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Dementia

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Charnelle Vincent

on 27 December 2013

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Transcript of Dementia

Memory Loss
Person Directed (Centered) Care:
Life
DOES NOT
end with a diagnosis!
What does this mean?
Why do we use this?
Dignity:
How would you want your family member treated?
A person is a psychological, spiritual, physical, and social be. The parts overlap and CANNOT be separated.
Everyone must have their physical needs met before quality of life can be established. In contrast, to consider only the physical part of a person is to ignore their ability to think, make decisions, and interact with others.
Communication: The Process of Sharing Information With Others
Communication includes both verbal and non-verbal messages. They must agree to send a clear message.
Most of what we say is communicated through our body language.
This includes eye contact, gestures, touch, posture, and spatial relationship
Dementia
A "Memory Impaired" Training Program

At the end of this presentation, you will be able to explore effective interventions that can be used to provide the person directed (centered) care that each individual deserves.

We will discuss the following:
Brain Failure
Safety
Person Directed (Centered) Care
Dignity
Communication
Dietary Needs
Brain Failure
Dementia
Alzheimer's Disease

What is brain failure?
The actual failure of the "operational system" of the body, which is the brain.
Affects all aspects of normal functioning
Causes severe problems with thinking & memory
What is Dementia?
An umbrella term that includes many cognitive loss conditions that are usually progressive & interfere with normal social & occupational activities.
Loss of some or all of the following: language, impulse control, emotional control, sleep rhythm,and self-care.
It is more than just forgetfulness, which is part of normal aging.
Types of dementia:
Vascular/ multi-infarct
Mixed
Parkinson's Disease
Cruetzfeldt-Jakob Disease
Alzheimer's Disease- most widely known form of dementia
Alzheimer's Disease
Approximately 5 million people have AD or related dementia.
Most common form
Features include neurofibrillary plaques and tangles.
Plaques are patches of disintegrated nerve-cell branches
Tangles are tangled clumps of nerve fibers
Loss of brain tissue
Definitive diagnosis only upon autopsy
No known cause or cure.
The Four A's of Alzheimer's
Amnesia: the loss of memory
Agnosia: the inability to recognize people or things
Aphasia: the loss of the ability to use or understand words
Apraxia: the loss of the ability to coordinate purposeful movement
The 5 Classic Changes Associated with Alzheimer's Disease
(JOMAC)
J
udgement impaired
O
rientation impaired (1st to time, then place, then person)
M
emory loss (1st affected is short term memory)
A
ffect inappropriate (Early in the disease emotions are labile, as the disease progresses the affect becomes flat.
C
ognition impaired (Disorderly cognition)
The Levels of Alzheimer's
Level 5: Routines & Repeats - Early Loss
Logic problems
Becomes anxious & frustrates easily
Has trouble with new locations & routines
Tries to maintain control & social behavior
Place & time confusion
Level 4: Task Oriented - Moderate Loss
Looking for what to do and where to be
Believes they can do it; doesn't want help
Uses visual information to figure out what to do.
Can't do an activity if visual prompt is not there
Specific & content in speech are poor
Level 3: Hunting & Gathering - Middle Loss (Touch it, take it, taste it)
Invades other's space to explore
Repeats actions over and over
May taste or eat what they see
Sees in pieces not whole
Uses hands to touch, feel, handle, and hold
Imitates actions
Level 2: Stuck on GO
Very limited communication skills
Can't stop
Poor appetite & intake
Limited visual processing
Imitates your general movements
Gross motor only
Poor hand function
Better with rhythm & repetition
Level 1: Reflexes Rule
Bedbound or chair bound
Unable to communicate verbally
Muscles shorten/ contractures form
Swallowing & eating problems
Still sensitive to voice & noise. Will also respond to touch, movement, and smells
Unable to sit up for any length of time
Can You Imagine??...
" You cannot create memory, but you can create an experience that is as powerful as memory."
-Gentlecare Program

