Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents

ContextNonverbal pain behaviors are effective indicators of pain among persons who have difficulty communicating. In nursing homes, racial/ethnic differences in self-reported pain and pain management have been documented.ObjectivesWe sought to examine racial/ethnic differences in nonverbal pain behaviors and pain management among residents with staff-assessed pain.MethodsWe used the U.S. national Minimum Data Set 3.0 and identified 994,510 newly admitted nursing home residents for whom staff evaluated pain behaviors and pain treatments between 2010 and 2016. Adjusted prevalence ratios (aPRs) and 95% CIs estimated using robust Poisson models compared pain behaviors and treatments across racial/ethnic groups.ResultsVocal complaints were most commonly recorded (18.3% non-Hispanic black residents, 19.3% of Hispanic residents, and 30.3% of non-Hispanic white residents). Documentation of pain behaviors was less frequent among non-Hispanic black and Hispanic residents than non-Hispanic white residents (e.g., vocal complaints: aPR_Black: 0.76; 95% CI: 0.73–0.78; with similar estimates for other pain behaviors). Non-Hispanic blacks (47.3%) and Hispanics (48.6%) were less likely to receive any type of pharmacologic pain intervention compared with non-Hispanic white residents (59.3%) (aPR_Black: 0.87; 95% CI: 0.86–0.88; aPR_Hispanics: 0.87; 95% CI: 0.84–0.89).ConclusionAmong residents requiring staff assessment of pain because they are unable to self-report, nursing home staff documented pain and its treatment less often in Non-Hispanic blacks and Hispanics than in non-Hispanic white residents. Studies to understand the role of differences in expression of pain, explicit bias, and implicit bias are needed to inform interventions to reduce disparities in pain documentation and treatment.     

Interrater Variability in Pain Assessment of Long-term Care Residents with Dementia

PurposePeople with dementia are at great risk of their pain being undetected. In long-term care facilities, certified nursing assistants are on the front-line to detect whether a resident with dementia is experiencing pain, but research on certified nursing assistants' abilities to accurately assess pain are scarce. This study aims to examine certified nursing assistants’ pain assessment skills using a simulated standardized video context.DesignA cross-sectional study was conducted.MethodsFifty certified nursing assistants and 40 individuals with no professional experience in the field of care (controls) watched the same video of an older adult woman with dementia experiencing pain. Afterwards, they completed visual analog scales (pain intensity, affective distress), an observational pain assessment scale (Algoplus), and a set of questionnaires.ResultsIn both groups, pain intensity assessment and empathic reaction scores showed important interrater variability. Moreover, certified nursing assistants and controls did not differ in detecting the presence of pain or assessing its intensity. But certified nursing assistants displayed lower empathic reactions and dispositions. Certified nursing assistants pain assessment scores decreased with experience and expertise.ConclusionsThe practice of pain assessment is challenging for certified nursing assistants in long-term care facilities. Their professional status does not prevent inter-personal inconsistency and tends to lower their empathic dispositions. Personal determinants may interfere with their assessment behaviors and must be considered to enhance pain management for residents with dementia.     

Pain assessment practices with nursing home residents

The purpose of this research was to describe the kinds of pain assessments nursing home staff use with nursing home residents and the characteristics and behaviors of residents that staff consider as they assess pain. Twenty-one focus groups were held in 12 nursing homes. Nurses and other nursing home staff attended the focus groups. Coding techniques consistent with ethnographic methodology were used for data analysis. Four themes identified an underlying uncertainty in assessing residents' pain, the staff relationship-centered approach to pain assessment, the resident cues that alert staff to pain, and residents' characteristics important to the nursing assessment. Composition of focus groups made a difference in participation of certified nursing assistants in focus group discussion. Urban and rural differences were noted across the focus groups. Research is needed to further refine pain assessment techniques specifically for nursing home settings.     

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes

PurposeThe Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US.DesignCross-sectional study.SettingsSixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama.ParticipantsOne hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment.MethodsValidity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician’s pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach’s alpha.ResultsMOBID overall scores were significantly associated with expert clinician’s rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83).Conclusions and Clinical ImplicationsResult of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.     

