The Dietetic Detectives by the DGRI Dietetic Team

As Dietitians’………………….. we are Detectives

The patient in front of us has a nutritional problem –they are underweight, they have lost weight and they are struggling to eat – but why? It’s a mystery! Could the mystery be they are malabsorbing due to chronic bowel inflammation, bowel obstruction, or pancreatitis? Or do they have difficulty swallowing due to stroke, neurological disorders or head and neck cancer? And the list goes on…

Cue the acute Dietitian!
To get to the bottom of this, we need to look for clues. Clues come in all forms;
anthropometry
biochemistry
presenting medical problem
current symptoms
past medical history
current medications
environment and the patient’s own beliefs
psychological factors
As Dietitians we gather this information and put it together to solve the mystery.

But then what?

We then need to work with the patient, carers and family as well as the multidisciplinary teams to translate our gathered finding (clues). We use our clues to calculate nutritional requirements, this allows us to individualise patients needs – their calorie, protein and fluid needs. We then draw from the evidence base and our own experience, incorporating the tools of our trade some of which are:
Oral nutrition – Fortified diet, nourishing drinks, snacks and oral nutritional supplements.
Enteral (tube) Feeding – Into the gastrointestinal tract
Parenteral (intravenous) Feeding – Into the blood stream via venflons or central lines

Here in Dumfries and Galloway Royal Infirmary our focus is on malnutrition.  People may think malnutrition is a thing of the past in this country, but according to a recent publication by the British Association of Parenteral and Enteral Nutrition (BAPEN) 25-34% of patients admitted to hospital in the UK are at risk of malnutrition (under nutrition).  Malnutrition is associated with less favourable outcomes such as increased length of hospital stay, impaired wound healing and reduced ability to fight infection. It is therefore important to identify and treat malnutrition as soon as possible.
Elsewhere in the other areas there are different patient groups receiving expert nutritional advice, projects being carried out and contributions to national research going on.
The evidence base regarding diet and health continues to grow; treating and preventing malnutrition in the hospital and community setting, gastroenterology, paediatrics, weight management, diabetes, renal, catering and mental health to name a few.

A few myths about dietitians:-
We never eat chocolate
We never drink alcohol
We judge you when we meet you in the local takeaway
Detox diets are good for you
Superfoods exist and are recommended
All we give is weight loss advice
Dietitians will inspect your poo (although we will ask about it)

 

So hopefully you see there is more to dietetics than the common misconceptions – that we’ll be spying on your trolley at the supermarket, and of course we never eat cake, we always have our five a day and we do in fact we always have the perfect diet!
We hope this gives you a small insight into our profession.

And so this morning we’re off to the wards again,

NG tubes, Fortisips and TPN,

We’ll calculate needs, and make sure they’re met,

We won’t stop until food charts are used, you can bet.

Ensuring good nutrition, we can’t get enough,

Though we know sometimes it’s gonna be tough,

So we’ll chat, and we’ll laugh but we’ll work till we’re blue,

So when the cake comes out remember, we’ll have some too!

This weeks blog was a joint effort by the Dietetic Team at Dumfries and Galloway Royal Infirmary