We must remember that Dementia patients
did not ask for Dementia
. They do not say and do things
intentionally
. Our job is to provide them with the
BEST
care and experiences that we can for as long as they are with us.
Impact on Cognition, Behavior, and Psychosocial Functioning
Even though the cerebellum does not initiate movements it interrelates with many brainstem structures in executing a variety of movements like balance and walking.
Tool manipulation and sequencing are lost
Motions and actions are preserved
The cortex shrivels up which damages areas involved in thinking, planning, and remembering.
The fluid-filled spaces within the brain (ventricles) grow larger.
Typically lost- Short term memory, clarity of time and place
Preserved- Long ago memories, emotional memories,confabulation, awareness of familiar versus unfamiliar "stuff"
Let's Play A Game
Understanding
Typically lost-Interpretation of abstract meaning, meaning one can't interpret information, can't make sense of words, and gets off target.
In the early stages they can miss 1/4 of the words spoken. In later stages they can miss 1/2 of the words. At the end they miss most words.
Preserved- can understand concrete meanings, can get facial expression which helps them grasp the message that is being sent
Language/ Speech
Losses include not being able to find the right words, word salad, single phrases
Preserved abilities include singing, swearing/sex words, forbidden words, automatic speech
Music is important especially hymns and childhood songs
Impulse & Emotional Control
Mentality: Think it - say it, Want it - do it, See it- use it
They still desire to be respected, to be in control, and have regrets after actions
These changes are linked with the cerebrum. The cerebrum is concerned with all voluntary muscular activities and interpretation of sensory impulses.
Self-Care Skills
PROGRESSION
Function of many of the body's organs is in jeopardy because of the destruction of the brain
Hunger and pleasure form eating is also destroyed
Amyloid plaques are an abnormal accumulation of protein normally found in dead brain cells. This jumbles and interrupts the thinking process.
The brain becomes unable to tell the body what to do.
Valuing people with dementia and those that care for them
Treating people as individuals
Looking at the world from the perspective of the person with dementia
Providing a positive social environment
Recognize that despite the dementia...there is still a person there!!
Meet the person where they are, and work with them to have a day and a life that is meaningful.
Challenges caregivers to examine attitudes& care practices
View the person 1st, the clinical disease 2nd
Caregivers greatly influence the quality of life and well being of the people they care for
Promotes genuine relationships
Consumers have higher expectations of quality care
Culture Change
Let's make our facilities places where people want to live, versus when they go to die.
We should also be making our facilities places where people want to go to work, versus places where they have to go to work.
Role of the Staff
Understand what reality is for the resident, and mirror it
Mirror means to try to be where they are in their thinking. Wherever their reality is, that's where your thinking MUST be
Don't try to convince or attempt to change their mind. It probably cannot be done!
Relate to them as one human being to another
Help them to hold on to and express their individual identities
All staff should be sensitive to the preference of the residents and their previous habits and routines
Help to compensate for the effects of their illness while supporting their independence
Help them to feel respected, valued, and wanted
Treat them as THEY wish to be treated (NOT the "golden rule")
Make an effort to understand their communication and help them to understand us.
Support them while they express their feelings
GIVE UP LABELS! -- "Whiner, good resident, etc."
When you know the resident, you know their preferences, what upsets them, what pleasures them, etc.
When you know these things you are intervene before behaviors become problems
Choose Your Attitude
Attitudes are contagious. We must not tolerate negativity
Accept full responsibility for all of your choices (even your attitude at work)
A positive attitude is a decision we make moment to moment
We assume that ill people (even children) do pick up messages that demean or depersonalize them,
Even in dementia, nonverbal communication can be received and processed by the resident
Facial expressions & tone of voice must agree in order to send a positive message to a resident
Ask for name of choice or how they prefer you address them
Ask questions, get input from family and friends
Acknowledge feelings (overwhelmed, scared, inadequate)
Figure out how to SLOW DOWN
Identifying Needs
A need is something necessary or desirable for maintaining life and mental well-being
Maslow's Hierarchy of Needs
Consider Bob's Feelings
He built his own home, was a commander on a ship, and received many metals and awards. Now he cannot dress or feed himself. How might he feel about himself?
You must treat all persons with respect. Although it takes more time, encourage them to do as much for themselves as possible. This helps increase self-esteem.
Stay Away From "SCDFU Care"
The old culture of dementia focuses on SCDFU. It stands for: safe, cleaned, dry, fed, and up.
It includes measuring loss, keeping rigorous schedules and routines, using chemical and physical restraints, locking units, and promoting meaningless activities.
It is dreary, boring, and almost like waiting to die.
To provide dignity:
Have courteous and dignified interactions
Give courteous and dignified care
Provide privacy & encourage the resident's self-determination
Help them maintain personal choices and independence
Courteous & Dignified Interactions
Use the right tone of voice
Use good eye contact
Use touch if the person approves
Listen with interest to what the person is saying
Do not yell, scold, or embarrass
Stand or sit as close enough as needed
Gain the persons attention before interacting with him or her
Respect the person's social status
Courteous & Dignified Interactions
Groom hair, beard, and nails as they prefer
Adhere to bathing/hygiene preferences
Assist with dressing in
CLEAN
clothes. Make sure it is the right clothing for the time of day, weather, and personal choice
Make sure dentures, hearing aids, eyeglasses, and other devices are used correctly
Privacy & Self-Determination
Drape properly during care and procedures to avoid exposure and embarrassment
Knock on the door before entering AND WAIT to be asked in (if possible)
Use privacy curtains during care and procedures
Close the room door as they desire
Close the bathroom door when the person uses the bathroom
Close window coverings
Maintain Personal Choice & Independence
Involve them in scheduling activities and care
Allow them to take part in activities according to his or her interests
Allow them to give input regarding their preferences and independence
ELDERSPEAK
Often residents may be denied the dignity and respect of being called by their appropriate titles
Instead, they are called Momma, Grandpa, or sweetheart
Elderspeak is a way of speaking to older adults using baby talk or "dumbing down" the conversation
This type of communication is commonly used when it is assumed that the older person cannot hear or understand what is being said
Referring to their careers or interests as "What did you used to be?" or "Who were you?"
Congratulating simple actions with "Good girl!" or "Good boy!"
Greeting someone who is claerly in their 80s as "Young man" or "Young lady"
Lack of respect for an individual's dignity in care can take many forms and may differ from person to person
Feeling neglected or ignored while receiving care
Being treated more as an object than a person
Feeling their privacy was not being respected during care (exposed on shower chair, door to room not closed during care)
Disrespectful attitude of staff
Having to eat with own fingers rather than being helped to eat
Generally being rushed and not listened to by staff
Have a ZERO TOLERANCE of all forms of abuse!!
Gestures

