietary and nutritional knowledge of some members of staff. Some staff members fortied residents meals whereas others did not. Making food fortication a standard practice within the care homes seems to be a possible area for improvement; however, evidence that clearly outlines what level of fortication maximizes food and nutrient intakes is lacking in the literature. Attention to safety concerns, and improving presentation and aesthetics of TMD could be addressed through staff
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training; for example, improvements in the preparation of modied meals, eg, blending of vegetables. Provision of a choice of suitable-texture snacks could enhance overall dietary intakes, as has been seen in some but not all populations.25 The need for assistance with eating and drinking is extremely common in residents within long-stay care settings,26,27 both those on a standard diet and those individuals requiring a TMD. A lack of sufcient trained staff to provide this assistance may be contributing to inadequate dietary intakes and poor nutritional health. It was not possible to analyze the impact of requiring assistance by meal texture, because of small subject numbers. The strengths of this study are that all meals were weighed and set snack times were observed, which provides a more quantitative assessment of food intakes than some of the previous studies reported.4,5 However, the study is not without limitations. Fluid intakes were not weighed but estimates using standard cup weights along with observation of how much of a cup was drunk were used. This method is the most common method used in uid intake studies but it does bring an element of error to the study. Hydration states were not assessed in this study, although they warrant further investigation. Assessing urine output would have increased the validity of the results. Resident demographics were not consistent across the 2 groups but it is unclear if there is a causal or consequential relationship. Energy requirements were based on recommendations11 that are aimed at a healthy population and thus may be an overestimate of the energy requirements of the group. It is worth noting that owing to staff being aware of residents taking part in the study, any food or drink consumed by residents requiring assistance with food and drink would have been less likely to be missed by the researcher than residents with the ability to feed and/or procure food and drink for themselves or residents with visitors. CONCLUSIONS This small study highlights the need for development and further investigation of strategies that maximize provision of appetizing energy- and nutrient-dense foods, including snacks of suitable textures. Identifying the optimal level of fortication to maximize food intakes, considering not only the nutritional content of such foods but also the aesthetic properties of the food to ensure that is enjoyed by the residents has to be considered in the development of such recipes and food choices. REFERENCES
1. Care Commission. National Care Standards for care homes for older people in Scotland, 2007. Available at: http://www.scotland.gov.uk/ Resource/Doc/205928/0054733.pdf. Accessed June 4, 2008. 2. Russell CA, Elia M. Nutrition Screening Survey in the UK in 2008. Hospitals, care homes and mental health Units. BAPEN. 2009. Available at, http://www.bapen.org.uk/pdfs/nsw/nsw_report2008-09. pdf. Accessed January 19, 2010. 3. British Dietetic Association and Royal College of Speech & Language Therapists. National Descriptors for Texture Modication in Adults. Birmingham: British Dietetic Association; 2009.

4. Johnson RM, Smiciklas-Wright H, Soucy IM, Rizzo JA. Nutrient intake of nursing-home residents receiving pureed foods or a regular diet. J Am Geriatr Soc 1995;43:344e348. 5. Nowson CA, Sherwin AJ, McPhee JG, et al. Energy, protein, calcium, vitamin D and bre intakes from meals in residential care establishments in Australia. Asia Pac J Clin Nutr 2003;12(2):172e177. 6. Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a texture modied diet with a normal hospital diet. J Hum Nutr Diet 2005;18:213e219. 7. National Association Care Catering. Menu planning and special diets manual. West Sussex: NACC; 2006. 8. Scottish Government. Food in hospitals: Catering and nutrition specication for food and uid provision and nutritional care in hospitals in Scotland. Edinburgh: Scottish Government; 2008. 9. Gall MJ, Grimble GK, Reeve NJ, Thomas SJ. Effect of providing fortied meals and between-meal snacks on energy and protein intake of hospital patients. Clin Nutr 1998;17:259e264. 10. Food Standard Agency. FSA nutrient and food based guidelines for UK institutions 2007. Available at: http://www.food.gov.uk/multimedia/ pdfs/nutrientinstitution.pdf. Accessed September 5, 2008. 11. Department of Health. Dietary Reference Values for food energy and nutrients for the United Kingdom. London: TSO; 1991. 12. Leydon N, Dahl W. Improving the nutritional status of elderly residents of long-term care homes. J Health Serv Res Policy 2008;13:25e29. 13. Bingham SA. The dietary assessment of individuals: Methods, accuracy, new techniques and recommendations. Nutr Abstr Rev 1987;57: 705e742. 14. PEN Group. A Pocket Guide to Clinical Nutrition. Adult requirements for uid and electrolytes. P. 3.9. Birmingham: British Dietetic Association; 2004. 15. Department of Health. Nutrition Guidelines for Hospital Catering: The Health of the Nation, Nutrition Task Force. UK: DH. Wetherby; 1995. 16. Nice Guideline 32. Nutrition support for adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. 2006. Available at: http://www.nice.org.uk/nicemedia/pdf/cg032fullguideline.pdf. Accessed August 4, 2008. 17. Royal College of Nursing and the National Patient Safety Agency. Hospital Hydration Best Practice Toolkit. 2007. Available at: http://www. rcn.org.uk/newsevents/campaigns/nutritionnow/tools_and_resources/ hydration. Accessed September 5, 2008. 18. American Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulphate. Washington, DC: National Academies Press; 2004. 19. Whelan K. Inadequate uid intakes in dysphagic acute stroke. Clin Nutr 2001;20:423e428. 20. Holben DH, Hassell JT, Williams JL, Helle B. Fluid intake compared with established standards and symptoms of dehydration among elderly residents of a long-term-care facility. J Am Diet Assoc 1999;99: 1447e1450. 21. Chernoff R. Thirst and uid requirements. Nutr Rev 1994;52:S3eS5. 22. Tariq SH. Constipation in long-term care. J Am Med Dir Assoc 2007;8: 209e218. 23. Mentes J. Oral hydration in older adults: Greater awareness is needed in preventing, recognizing, and treating dehydration. Am J Nurs 2006;106: 40e49. 24. Water UK. Water for Healthy Ageing Hydration Best Practice Toolkit for Care Homes 2005. Available at: http://www.water.org.uk/home/ water-for-health/older-people/care-homes-toolkit/hydration-toolkit-forcare-homes.pdf. Accessed September 5, 2008. 25. Wright L, Cotter D, Hickson M. The effectiveness of targeted feeding assistance to improve the nutritional intake of elderly dysphagic patients in hospital. J Hum Nutr Diet 2008;21:555e562. 26. Tsang MF. Is there adequate feeding assistance for the hospitalised elderly who are unable to feed themselves? Nutr Diet 2008;65:222e228. 27. Westergren A, Karlsson S, Andersson P, et al. Eating difculties, need for assisted eating, nutritional status and pressure ulcers in patients admitted for stroke rehabilitation. J Clin Nurs 2001;10:257e269.

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