The beat goes on by Julie Garton

Music has the power to help improve quality of life for people living with dementia and their families. It can bring back memories, open up conversation, improve mood, restore calm and strengthen the person’s sense of self and relationships
There are around 90, 000 people living with dementia in Scotland and we have a responsibility to find and employ strategies and interventions that help people to live well with dementia
A key part of my role is to encourage and support the use of strategies and interventions that can increase wellbeing for people with dementia. Dementia is characterised by progressive and irreversible memory loss, and often verbal communication and thought processes deteriorate to such an extent that it interferes with daily life and activities.
The charity, Playlist for Life, aims to spread the word about the benefits of music and to help families and carers build playlists of personally meaningful music for their loved one. Founded in June 2013 by journalist and broadcaster Sally Magnuson, after she saw the impact that music had on her mother who had dementia.
Sally researched the neurological effect familiar music had on the brain, and found a growing body of evidence to support the use of personal music for people with dementia, and an American organisation, Music and Memories, who had discovered the most amazing results after introducing personalised music on iPods for people with dementia.
So, while it was obvious that ‘live ‘music could bring bouts of joy and sudden flashes of memory to people, the effect on individuals was transient. But playlists on an iPod, this was personal. This could go through life with you.
Please check out the website Playlistforlife.org for more details, but already, people have been reconnected to their loved ones and that elusive thing, their ‘ selves’ through sharing their music from their past on an iPod.
Music is the first and last channel of communication. Our auditory system is the first to fully function, even at 16 weeks in the womb we can hear and respond to music. It’s recognised that babies as young as 5 months can distinguish between happy and sad songs.
This forms a soundtrack to our lives. We can remember words and tunes to music and songs that we may not have heard for a very long time, but often the first few notes are enough to prompt a flood of memories, emotions and/or bad dancing in the kitchen.
In dementia, musical communication remains strong while often other forms of communication fade. Music can help those living with dementia connect with their past and their present. The brain structures involved in processing musical information often remains intact

The Benefits of music in dementia
Speeds healing – early healers used incantation and the Egyptians used music to treat a range of disorders
Increase optimism
Decrease pain
Reduce isolation
Reduce stress and distress
Promote active engagement & communication
Increase affection, creativity and expression
Reduce anxiety and depression
Increases co-ordination of motor movement, especially if combined with dancing

There is growing evidence that listening to music can stimulate seemingly lost memories and may even help restore some cognitive function. Not to mention, music engages the areas of the brain involved with paying attention, making predictions and updating events into the memory. Research suggests that even as dementia progresses, the brain has the ability to make neural connections which allow the person to reconnect with memories and emotions and expression. This provides an opportunity for families to share experiences and maintain a relationship with their loved ones, and can make visits easier and more meaningful.

This is simple, easy and cheap. Where we can use personalised music, why wouldn’t we? When it’s effective, there’s not a dry eye in the house. I’m not sure if the days of forced communal listening to Daniel O’Donnell /Val Doonican/Scottish Country Dancing music and the like are over- I am emotionally scarred by years of Jimmy Shand and his band, (apologies to fans of the above) played relentlessly in older people s wards over the course of my career, but iPods are the way to go folks! Other Mp3 players are available.
Working in dementia care is fascinating, motivating and can give those working in the field a huge sense of satisfaction, but we have a long way to go before we have really got to grips with how to prevent stress, manage distress and ensure people are receiving consistently high quality, person centred care. Using personalised music is just one small way to work towards those goals, but a good one.
We had a training day in June for 15 members of staff from across the region. Staff from community hospitals, Midpark Hospital, community hospitals and palliative care attended and the impact of the training was tangible.
Staff will work with families to create personalised playlists for their loved ones. Favourite songs of course (and make sure the artist is the identified, we all have a favourite tune that’s been ‘covered/ruined’ (delete as appropriate) ), but other favourite music such as, nursery rhymes, TV theme tunes, Christmas songs can all help build the music to that persons’ life .
It also allows staff to deepen their knowledge of the person, allowing developed and enhanced relationships between staff and families and helps promote the use of This is Me as yet another tool to really get to know the person we are caring for.
My gratitude to League of Friends for their generous donation to buy a number of starter kits (iPods/earphones/splitter cables) and also to the IT department who have been hugely supportive, overcoming the technical challenges (and technophobes!) Thanks also to the Mental Health, Psychology and Learning Disability Directorate for enabling the training.
‘It took a lost weekend in a hotel in Amsterdam ……..One of my top three tunes of all time, but the memory behind it is mine and not for sharing!
So, what’s on your playlist?

Julie Garton is an Alzheimer Scotland Dementia Nurse Consultant for NHS Dumfries and Galloway

Person centred care… AKA being nice to each other! by Wendy Copeland

When I joined the NHS two years ago I was like a rabbit caught in the headlights… I never even really knew what Primary care was!!! (Please don’t judge me).

However I was given a book to read called Talking Points… Good Conversations. For someone who had spent 30 years in various service industries ‘I got it’…I knew something!! Person Centred Care was all about providing needs lead Customer service… and I have designed and delivered more customer service course than I have had cooked breakfasts.