Help convey information
Maintain the rhythm of speech
Help store and retrieve words
Valuable tools to the cognitively impaired
Those with dementia more often rely on gestures instead of speaking because of the many difficulties that they experience
Non-Verbal Communication
Appearance
Posture
Gait
Facial Expressions
Touch
Space
Territory
NEVER sya or do anything that could upset or distress the person when they are able to see or hear you. Remember that you are communicating with your voice, your face, and your body.
Let the person know you are listening and trying to understand what is being said... and most of all THAT YOU CARE about what is being said!
Avoid criticizing, correcting, interrupting, and arguing
If you don't understand what is being said, then ask the person to point or gesture.
Call the person by name because it helps to orient the person and gets their attention
Talk slowly and clearly
Remember that a person may need extra time to process your request. Repeat information if needed, wait a moment, then ask again.
Touch
An effective method of communicating with the memory impaired
Unfulfilled need for touch may lead to rocking, grabbing, or stroking inanimate objects
May cause negative reactions: Friendly touches on the arm or shoulder are usually accepted. Hugs may or MAY NOT be accepted
Remember that not everyone likes being that close!
Space & Territory
Some residents may be threatened by closeness
Keep distance of 18 inches to 4 feet unless close contact is necessary
Be alert to residents' non-verbal messages (putting arm out to stop you)
Barriers to Communication With the Memory Impaired
Conceptual Loss: Inability to "see" what is not in front of them. Loss of the abstract.
Perceptual Distortions: Can't tell if the design on the rug is raised or not; Can't tell the height of a step; physical closeness or distance can be misleading to them
Inability to Concentrate: Short attention span. Only give one concept at a time when explaining a task.
Keep speech SHORT and SIMPLE

