Caring for the Elderly
This article first appeared in the Sunday Herald. It was awarded a Norwich Union Medical Journalism Award in 2007.
Mollie Rafferty enjoying a restaurant meal in happier times
Pictures by Mary Rafferty
Revolution on the ward starts quietly, with Annette's muted croak, 'This food is disgusting. I'm not eating it.' A tiny little doll of a woman, she makes an unlikely rebel. She's God-loving and quiet and sits motionless for much of the day, a Polly Pocket old lady whose skinny, straight-up-and-down legs dangle to the floor like a marionette's. The nurses say she's let her soup go cold, which is why it's unpalatable now, but the second course, burger, looks like a slim slice of excrement and probably has less nutrition. 'You wouldn't eat this stuff,' says Annette accusingly, and neither I would. Betty, her 78 year old neighbour in the next bed, has a sardonic look on her worn, pale old face. 'I'm sorry to have to tell you, darling,' she says, ' but they're killing us in here - for fun.
Here is the geriatric unit of a large Glasgow hospital where my mother is currently incarcerated with a broken hip. She over-balanced in the house on her way to watch Countdown and has now had a half hip replacement. The staff here think we're bonkers because someone from our large clan goes in every day at lunchtime to see that she's eating enough. 'That's our job,' one of the auxiliaries told me, but the three other ladies on the ward are often left completely on their own at mealtimes, mainly because each member of staff has six or seven patients to look after. One person requiring help in the room next door would mean there is no-one to help Annette or Betty or tragic Beth, who has frontal lobe damage and Parkinson's and is often locked in a private hell of fear, unable to move and afraid of what is happening to her. She can sometimes manage to eat, mostly sandwiches or crisps. Sometimes she doesn't want to and can't be coaxed into anything.
Making sure that elderly patients are fed is one of the most crucial things in their treatment. Without healthy food they take longer to recover, using much-needed bed space for longer. They are more likely to develop complications during surgery or indeed die. A new report by charity Age Concern shows that six out of 10 older patients in England are at risk of malnutrition simply by being in hospital. Many of them go in already malnourished and the problem is exacerbated by understaffing, poor quality food and slack practice on individual wards.
In Scotland the amount spent on food can vary enormously. Patients in Stranraer have £216 a week spent on them for catering and domestic services. My Mum gets just £45, the sixth lowest amount in Scotland. I know there are all sorts of reasons for the differing costs - rural transport costs, staff pay and so on - but she is in the largest city in Scotland, where things are expensive, and I am less than impressed. A close friend of mine who is medical director for a rural area told me, 'It's not the broken hip or the operation or even the anaesthetic that's the worst thing for your Mum. It's the fact that she's in hospital.'
Despite the constant scares about the MRSA bug and hospital cleaning, it is actually malnutrition which is the biggest danger for elderly patients. Age Concern's report reckons that £7.3 billion is lost to the NHS throughout the UK because of it, a far greater problem than the much-publicised one of obesity. Over the age of 80 people's chance of malnutrition is five times higher than that of those in their 50s, partly because older people have smaller appetites but also because they are less able to cook and shop for their own food.
In Scotland our social policy has meant that more and more frail old people are living independently - in the 2000 census there was a 50 percent rise in the number of people over 80 living on their own. 'The increasing complexity of the needs of older people means that an increasingly complex range of assessments and solutions will be required,' says Andrew Sim of Age Concern Scotland. 'For example, for people with dementia Meals on Wheels may not be the best solution. A range of snacks left around the house can be better for them.'
In hospitals in Scotland patients have registered high levels of satisfaction with the food - over 90 percent in one survey - but it's hard to imagine how when you see what is routinely served. Some of the menu choices could only be considered healthy on Planet Glasgow - in the hospital's garden cum smoking area I heard one man asking his sick wife if she wanted him to bring her in a pudding supper.
Age Concern's report suggest a three weekly rotation of meals, but in my Mum's hospital it's more like three days. Mince appears on the menu every couple of days alongside such delicacies as sausage and bean casserole made from cheap frankfurters, or macaroni cheese served with turnip and boiled potatoes. Sprouts are always frozen and therefore soggy. The mashed potato looks like it comes from big catering packs, probably in frozen pellets according to my pub manager sister, who says you have to add lots of butter and milk to make it tasty. The only vegetarian options I've seen in the last two weeks are macaroni, quiche and egg or cheese sandwiches. No wonder the vegetarian Betty is sardonic, given the limited diet she's on in hospital.
