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Evaluation article: Causes of refusal to eat and drink

Published: Monday, 14 September 2015

Tim Dallinger looks at the reasons why some people may refuse to eat or drink, and discusses techniques to help manage the situation.

Summary

  • Everyone is entitled to food and drink of adequate quantity and quality.
  • Refusal to eat and drink compromises both personal and professional ethics.
  • There are many reasons why a person may turn down food and drink.
  • Identifying the potential cause of refusal to eat and drink is important.
  • Knowing the person well enables a person-centred eating and drinking plan to be implemented.

Meeting nutritional needs is part of Regulation 12 of the Health and Social Care (Regulated Activities) Regulations 2014. In this article we explore some of the reasons why people may refuse nourishment and hydration and discuss some techniques which may help those who care for them to manage this situation.

One of the most difficult situations any care professional has to face is when someone in their care refuses to eat or drink. This situation evokes a range of powerful emotional responses as it compromises both personal and professional ethics.

Everyone is entitled to food and drink of adequate quantity and quality and to the help they need to eat and drink. Malnutrition and dehydration can be both a cause and consequence of ill health, so maintaining a healthy level of nutrition and hydration can help to prevent or treat illness and symptoms and improve treatment outcomes for people. Care providers have a legal obligation to keep the nutrition and hydration status of people in their care under review. It is essential that nutrition and hydration are being provided in a way that meets peoples’ individual needs, and that if necessary people are being given adequate help to enable them to eat and drink.

Identifying the potential cause of refusal to eat and drink

Identifying the potential cause of refusal to eat and drink is important. There are many reasons why a person may turn down food and drink. These include:

  • depression
  • communication
  • pain
  • tiredness
  • medication
  • physical activity
  • constipation
  • co-ordination
  • recognising food and drink
  • concentration
  • chewing and swallowing
  • temperature
  • eating behaviours
  • changes in eating habits and food preferences
  • voluntary stopping eating and drinking.

Depression

Loss of appetite can be a sign of depression. There are effective treatments for depression, including medication and other therapies. If you suspect that this is the problem, consult the persons’ GP for advice.

Concentration

Some people may not be able to concentrate well, which means they may have difficulties focusing on a meal until it is finished. This may be because they are tired. Don’t assume someone has finished because they have stopped eating. Finger foods and smaller portions can help to make the task easier. If you are helping someone to eat and it goes on for too long, it can turn into a negative experience. The food can become cold or the process may be overwhelming.

Chewing and swallowing

A person may have difficulties with chewing food. They may forget to chew or they may hold food in their mouth. Certain foods, such as sweetcorn or dry biscuits, may be more difficult for the person to chew or swallow. These should be avoided.

Good oral hygiene is important. If the person is experiencing pain in their mouth it will make chewing uncomfortable and difficult.

Often with conditions such as dementia swallowing difficulties (called dysphagia) become more common, although they can vary from person to person. If a person is having difficulty with swallowing, a referral to a speech and language therapist can help. Difficulties can include holding food in the mouth, continuous chewing, and leaving harder-to-chew foods (eg hard vegetables) on the plate. Weight loss, malnutrition and dehydration can also be consequences of swallowing difficulties. If the person is drowsy or lying down, they may struggle to swallow safely. Ensure that they are alert, comfortable and sitting upright or, if in bed, well positioned, before offering food and drink. A physiotherapist can advise on positioning techniques and an occupational therapist can advise on aids for eating and drinking.

Temperature

Some people will lose the ability to judge the temperature of food. Make sure food is not too hot, as it could burn the person’s mouth and result in eating becoming uncomfortable.

Eating behaviours

People may refuse to eat food or may spit it out. This may be because they dislike the food, are trying to communicate something such as the food being too hot, or they are unsure what to do with the food. The person may become angry or agitated or exhibit challenging behaviour during mealtimes. This can be for a variety of reasons, such as:

  • frustration at any difficulties they are having
  • feeling rushed during mealtimes
  • the environment they are in
  • the people that they are with
  • or not liking the food.

They may not want to accept assistance with eating. It can be a challenge to identify what the problem is, particularly if the person is struggling to find the words to explain it. It is important to remember that these reactions are not a deliberate attempt to be ‘difficult’, or a personal attack. Try not to rush them, and help them maintain as much independence as possible. Look for non-verbal clues such as body language and eye contact as a means of communication. If a person is agitated or distressed, do not put pressure on them to eat or drink. Wait until the person is calm and less anxious before offering food and drink.

Changes in eating habits and food preference

People with dementia often experience changes in eating habits, both in terms of how much food they eat and when, and what food they prefer. As a person gets older it is common for the senses of taste and smell to decline, which can lead to food being less palatable. People may have a preference for additional sugar and salt. It is not uncommon for people with dementia to develop a fondness for sweet foods. People with dementia may enjoy unusual flavour combinations or ways of eating. Often people mix sweet and savoury food and flavours. People may start to have a less varied diet, only eating certain types of food. Damage to specific parts of the brain or a change in taste perception may mean some people start to enjoy tastes they never liked before or dislike foods they always liked, so those providing food should try to be flexible. People with Alzheimer’s disease can show even greater problems with their sense of smell, especially with odour memory.

Voluntary stopping eating and drinking (VSED)

This refers to the decision by a person to stop eating food and drinking liquids when they have a terminal or life-limiting disease, so that their death can be hastened (and therefore their dying will not be prolonged). VSED is thought to be relatively painless and most people die within 10 days from the time they have no more fluids or food.

Knowing the person well

Knowing the person well enables a person-centred eating and drinking plan to be implemented. There are lots of ways to stimulate appetite and interest in food and drink. Knowing the person will help, as everyone has their own routines, preferences and needs. You will also have a better idea about their likes and dislikes. This will enable you to develop a person-centred eating and drinking plan which will form part of their overall care plan.

Toolkit

Use the following items in the Toolkit to help you to put the ideas in this article into practice:

About the author

Tim Dallinger provides training and consultancy services to care homes, care agencies and local authorities with an emphasis on practical techniques that work in the real world. You can contact Tim via email (This email address is being protected from spambots. You need JavaScript enabled to view it.)

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