Age changes involve the following:
Impaired hearing, especially the higher frequencies
"S" and "F" sounds are likely to be lost in older ears
Less ability to determine where a sound is coming from
Decreased vision makes lip reading and seeing facial expressions more difficult
Aphasia
The loss or impairment of the power to use or understand speech
Expressive Aphasia- is the loss of the ability to say words
Receptive Aphasia- is the loss of the ability to understand
Which one do you think is lost first?
We must be careful not to quickly write off so-called gibberish and problem behavior as the illogical ravings of dementia. The person-centered approach considers them to be attempts to communicate.
Be careful not to ask open-ended questions
Word Salad
Sometimes due to temporal lobe a resident may have expressive aphasia and their speech will result in a word salad
Example: "This is good and you wear it and it's OK, but it's not up."
Words don't make sense or complete sentences
The most effective method of communicating who a resident who speaks in "word salad", is relying on their tone of voice and body language.
Let's Play A Game!
Communication Is Key
Supply proper nouns with "word searchers" but do not correct them
Do not rush the residents
Never laugh at or make fun of residents' speech/words
Avoid environmental stimuli
In advancing stages, use their first name as they may have forgotten their married name
Awaken a resident with a very gentle touch to the hand or forearm while quietly saying their name
Approach the person with dementia from the front, not the side or rear
Demonstrate an activity that they may be having trouble completing
Remember, Reassurance
Validations of feelings: "I understand that you want to go home."
Reassuring voice tone: Calm and caring
Redirection through questions: "Tell me about home, what do you especially like about your home?"
Redirection through new activity: Give them something to eat or walking with them to an activity
Avoid saying "NO" or other statements like "Don't touch that" or "Stop it"
Safety: Identifying Safety Risks & Considerations
Our goal is to provide a simplified and soothing environment
We attempt to minimize disorientation, distraction, and anxiety
Also, to provide a safe atmosphere that fosters independence
The unit must be safe with alarmed doors that have delayed opening
Areas that are unsafe for the resident are locked (exs. nurses station, equipment, and supply storage)
Lack of clutter in the hallways so that safe ambulation/wandering is possible
Provide shoes, or "grid" socks to minimize falls
The environment should not discourage wandering as this may frustrate the individual, but should provide a safe and comfortable place for wandering
To look at safety issues and risks we have to look at the environment itself
The three components of the environment are: Physical, Social, and Cultural
Physical
Our surroundings, which includes the space we are in, the items within that space, and the sensory input we receive while in that space
A resident with dementia may feel confused and frightened. Creating a safe and comfortable surroundings can help a person feel more relaxed and less overwhelmed
Adapt the Environment
Diffuse glare and bright light by removing mirrors and glass tops
Create an even level of lighting because changes in levels of light can be disorienting to a person with dementia
Use night lights in hallways, bedrooms, and bathrooms to prevent accidents and reduce disorientation
Keep things like carts to one side only
Avoid Injuries
Watch the temperature of water in the rooms and in the shower-rooms
A person with cognitive impairment may experience loss of sensation or may no longer feel heat, cold, or pain
Accidents seem to occur during daily activities such as eating, bathing, and using the bathroom. Staff should take special precaution during these times.
Water temperature should not be hot enough to scald the resident while washing their hands, or turning the water on.
Watch Out For "Hot Foods"
The resident with dementia is not able to know the difference between hot and cold
As their judgement declines they may place dangerous or inappropriate things in their mouth
Just as we must monitor their food intake, we must monitor them taking in their food
Items that are too hot or spicy (hot peppers) should be closely watched if not eliminated.
Temperature of food must be at a level where it will not burn the resident's mouth, or body if spilled (exs. coffee, tea, and soups)
Medications
Nurses must watch residents that take medicine on their own
Med carts MUST be kept locked; Nothing left on top that could injure
Dementia residents can deceive nurses and not swallow their medications
With swallowing difficulties, medications must be crushed or presented in liquid form
Mouths must be opened & checked after ingestion to make sure they are swallowed
After medications are passed, carts need to be moved off hallways and into secure areas
Social
Persons with cognitive impairment lose the ability to recognize familiar objects or people. They are no longer able to interpret what they see
This can lead to falls, conflicts with other persons, and inappropriate use of common objects.
A positive social environment is one where staff and participants feel comfortable with one another, and respect and care for each other
Care provided should be as you would care for a family member, showing kindness and patience in the care you give.
Social interactions can be safety issues for the resident if they perceive harm or danger
Personal Care
Is a very social contact, and can be very stressful for the resident
WE must make sure that they are active in this process, but at the same time that they are safe
Cultural
A culture develops when people work or live together
It also develops when people work toward a positive, inclusive, and supportive culture
The ideal culture respects the ethnic and spiritual backgrounds of all members of the group
Can be accomplished by providing activities that support a sense of community, such as having holiday celebrations, working on fundraisers, and providing programs that celebrate the ethnicity and spirituality of staff and participants while enhancing the safety of the facility
Assessment Skills
Nursing assessment skills HAVE TO BE SUPERB!
Residents are often unable to express needs or complaints. Nurses must know the "norms" for each resident and be alert to the most subtle changes
We must be alert to the subtle changes and be advocates for the resident's health
Assessment is a key factor in finding underlying causes of behavior (history, labs, meds, etc.)
Areas of concern or problems that our residents may develop are: UTI's, arthritis, heart disease, GI disturbances, and every infection that every visitor brings through the door
Pain Assessment
Completed on admission
Initiated upon change in condition- 24 hours pain assessment-monitored each shift
Along with pain assessment, the staff must think of ways to protect the skin. This includes the following: alleviate body ssure, keep the skin clean and dry, promote the circulation by using gentle massage lotion, protect bony areas, and prevent contractures. (For example, have OT assess if a splint/brace will help)
Guidelines to Assessing Pain
Look for physical signs that may indicate illness
Pay attention to nonverbal signs and body language that may indicate discomfort or pain
Be alert to changes in behavior
CLUES!!!!
Rubbing joints
Favoring a limb
Short of breath
Last bowel movement
Eating habit changes
Urine odor
Manipulating genitals
"Out of sorts"