She swings between extolling God and execrating the hospital, in language saltier than the soup the patients all complain about. She often says the doctors are poisoning her. 'We were invited here by letter and this is how they treat us,' she declares, though in fact, like my mother, she broke her hip in a fall. One of the huge problems for older people in hospital is that they get confused - the anaesthetic, the drugs and their changed surroundings mean that many fail to recognise where they are. Annette the rebel has several times asked me where she is though she's been on the ward for some weeks. 'Is this my house?' she says, in her wispy little voice.
On the day of revolution in the ward, she said the soup was cold. The food often is because the nursing auxiliaries come in with plates of whatever's on offer and ask the patients to choose on the spot. In the main hospital they are given a menu the day before and asked to tick their choices, but the staff in the geriatric unit say the patients get confused and don't want what they've ordered. This may be true, though it seems strange to predicate a system on its failures.
Annalena Winslow, the press officer for NHS Greater Glasgow and Clyde, says that the practice in my mother's geriatric unit is to offer patients a choice of food. 'This is kept hot via a heated food trolley while patients choose. Once the choice is made the food is immediately delivered directly to the patient. It should never be cold, as all meals served comply with legal temperature requirements. If anyone has any concerns we would encourage them to speak to staff.'
I did, and was told that Annette's soup could not be reheated in the microwave for 'health and safety reasons.' They could add some hot water to it. Given that she wasn't sure where she was, it's doubtful that she would have grasped the concept of legal temperature requirements. The food is certainly kept on a heated trolley but it comes from another hospital over seven miles away, so is presumably already less appetising than where it is produced. The staff do not keep it on the trolley. They waft uncovered meals in front of the patients' noses, asking them to choose what they want. Some clearly find the idea of a client-driven service exasperating. One day this week a manager on the ward put up a notice about patient choice. 'Make sure they all see it,' she said. When she'd gone, the nurse shrugged her shoulders and muttered, 'Patient choice,' as if the very idea was ridiculous.
Most of the patients, being elderly, don't really want much at all. Mollie, my mother, often nicknamed 'Mops' despite her lifelong distaste for domestic chores, is the fittest in the room. She puts her makeup on every day and has started doing the word game in her daily paper again while the others sit staring into space, too tired to move. I think that's because one of us is almost always there to cajole her into eating the soup and usually some of the main course. Her staple over the first couple of weeks has been little pots of yoghurt with fresh fruit which we bring in from home. We also brought in Fruit and Fibre, prunes and bananas to keep her regular. She forgot it was there one day and the auxiliary didn't notice. When I asked one of the staff about it she dismissed the whole question of dietary fibre and roughage. 'Rice Krispies are just as good,' she said.
Age Concern's report urges all hospital staff to become 'food aware.' In England the government takes this so seriously they asked Lloyd Grossman and various other celebrity chefs to have a look at changing hospital food. Lloyd may have gone over the top in suggesting dishes such as navarin of lamb with couscous and grilled vegetables, but in Scotland they're still serving gruesome food like Forfar bridies. 'Menu compilation is not about a particular item being therapeutic,' says Annalena Winslow of NHS Greater Glasgow and Clyde in a fine example of corporate statement of the obvious. 'The entire intake of a patient during his or her stay in hospital is taken into consideration.'
In my mother's ward, someone goes round every day measuring what the old ladies have eaten for lunch, but there is no consistent effort that I can see to ensure they are properly nourished. On any given day there is always someone who doesn't feel like eating at all. 'We can't make them eat,' the staff protest and of course legally they can't. Maybe they simply don't have the time to sit there and wait while Beth's wavering hand flutters and hesitates on its way to her mouth; they don't have the time to sit and chat long enough with the feisty Betty to galvanise her into eating. Everything is done to a timetable so there is little chance for anything other than a diffuse and sometimes distant kindness, though there are always exceptional members of staff who make a real connection with individual patients.
Mollie Rafferty with her son David
Most of us couldn't bear to do their job, so we can only hope we would have the patience to sit a little longer, to think a little bit harder about how to entice the patients into eating. We can only hope we wouldn't be like the nurses reported by Age Concern England who left food at the end of the bed for an elderly patient with no arms. 'Its such a basic care,' says Helen Wanless of Age Concern. 'It's fine if you can go in every day to help your relatives but a lot of people don't have that support.
'What about the people who don't have family or friends? What happens to them? Who helps them?'