Network Health Dietitians July 08 Issue 36

case study: learning disabilities
by Rebecca Martin
Specialist Dietitian, Learning Disabilities
Eating and drinking difﬁ culties and diabetes
Imran was referred to the dietitian supplement. Dad added 20-25mls of
Imran’s weight. As a result, we tried a
by speech and language therapy
this to his food three times per day,
milk-based supplement (thickened),
(SALT) for dietary assessment and
providing an extra 270-340 calories.
to have with breakfast, and later in
consideration of percutaneous
Imran was meeting his nutritional
the day, aiming for one to two per
endoscopic gastrostomy (PEG)
requirements most of the time but
day, depending on tolerance.
feeding due to difﬁ culties swallow-
when unwell, it became more dif-
As a result of on-going concerns a
ing. He was 24 years old, of Paki-
ﬁ cult to achieve.
multidisciplinary team meeting was
stani ethnicity, had profound learn-
SALT explained that they could
held with a representative from the
ing and physical disabilities with no
provide no further advice to improve
GP practice and Imran’s parents.
verbal communication and was
Imran’s symptoms and wanted to
Discussion was around diabetes
ask GP for referral for PEG place-
initially. I suggested the milk-based
diagnosed with type 1 diabetes.
ment. Previously Imran had a chest
supplement be stopped as it had
He lived at home with his parents
drain placed which he used to pull
not improved Imran’s weight due to
and attended two different day
out. This led to frequent admissions
it being given in place of a snack. It
care centres ﬁ ve days a week.
to hospital and Dad didn’t want a
also seemed to be increasing blood
SALT had already recommended
similar situation happening again
glucose levels. The fat-based supple-
a puree diet and custard thick
with a PEG. I gave Dad information
ment was increased to 30mls three
ﬂ uids in order to reduce the risk of
about the procedure and discussed
times per day and we discussed
aspiration of food and drink beneﬁ ts and limitations of PEG
some dessert and snack options,
Initial appointment was a home feeding. I left information for Dad
which were high in calories but lower
visit with the speech and language to read and discuss with the rest of
in sugar. PEG feeding was discussed
therapist. We used pulse oximetry the family. I recommended food
further and Dad agreed that re-re-
to monitor oxygen levels during fortiﬁ cation, for example, adding
ferral to the gastroenterologist was in
eating and drinking and spoke to two to four tablespoons of skimmed
Imran’s best interests. It was decided
Dad about Imran’s medical and milk powder to one pint of full cream
that using the Disability Distress
weight history. During the meal milk, adding cheese to mash potato,
Assessment Tool (DisDAT) (1) may
Imran displayed signs that he may margarine to vegetables etc, in
provide quantitative evidence as to
have been in distress. These included order to maximize nutritional intake
whether Imran’s indicators of distress
raising his leg during each mouth- at times when Imran’s intake was
were occurring more signiﬁ cantly
ful, visibly becoming tense, gagging good. This was especially relevant
during mealtimes.
and coughing. Oxygen saturation for the puree meal, which was likely
In someone with such complex
levels dropped from 98-100 percent to be lower in calories, due to dilu-
needs and many different profes-
to 84-92 percent on three occasions tion of nutrients with ﬂ uid.
sionals involved in their care, multi-
during eating. Dad informed us that The GP referred Imran to the
disciplinary team working is vital in
Imran suffered with frequent chest consultant for a PEG, however, Dad
sharing information and experienc-
infections. refused the intervention. During the
es. Providing sufﬁ cient information
Imran’s weight had been stable next appointment I again discussed
for families and carers allows them
for the past six months at 43kg. PEG feeding with Dad and having
to work towards agreement on the
Height was estimated at 1.69m, had more time to think about it,
decision that is in the best interests
Body Mass Index (BMI) 15kg/m2 he seemed more willing to investi-
of the person. This is especially the
(ideal 20-24.9kg/m2). With no use of gate this option. We also discussed
case when professionals need to
his legs for weight-bearing and no diabetes control and Imran’s weight.
refer to the Mental Capacity Act (2)
functional use of his arms, his muscle At home, blood glucose levels were
for people who lack capacity.
mass was low. He had no pressure between ﬁ ve and eight mmols/l.
areas and no other physical signs However, levels were consistently
References:
1. Northgate & Prudhoe NHS Trust and St. Oswald’s
of malnutrition, although Dad was high when he had attended one of
Hospice 2005. Disability Distress Assessment Tool.
concerned that he did appear to the day care centres and sometimes
Available from www.disdat.co.uk
be underweight. He had previously dropping low when Imran became
2. Department for Constitutional Affairs. Mental
Capacity Act 2005. Code of Practice. London:
been seen by a dietitian, who had unwell. Dad wanted to try a supple- The Stationary Ofﬁ ce, Crown Copyright 2007.
commenced Imran on a fat based ment drink in order to improve
Available to view at: www.opsi.gov.uk.
30 NHDmag.com July ‘08 - issue 36
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