'Light' meals improve nutrition by the footcandle.

You've likely heard the saying: "We ate with our eyes." In the long term care dining room, that adage is especially true.

Aside from the subjective issue of visual appeal, objectively speaking, aging eyes simply can't see as well as their younger counterparts. Add dementia to the mix, and the results can be problematic in terms of functional ability, and disastrous in terms of nutrition.

A recent study sheds light on how administrators can improve the well-being of their residents while reducing overall food waste and potentially trimming costs of subsequent nutritional supplements. Such improvements could also help facilities see more black than red in their bottom line.

It might sound like something off one of those home improvement reality shows, but with a budget $500 a team was able to improve the lighting of two facilities, enabling better nutrition among residents with dementia.

Waning desire

When the desire to eat begins to wane among those with dementia, the first line of defense isn't normally to adjust dining room lighting and contrast. Instead, said Jennifer Brush, a clinical speech-language pathologist (SLP), "Residents are put on liquid supplements to boost their caloric and nutritional intake. But making positive changes to the physical environment can not only make the dining experience more comfortable and positive, the facility can increase the amount of food being consumed at meals, and therefore decrease the amount of liquid supplements they're giving residents."

She added that a social setting is better for residents at mealtimes. "Plus it's less expensive for the facility because they don't have to purchase as many supplements, designate one person to pass them out, and another to keep track of them. So it's a win-win situation."

Long term care facility designer Margaret P. Calkins, Ph.D., is president of I.D.E.A.S., Inc., (Innovative Designs in Environments for an Aging Society), based in Kirtland, Ohio. Along with Rebecca Meehan, Ph.D., she and Brush co-authored the study, Using the Environment to Improve Intake for People with Dementia.

Brush specializes in evaluating the swallowing abilities of LTC residents, working with patients with dementia as well as those who weren't eating well or had decreased their food intake. "Difficulty in swallowing is a trigger to staff to call for an SLP, "she said. For many such residents, "their swallowing abilities were quite functional, yet they had a decrease in intake and an increase in behaviors that affected intake. They'd get up and walk around or take food from other people or be easily distracted."

Brush explained that her work with I.D.E.A.S. has shown her how the physical environment could impact many different behaviors of older adults, especially those with dementia. "So, I thought maybe the physical environment was impacting how they ate their meals."

She and Calkins investigated the environment of certain facilities, looking for what facilities could easily change. "Our research is very applied, very practical;' Brush said. "It's easy to find 25 expensive things you can fix in the dining room. We wanted to identify a few reasonable inexpensive things for people to change that could have a positive impact on the results. And that's what led us to contrast and lighting."

The team selected two facilities to institute a pilot program, in which lighting and contrast were analyzed and upgraded. The measurement they used in their research was the foot-candle, or the amount of light put out by one candle, one foot away. The Illuminating Engineering Society of North America (IESNA) has set the standard for older adults at 50 foot-candles.

Facility 1 had three sources of light in the dining room. There were three 10-bulb chandeliers that were not lit during most meals, and eight four-bulb, fluorescent fixtures designed to hold four tubes. Only two tubes were in each fixture, though, because it was assumed that the dining room would have been too bright with all four tubes. The third light source--windows--allowed natural light to stream in, but illumination was poor on the perimeter of the room where the tables were situated. At baseline, room lighting was measured at 25 foot-candles--half the recommended standard.

The second facility had a pair of two-bulb fluorescent fixtures on the ceiling and four recessed lights with 60-watt incandescent bulbs. The fixtures were not located over any of the tables, and there were no windows in the dining area.

"We asked Facility 1 to replace all the missing bulbs, which brought it close to 50 foot-candles." Calkins said. "So all we had to do was to get them to use their existing fixtures appropriately.

In Facility 2, however, residents were eating at tables with illumination of less than five foot-candles. "This facility had a limited budget for modification, so we replaced the existing fixtures with four-bulb fluorescent standard ceiling fixtures for $50 a piece that we purchased from a home improvement store," she explained. "By changing that, we were able to get the foot-candles up to 25. We would have liked to have done more, but we didn't have the budget.

The "intervention" involved more than illumination, as the team looked to improve the contrast in place settings. "Facility 1 had white dishes on pale dusty pink paper place mats on the trays," according to Calkins. "We replaced the place mats with dark blue ones so that the white plate, white napkin and silverware stood out in sharp contrast to the haw blue background.