These things could be indicators of a SERIOUS injury or illness
Be an ENABLER!!
Keep the residents safe, while still encouraging them to perform tasks. This will boost their self-esteem!
Staff should be "enablers" rather than "caregivers"
An enabler is an individual who enables a resident to successfully "do for themselves such as ADL's. Caregivers are individuals who take care of or assist the resident with their ADL's
Staff must position themselves to help the residents maintain their "skills" for as long as possible.
Dietary Needs
Mealtimes can present many challenges. A person with dementia may have a poor appetite, loss of interest in food, may forget to eat or that he or she has already eaten
Redesigning Dining
Our goal is to make dining "enhanced" to improve the residents quality of life
How often have we watched residents leave the table with the nutrients so important for health untouched on their plates?
Traditional tray service limits our opportunities to change this scenario.
Offer Choices
Let the residents know about choices and involve them in menu development
Move food preparation closer to residents
Identify the small things that make dining enjoyable, and establish the dining area as the heart of the home
More Choices
Although resident seating choice is always the priority, it can be helpful to encourage those with similar functional ability to be seated together
Regular seating arrangements can offer familiarity and routine; both of which are important in good memory support
Menu Preparation
All meals are prepared as ordered, with the same guidelines as the rest of the facility except: decaffeinated foods/beverages used whenever possible or foods that cause perceptual difficulties are avoided
Have meals reviewed by the registered dietician on a regular basis
Use only the utensils needed for the meal. Also, avoid plastic utensils because of exaggerated bite reflex
Mealtime Suggestions
Set up regular mealtimes
Limit distractions
Keep the table setting simple
Residents should be offered 3 meals per day plus snacks
Adequate fluids should be offered between meals
Finger Foods & Supplements
These help wanderers and also help assist residents to be more independent
This is simple food that is easier to travel with for those who walk. It also makes it easier to feed themselves longer.
Fruit, cereal, cookies, protein bars, and a variety of beverages should be available to residents
These can be given to residents between meals as an alternate to meals when necessary
More Mealtime Suggestions
Calm, pleasant environment
Residents assisted to seats to limit confusion
DISTINGUISH FOOD! Changes in the dementia resident's visual and spatial abilities may make it tough to distinguish food from the plate
Avoid patterned dishes, tablecloths, and place mats that might confuse the person
Give the resident the opportunity to wash their hands. (ex. a warm washcloth)
Make The Occasion Special
Invite the resident to the meal in a positive way. Such as " Dinner is being served." or "You have a table reserved in the dining room."
Escort the resident as if you are going somewhere special
Know what is on the menu so that you can discuss it with the resident on the way
When possible, help the resident walk to the dining room rather than ride in a wheelchair
Some residents do prefer to have breakfast in bed and should be accommodated
Presentation
Begin with the smells of breakfast cooking and coffee perking
Aroma therapy helps encourage the eating experience
Involve residents in the preparation of the dining room when possible (exs. greet others as they arrive, pass out napkins)
Have ALL staff actively assist residents in the dining area
Time to Eat!
We need to change our thinking and consider the best practice
Serving one of course of food at a time can reduce the overwhelming feelings that people with dementia feel when too many items are put before them
Encourage them to feed themselves and assess them for assistive devices as appropriate
Making Changes
We must look at altering the traditional dining practices to offer residents more choice
Exs.: Extended breakfast hours, a large breakfast offer later
We want dining to become an experience, not just a way of getting nutrition into the body.
During the Meal
Know each resident's favorite dishes
Talk with the resident during the meal
Remember that this is a social occasion for the resident . Include residents in other conversations . Do not "talk around" residents . Lastly, when speaking with other staff keep your voices down.
During the Meal Continued
Residents must be allowed to eat at their own pace and never hurried
Ask permission before you do something for the resident
Apologize if the resident is unhappy with the food, even if you had nothing to do with it
Making mealtime an enjoyable experience for residents will make it pleasant for you as well

