Nectar, Honey and Pudding22 August 2017
“One must ask children and birds how cherries and strawberries taste”
– Johann Wolfgang von Goethe
I heap powder from a tin that reads ‘Thick and Easy’. It has a background like a milk carton and reminds me vaguely of banana flavoured Nesquik. It has the same colour and the powder is grainy in the same way. The kettle clicks off, rumbling, and I fill a mug. After the water has turned a dark tannen, I shake the teabag out. I swirl the thickener in and particles clump like bad cream. It is gritty in the brown, until the powder dissolves and the drink has turned thick. I hand the tea to my Opa in his well-worn seat on the tan, cracked leather sofa in our lounge and imagine drinking it would be like swallowing phlegm back down when you’re sick.
There are three consistencies of thickened liquids. Nectar-thick, honey-thick and pudding-thick. These are used for varying degrees of severity for dysphagia, which is a difficulty or discomfort in swallowing. It can be a condition on its own, but it usually results from another medical issue, such as a stroke or dementia. Left on its own, the thickened liquid retains the colour of watery urine. Essentially the role of thickened liquids is to prevent choking and to stop fluid from entering the lungs. Thin liquids like coffee, tea, soup and most jarringly, water, all need to be mixed with a thickener for a person who has dysphagia. Nectar-thick liquids are easy to pour and have the same consistency as cauliflower soup. Honey-thick liquids are a little thicker and don’t pour as easily. Like honey, you can drizzle it. Pudding-thick liquids retain their own shape entirely, not really a liquid at all. They must be eaten instead, the same way you would eat jelly or a créme brûlée that you buy from the supermarket, and snap the base to release the custard. Pudding-thick liquids are eaten with a spoon, even water.
Dysphagia is common for people young and old, but it is perhaps most detrimental to health in the elderly with dementia.
Most nursing homes in Victoria have dementia-specific units. On their website, Alzheimer’s Australia describes ‘good care’ in a dementia unit as “ensuring that the environment is as home-like as possible”. The dementia ward in the aged care home in Berwick is shaped like a coathanger. Residents’ rooms bend down from either side of a large kitchen and dining room, that opens into a garden. Like Alzheimer’s Australia outlines, the ward has safe wandering areas: two hallways pointing in opposite directions that the residents can walk down. There is also a humidifier with lavender perfumed oil in the small sitting room. This is suggested to help with residents who are ‘agitated or restless.’ There are no more than 20 residents in all, with a few confined to bed, all with varying severities of speech and movement difficulties. Almost all of them require food and drink to be thickened and, despite a staff of nurses and carers, volunteers are snapped up throughout the day, providing company, support and help with feeding.
Dysphagia has been compared to waterboarding, a torture technique that generates the sensation of drowning, through continuously pouring water over a person’s face, covered with cloth. Dysphagia presents the danger of drowning in your own saliva. This condition seems like a relative norm for most elderly people. At some point, complications from other medical conditions result in them getting dysphagia, or at the very least requiring food that is softer and all of a similar texture.
Pam and Rose are inseparable friends. In January, it’s Rose’s birthday and her family come to visit. They bring her a yellow helium balloon that is tied to the handle of her walking frame. It bobs in the breeze as they spend the afternoon on the concrete porch of the garden. A little girl, she must be Rose’s granddaughter, plays on the thick, short grass in front of high wooden planter boxes of lavender. At the day’s end, Rose waves them tearful goodbyes, her only intelligible words ‘my son’, and Rose and Pam hug like small girls who comfort each other when they’ve become lost, their hair pressed together, arms wrapped tight .
The two women are always found wheeling their walking frames up and down the elbowed hallway of the ward and on sunny days, they come out the glass doors, and into the garden off the main sitting room. It is a sensory garden, with chimes and bells on a big corrugated wall, and a bus stop and sign that looks so tragic. There are voluminous lavender beds on raised boxes. JM Boyce, in Effects of Aging on Smell and Taste says that ‘we lose our ability to discriminate between smells’ as we age. A nurse plucks a stem of lavender and scrunches it in her palm. She offers it to Pam, but she is invested in pulling yellowed weeds from the roots of the lavender. The crushed stem has a smell that is sharp and pungent, like the beginning of rain.
Tomato plants climb the lattice, grown dry and straw-like in the summer. Residents pick at them, handing out their small, green, inedible fruit so generously. In Gardens That Care, Tara Graham-Cochrane, for Alzheimer’s Australia, describes sensory gardens as being important because they ‘support quality of life … and [are] aids in therapy programs’.
It makes most sense for a sensory garden to be circular, where a simple looped path makes it easier for residents to work out where they are. They’re less likely to become confused and lost. Signposts are common too. They seem so similar to the jumbled bearings nailed to a tree in the children’s book Alice in Wonderland. Jagged arrows point in all directions. That way. This way. Wrong way. Go back. Maybe it’s the familiarity of the presence of the sign that’s helpful. Alzheimer’s Australia determines that sensory gardens should have key design principles of reminiscence, elements that evoke memories for the elderly. Wheelbarrows and old cars, pottery, kitchen utensils and old gates seem to be popular for our grandparents. Farming elements too are incorporated into many garden beds. A stray shovel, wedged firmly into a concrete slab in the middle of the bursting lavender beds. Silver, upright and shining through scratched paint on the handle. Impossible to remove, like a sword in stone. The paths should be wide enough for wheelchairs and walking frames. Ideally for more than one person at a time, because safe, white sneakers need plenty of concrete to amble. But then pathways must be widened into roadways, and there is not always enough garden for that.
Dinner is a race to the finish and a silent affair, with each helper determined not to fall behind. Every resident has a white ceramic soup plate, the kind with the large flat lip. They use the same plates for every meal and never have soup. In ‘Food Issues’ an FSA prospective menu plan for care homes in the United States, it is explained that care homes ‘cannot use any dried soup or canned soup product daily as these products contain too much sodium’. If residents were to have soup, they would need a dangerously high sodium intake to be able to taste any salt at all. Boyce says that ‘it has been reported that the elderly person requires a twofold to threefold concentration of salt to detect it in tomato soup’. Despite the fact this salt intake is unsustainable, for residents with dysphagia the increased salivary production again returns with the danger of choking.
Today, dinner is the same as yesterday. Meat with gravy, mashed potato and carrots. Three parts, each placed in an imaginary third of the plate. The meat is pureed, the same consistency as oatmeal. The potatoes are mashed, soft and smooth, and the carrots are a thick orange cream. Dark brown gravy is poured in a thin stream around the edge of the plate, like a moat surrounding the damp mounds. It is the gravy that smells so strong. It is the same wet scent of the meals you get on an aeroplane. The meals that come in those warm tinfoil containers on an overnight flight. Cold around the edges, but they burn your palm if you keep your hand underneath for too long. Peel off the lid and sharp steam streams out. The underside of the foil is soaked in beads of sweat. That’s the smell. Some of the residents mix their meal together into a marble swirl of brown. Others will only eat if their food is separated, and there is a box of tissues kept in the middle of the table for one lady who separates the sections with her fingers. She points and explains in garbled speech what she wants to eat and prods at distasteful bits of orange.
“First this one. This one,” a nurse tells her, mound hovering on the spoon. This is the language used and it makes perfect sense here.
Boyce says that “smell and taste disorders in the elderly person are commonly overlooked, as they are not considered critical to life”. Sitting next to such a state of weariness in eating, of a slipping loss of weight, it seems this cannot be true. In place of smell and taste there is only company.