In the second facility the serving plates were placed on the tables, without trays. "But the tables had a standard woodgrain-type finish," she added, "and that finish was peeling off. It was mottled and created glare, resulting in color and texture variations that proved distracting to many of the residents. So we put a dark blue vinyl tablecloth on each table allowing the white plates and silverware to become more visible."

The results for Facility 1, which had 11 of the 25 residents studied, showed an average of slightly more than 1,000-calorie increase in the average three-day count. Though this didn't achieve statistical significance, Calkins and Brush said that the improvement among the group was an encouraging sign. "A few residents experienced slightly greater than 1,000-calorie gains, while others increased only slightly," Calkins said.

At Facility 2, with 14 residents in the study, the average gain in caloric intake was 900 calories, after the lighting and contrast was improved. "Although this is slightly less than the average gain in Facility 1, the gain was more evenly distributed among the residents--meaning all 14 residents increased roughly the same," Calkins explained, "thus these results were statistically significant. Also, the lighting intervention in this facility was more dramatic, rising from five to 25 footcandles, which may help explain why so many of the residents improved."

Visual deficits

"Elders in general experience a host of visual problems," Calkins noted. "Those with dementia possess Contrast Sensitivity Deficit (see sidebar, page 12), meaning they have a harder time perceiving differences in foreground and background when the two have similar color or contrast."

According to Sharon Roberts, RN, BSN, NHA, MA, a gerontologist with the Lake County Health Department in Waukegan, Ill., older people with dementia experience visual deficits that accompany aging as well as greater incidences of eye diseases that further impair vision. "They lose the ability to readily distinguish colors, especially blues and green," she said. "The ability to see food and recognize what it is increases the likelihood that it will be consumed."

In addition to providing adequate lighting and appropriate contrast to improve intake, Roberts said that facilities "serve colorful foods that look good, and place them within the person's visual field to maximize his or her ability to identify foods, and place fewer objects within their visual field to improve their ability to discern individual objects."

According to Eunice Noell-Waggoner, LC, glare is an even greater culprit than contrast when it comes to diminished resident intake. The president of the Center of Design for an Aging Society, and founding chair of the IESNA Lighting for the Aged and Partially Sighted Committee, noted that age brings increased sensitivity to glare because of changes in eye structure. "If there's a bright light source, it throws the light like a disco ball," she said, "and that can be painful. It can also dilute the visual image on the retina." Though this is a normal age-related change, it doesn't make it any easier to cope with. Therefore, Noell-Waggoner suggested the use of diffused light. "I use fluorescent light," she said, even though a study that was done long ago deemed it inferior. She attributed the undesirable flicker, bad color, and hum to an old-style transformer that ran the fixture. "The new fluorescents are technology-driven. So if facilities haven't updated their knowledge of fluorescents since they updated their computers, they're about four steps behind."

In addition, "A lot of older facilities were designed for incandescent lighting, so they can simply change from incandescent to fluorescent. The cost would just be an exchange of one fixture for another.

Plus, you can get a lot more light for less energy, and by doing so, you'd be saving energy over a tong period of time. Some utility companies even offer programs that will give you money toward buying the new energy efficient fixtures."

RELATED ARTICLE: The Red Plate Study.

Aware that those with severe, Alzheimer's disease (AD) often suffer from contrast sensitivity deficit, which can result in poor food and liquid intake, the team of Tracy Dunne, Sandra Neargarder, Patsy Cipolloni and Alice Cronin-Golomb of the Boston University psychology department performed a study published in 2004. Though its official title is Visual Contrast Enhances Food and Liquid Intake in Advanced-Alzheimer's Disease, it has to be known "The Red Plate Study."

During the study, the standard issue white plates found in most skilled nursing facilities were switched with brightly colored plates, with results that offer promise for AD patients.

Though 40 percent of those with severe AD suffer pernicious weight loss, a definitive reason has never been identified, according to the study, which appeared in Clinical Nutrition. Most often, one or all of three factors are blamed; depression, inability to focus on more than one food at a time, and inability to eat independently.

The BU team hypothesized that weight loss could be the result of visual impairment, but impairment that goes beyond what naturally occurs with age--specifically, visual impairment due to the inability to distinguish a plate from the table setting, food from a plate or liquid from e cup.

Their study yielded encouraging results. When tableware was switched from white to bright red, food intake among study participants increased 24.6 percent, and liquid intake increased by an astounding 83.7 percent. In a follow-up study tableware was switched from white to bright blue. Even in that case food intake increased 25.1 percent and liquid increased 29.8 percent.

Pastel dishes were also put to the test, but resulted in 0 to 5 percent change in intake amounts.--TSC