Pain Management for Older Persons Living in Nursing Homes: A Pilot Study

Because the prevalence of chronic pain among the elderly in nursing homes is high and decreases their quality of life, effective nonpharmacologic pain management should be promoted. The purpose of this quasiexperimental pretest and posttest control design was to enhance pain management in nursing homes via an integrated pain management program (IPMP) for staff and residents. Nursing staff and residents from the experimental nursing home were invited to join the 8-week IPMP, whereas staff and residents from the control nursing home did not receive the IPMP. Baseline data were collected from nursing staff and residents in both groups before and after the IPMP. The IPMP consisted of eight lectures on pain assessment, drug knowledge,and nondrug strategies for the nursing staff, and 8 weeks of activities, including gardening therapy and physiotherapy exercise, for the residents. There were 48 and 42 older people in the experimental and control groups, respectively. No significant differences were found in their educational level, sleep quality, bowel habits, past and present health conditions, pain conditions and psychologic well-being parameters (p > .05) at baseline. After the IPMP, the experimental nursing staff showed a significant improvement in their knowledge of and attitudes to pain management (p < .05), and the experimental residents reported significantly lower pain scores and used more nondrug strategies for pain relief compared with the control group (p < .05). Moreover, the psychologic well-being parameters, including happiness, loneliness, life satisfaction, and geriatric depression, had significantly improved among the experimental residents (p < .05). The IPMP was effective in enhancing the knowledge and attitudes of nursing staff, as well as reducing pain conditions and enhancing psychologic well-being for older persons in nursing homes.     

Pain Assessment in Noncommunicative Elderly persons--PAINE

OBJECTIVES: We describe the validation of an informant-based pain assessment for persons suffering from dementia called Pain Assessment in Noncommunicative Elderly persons (PAINE) using 2 different samples. METHODS: In the first study, the participants included 80 residents from one nursing home. We assessed internal consistency using Cronbach alpha, interrater and test-retest reliability using Pearson correlations, and validity using receiver operating characteristic curve analyses, comparing PAINE to these criteria on the basis of reports from physicians, nurses, relatives, and the residents themselves. In the second study, the participants included 91 residents from 2 different nursing homes. We assessed validity by correlating scores on PAINE with those from other assessments designed to detect pain. RESULTS: PAINE shows adequate internal consistency and both interrater and test-retest reliability. It also shows adequate receiver operating characteristic curve results and reasonable correlations with the existing measures of pain in persons with dementia. DISCUSSION: PAINE has the advantage of using a comprehensive list of pain symptoms on the basis of systematic questioning of direct caregivers from several institutions. The validity results suggest that this assessment could be a useful tool in detecting pain in persons with dementia.     

An Exploration of Pain Documentation for People Living with Dementia in Aged Care Services

BackgroundPain in people with dementia is a common occurrence. Providing evidence-based pain management for people with dementia in residential aged care services is imperative to providing quality care. However, it remains unclear from current research how various aged care staff (Registered Nurses (RNs), Enrolled Nurses (ENs), Personal Care Assistants (PCAs)) engage at specific points of the pain management pathway. With structural changes to the residential aged care workforce over the past two decades, understanding the relative contributions of these aged care staff to pain management practices is crucial for future practice development.AimTo investigate the quality and completeness of pain documentation for people living with dementia, and assess the extent to aged care staff are engaged in documentation processes.DesignA three-month retrospective documentation audit.Setting and ParticipantsThe audit was conducted on the files of 114 residents with moderate to very severe dementia, across four Australian residential aged care facilities.MethodsData was collected on each resident’s pain profile (n=114). One hundred and sixty-nine (169) pain episodes were audited for quality and completeness of pain documentation and the extent to which aged care staff (RNs/ENs and PCAs) were engaged in the documentation of pain management.ResultsTwenty-nine percent of pain episodes had no documentation about how resident pain was identified and only 22% of the episodes contained an evidence-based (E-B) assessment. At least one intervention was documented for 89% of the pain episodes, the majority (68%) being non-pharmacological. Only 8% of pain episodes had an E-B evaluation reported. Thirteen percent (13%) of episodes contained information across all four pain management domains (Identification/ problems, assessment, intervention and evaluation). Documentation by PCAs was evident at all points in the pain management pathway. PCAs were responsible for considerately more episodes of assessment (50% vs 18%) compared to nursing staff.Conclusion and Clinical ImplicationsDespite the high prevalence of pain in people with dementia in aged care settings, current pain management documentation does not reflect best practice standards. Future capacity building initiatives must engage PCAs, as key stakeholders in pain management, with support and clinical leadership of nursing staff.     

Dementia and Risk of Adverse Warfarin-Related Events in the Nursing Home Setting

BackgroundLittle attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events.ObjectivesTo test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics.MethodsA prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes.ResultsResidents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20–1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06–1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48–0.90) but not for nonpreventable AWEs.ConclusionA diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.     

Providing tender touch massage to elderly nursing home residents: a demonstration project

This 1-year demonstration project looked at the effects of gentle massage on two groups of elderly nursing home residents: those suffering from chronic pain and those with dementia who were exhibiting anxious or agitated behaviors. The certified nursing attendants were trained by a licensed massage therapist. The project was divided into three 12-week phases; different staff and residents were involved in each phase. Fifty-nine of 71 residents completed the 12-week program. Pain scores declined at the end of each phase, and anxiety scores declined in two of the three phases. Eighty-four percent of the nursing attendants reported that the residents enjoyed receiving tender touch, and 71% thought this type of massage improved their ability to communicate with the residents.     