Drinking
Search for the right cup or glass for dignified drinking
How embarrassing is it to spill your drink?...How frustrating is it to not be able to drink when we are thirsty?
Issues for residents- Cups that are too heavy, handles that are too small, glasses that are too small or too large to hold tightly, liquids that are too thick or too thin to drink can challenge elders (especially if they have dementia)
Real China & Enhancing The Experience
At home we eat on plates that we have chosen, not cafeteria trays
Does a specific color help them identify food and stimulate their appetite?
Just like wheelchairs are transportation, trays are for delivery, not for dining
Delivery of meals to the room may be best accomplished with tray service (Think Room Service)
This should only be for residents who truly choose to dine in their room for their own privacy...not to avoid an atmosphere that is not pleasing to them
Should not be used for staff when rushed for time
Clothing Protectors
Children often protest the wearing of a bib...so why should our elders have to wear them?
WE should try things like a large napkin tucked in or tied, like a lobster dinner in a fine Boston dining experience
In general, we want to use products and assistance that honors each individual resident's quality dining experience above all else.
Poor Eating
The consequences of not eating enough include:
Weight Loss
Pressure Sores
Dehydration
Malnutrition
Fatigue
Confusion
Agitation
Weakness
Skin Breakdown
Less Immunity
Infections
Problems Healing
Risks of Dehydration
Feels less thirst
Becomes dehydrated quicker
Kidneys do not work as well
More swallowing difficulty
Greater use of laxatives
Dependence

Dietary and Nutritional Requirements
Residents need to be interviewed after they are admitted to the facility regarding nutritional history and food preferences
If residents are unable to respond appropriately, family members or friends should be contacted
If food preferences cannot be obtained by interview, then they will be obtained through observation of the resident's eating habits
Typically the Alzheimer resident requires 500-600 more calories per day than the resident without dementia
Restlessness
Often when residents awaken in the night, a warm glass of milk and a snack can replace medications
Weight Loss
Staff should try and encourage eating to prevent rapid weight loss
When a resident with dementia gets sick, they lose weight quickly
Often, they stop eating for no apparent reason. They just quit and refuse to eat
Some residents can consume 4000 calories a day and still lose weight
Dietary Continued
Initial Assessment

An initial nutritional assessment is completed prior to the initial Interdisciplinary Care Conference
Particular attention is paid to content regarding weight history, including present weight in relation to ideal body weight, etc.
A progress note is written at least quarterly, and more frequently if nutritional condition changes

Care Plan
Using a team approach, an Interdisciplinary Care Plan is written within 14 days of admission
Goals are formulated and progress toward these goals is documented. The care plan is updated as necessary to reflect the resident's current condition.
Nutritional care and problems requiring intervention for residents with dementia may include being underweight, recent weight loss, steady weight loss, difficulty swallowing or chewing, inability to eat independently, and inability to communicate food preferences
The goal is to make dining "enhanced" to improve the resident's quality of life.
Mealtime must be calm, and pleasant, offer choices, and have a "home-like" atmosphere
We must look at altering the traditional dining practices to offer residents more choices in the eating
We must continue to monitor for weight loss, and be creative in efforts to keep the resident well fed and hydrated
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