This revelation took me back to a horrific period in my daughter’s life.

On the 7 August 2006… After a weekend of ignoring her moaning about a sore swollen leg and her increasing breathlessness, I finally called NHS 24 when I got home from work on a Monday night.

I was calm and thought she had overdone her two week holiday in Magaluf where she virtually lived at BCM to celebrate her finishing school.

I was bit alarmed when I was instructed to get her to A&E asap, and they would have a team waiting for her. After an incredibly stressful night Lindsey was diagnosed with a DVT and a PE, her heart was under immense pressure and all that we could do was keep her stable, pump her with blood thinners and wait….and wait we did, I think we went through 6 stages of being told the next 24 hours are critical… The clot in her lung could move at any time…

Lindsey had amazing care from all staff, Nurses, HCSWs, AHPs, ( I had no idea obviously at time, all about these different titles) Everyone was great and appreciated that Lindz was in a ward with ‘old folk’ and got her a single room, no visiting restrictions; in fact we took over… (no surprise there!).

The person that did stick in my mind was Dr John Simpson, John was a Hibee and Lindz a Jambo… he totally connected with her…. and in the days before Person Centred Care… as we were planning Lindsey’s discharge… he asked ‘what’s important to you Lindsey? All she wanted, was to go and start her new college course in 2 weeks to study Beauty Therapy…. he helped us make this happen, negotiating more physio, GPs’ to check Lindsey’s INR at a suitable time….. for a Hibee he was a top bloke!

Lindz is great now, off warfrain, her heart has fully recovered and she just needs to be sensible… no sitting around for too long, drink lots of water, injecting before flights, in fact things that we should all do!! Although I have given up nagging her to wear her compression stockings.

4 Years ago she decided on a career change and is now Staff Nurse Agnew in the Acute Medical Receiving unit at ERI, where she spent her first 24 hours, nearly 10 years ago.

Here’s a lovely Facebook message she received from one of her nursing peers before starting on.

‘Welcome to the world of nursing where give out medication becomes second nature, and putting a smile on a patients face makes your day. Wishing you lots of luck in your new post Staff Nurse Agnew xx’

I know she will make a cracking nurse and her skills and experience as a beauty therapist will means she will always be able to have great hairdresser chats with patients. I am an immensely proud mummy.

Back to Dr Simpson and person centred care. Earlier this year I heard about the premature death of a young man caused by a PE… it really threw me and I spent a lot of time reflecting.

I ‘googled’ John as I was curious to what he was now doing… Dean of Research and Innovation (Clinical) & Professor of Respiratory Medicine, Newcastle University.

And of course I emailed him….

Hello John

This is totally random. You treated my daughter Lindsey with a DVT and PE over nine years ago at ERI.

I am now working in NHS and today I am designing a session on Person Centred Care … and I’m using you as an example of how you treated Lindsey as a person and not just her condition… I’ll not name you so hope you are OK with this!

I also wanted to share that Lindsey has recently qualified as an adult nurse and is now working in ERI, acute assessment unit, and of course is still a Hearts supporter.

Best regards

Wendy  

His reply brought me to tears…

Ha ha ha – what a lovely email that has lit up an uncharacteristically TERRIBLE day (we had an MHRA inspection!).

You won’t believe this, but I still have my coffee at home from the Hibs mug that Lindsey gave me after that episode, and so I think of her often, and had wondered where she ended up. I hope she is very well. Do tell her I was asking for her, and it is so funny that she ended up on the Unit. Ironically, I now run one of the few dedicated PE clinics in England. 

I’m very happy for you to mention whatever you like in your session, and I hope it goes well. Do tell Lindsey that although I watch Newcastle too, I still go up to see the Hibs when I can, and have my ticket for the cup final…..my little superstition is that I never drink from the mug she gave me on days when Hibs are playing!!

Anyway, what a lovely e-mail, it really cheered me up. I hope this finds you well too. Very best wishes

John 

Person Centred Care at its best, go on make someone’s day… every day!

Wendy Copeland is a Workforce Development Partner for NHS Dumfries and Galloway