“Behind Closed Doors with open minds?”: A qualitative study exploring nursing home staff’s narratives towards their roles and duties within the context of sexuality in dementia

BackgroundDespite sexual expression being recognised as a fundamental human need, sexuality in old age is often ignored and frequently misunderstood, with residents with dementia in a nursing home often viewed as asexual or incapable of being sexually active.ObjectivesThe current study aims to understand the views held by nursing care home staff towards dementia and sexuality and explore the roles they may adopt whilst responding and managing sexual needs and expression for residents with dementia.MethodsFace to face, in-depth, semi structured interviews were conducted with eight staff members working in two nursing homes in Greater London, United Kingdom. Data were analysed using Interpretative Phenomenological Analysis.ResultsThe findings suggest that representations of sexuality in dementia held by nursing home staff ranged from the perception that sexual expression in old age was part of human nature and a basic human right to others that proposed that with the loss of memory, people with dementia may also experience loss of interest in sexuality and intimacy. Based on the representation of sexuality held (personhood versus biomedical model), nursing home staff adopted a role or a combination of roles (a facilitator, an informant, a distractor, an empathiser, a safeguarder) that legitimised past and anticipated responses in managing sexual expression in the nursing home setting. Nursing home staff’s responses varied depending on the severity of the condition, level of involvement of the resident’s family and their own personal views on their duty of care, old age, sexuality and dementia.ConclusionThe simplified binary labelling and classification of sexual behaviour in dementia as appropriate or inappropriate often applied in institutional settings, fails to account for complex factors that may influence staff’s decisions on the ethical dilemmas raised by dementia. A role based continuum approach could help staff move away from rigid binary judgments and train them to adopt formal carer roles that promote a more contextualised rights based approach in the provision of dementia care.     

Pain and Associated Factors in Nursing Home Residents

BackgroundUnderstanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied.AimTo evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics.DesignRetrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060).ResultsPain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression.ConclusionsPain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.     

Nursing staff members' perceptions of pain indicators in persons with severe dementia.

OBJECTIVES: The aims of this study were to (1) identify behaviors that occur in noncommunicative nursing home residents that are perceived by nurses to be indicators of pain, (2) determine factors affecting the differentiation of pain behaviors from similar behaviors due to other causes, and (3) assess nurses' perceptions of the prevalence and importance of specific indicators of pain as well as barriers to the detection of pain in this population. SETTING AND PATIENTS: Seventy-two staff members of three nursing homes were interviewed and surveyed about specific behaviors associated with pain. Focus groups were conducted with staff to validate pain indicators and investigate perceptions of their own ability to identify pain. RESULTS: Nursing staff members agreed on a core group of behaviors that they perceive as pain indicators in elderly persons suffering from dementia. These indicators include specific physical repetitive movements, vocal repetitive behaviors, physical signs of pain, and changes in behavior from the norm for that person. The nursing staff members' level of familiarity with the residents was reported to have a significant effect on staff members' ability to identify and differentiate pain behaviors from other behaviors of impaired residents. Barriers to the detection of pain pertain to staff issues, resident behaviors, and resident-staff relationships. CONCLUSIONS: The study of pain among the noncommunicative elderly and, in particular, the development of a tool that can be used to assess their pain may greatly improve the quality of life of the estimated 20% to 35% of nursing home residents who cannot adequately express their needs.     

Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions

Pain assessment in nursing home residents poses challenges since many of these individuals are too cognitively impaired to respond to traditional self-report instruments. Assessment of pain behavior in this population offers a logical alternative. The purpose of this study was to compare perceptions of behaviors identified as being pain-related in 42 nursing home residents with chronic pain, as reported by residents themselves, their nursing home caregivers and their family caregivers. Our specific research agenda was to identify the most salient behaviors that signal pain in nursing home residents; to determine the test-retest agreement of residents' self-perceived pain behaviors; to learn of the confidence that caregivers feel regarding assessment of residents' pain behavior; and to examine the agreement between caregivers and residents about pain behaviors in particular residents. We also wanted to compare residents' and caregivers' ratings of the residents' pain intensity. Finally, we explored the beliefs of nursing home staff about the influence of dementia on pain and pain assessment. Twenty-two of 26 pain-related behaviors identified by residents showed fair to perfect test-retest agreement (kappas 0.40–1). For the vast majority of pain-related behavior items, kappas for resident–caregiver agreement were <0.30. Agreement with regard to pain intensity was similarly poor (r=−0.19–0.34). Confidence in pain rating was high for both nurse (on average, 7.2 on a scale of 0–10) and family (on average, 6.7) caregivers. Seventy-one percent of nurses felt that pain assessment is more difficult in demented individuals, but that cognitive function does not influence pain prevalence. While nursing home residents with chronic pain and their caregivers have different perceptions regarding which behaviors are pain-related, additional studies are required to determine the underpinnings of these differing perceptions and to determine the extent to which formal pain behavior observation protocols will be useful for evaluating nursing home residents with chronic pain.     

Certified nursing assistants' perspectives of the CARES® activities of daily living dementia care program

BackgroundThere has been a proliferation of online training programs for nursing home direct care staff related to dementia care, yet little is known about the effectiveness of the training. Some evidence exists that online training is effective in addressing problem behaviors of nursing home residents with dementia by enhancing self-efficacy, improving attitudes, and increasing knowledge of nursing home staff.Study aimThe current study aim was to evaluate the implementation of an online training program consisting of ten, one-hour modules which applies the CARES® concepts and learning framework to activities of daily living (ADL) care for persons with dementia.MethodsResponses from Likert-type items, and open-ended questions were analyzed in a sample of 48 certified nursing assistants (CNAs) from 10 nursing homes in six states (ME, MT, ND, WI, MN, MO) that were part of a National Institute of Aging funded intervention study (Grant #AG026210).ResultsThe mixed-method study findings indicated that CNAs gained a better understanding, more knowledge, and more confidence in caring for persons with dementia. Recommendations were made regarding training length and technical issues, and some questioned the practicality of providing person-centered care when resident assignment was very high. CNAs expressed satisfaction with the online training, found it easy to use, and many said they would recommend the training. CARES® ADL Dementia Care online training appears to be a viable way of helping CNAs address the personal care needs of long-term care residents. Future CARES® ADL Dementia Care program research should include more racially diverse CNAs.     

Nursing staff members' assessments of pain in cognitively impaired nursing home residents.

Our aim was to assess the reliability and validity of nursing staff members' assessments of pain in cognitively impaired nursing home residents. Participants were 57 cognitively impaired nursing home residents and 52 nursing staff members. Twenty-eight residents had mild/moderate cognitive impairment and 29 were severely impaired. Nursing staff members were asked to evaluate their patients' pain using 2 scales: the Nurse Global Scale of pain (NGS) and the Present Pain Inventory (PPI). Independent measures of pain were obtained from patient interviews, physician assessments, and from the Minimum Data Set (MDS) items; these were used to measure validity of the nursing staff's perception of pain. Test-retest and inter-rater reliabilities were also computed. Significant correlations were obtained between most of the physician-derived measures and the PPI for the moderately impaired group, but not for the severely impaired group. Both measures of nursing assistants' pain assessments correlated significantly with MDS-based measures; these correlations were higher for the less cognitively impaired group. Finally, the PPI correlated significantly and positively with resident-derived measures for those with moderate rather than severe cognitive impairment. Nursing staff members' ratings of pain were correlated with residents' level of cognitive functioning and with intake of pain medication. The results underscore the difficulty in assessing pain in those with severe cognitive impairment.     

An Evidence-Based Guideline on Pain Assessment in Nursing Homes For Residents and Informal Caregivers

BackgroundNursing home residents are often affected by pain. Pain assessment aims to determine pain intensity and quality. An evidence-based guideline on pain assessment in nursing homes was developed to support residents and informal caregivers in archiving an adequate pain assessment prerequisite to pain treatment.AimThe residents’ guideline presents key recommendations that is comprehensible and accessible to residents and informal carers.DesignWe conducted a content analysis.Setting/SubjectsTherefore, all recommendations of an evidence-based guideline for pain assessment in nursing home were evaluated on relevance for supporting residents’ decision-making process.MethodsTwo researchers conducted the content analysis independently and as a result, 29 recommendations could be included. In addition, representatives of a support-group organization for patients with pain validated the derived recommendations.ResultsThe present residents’ guideline of pain assessment consists of nine thematic categories, written in laymen’s terms to enable older persons to make informed choices and optimizing their own pain management process.ConclusionsThe Guideline is available in print format and ready for implementation to enhance the effects on maintaining the physical and psychological well-being and optimal care of older adults in Nursing Homes.     

Factors related to aggressive behaviors among older adults in nursing homes of Korea: A cross-sectional survey study

BackgroundAggressive behavior is one of the most challenging behavioral psychological symptoms for older adults and their caregivers in nursing homes.ObjectivesThe purpose of this study was to examine and identify contributing factors of aggressive behaviors among older adults in nursing homes in South Korea.DesignThis is a secondary analysis of a national survey on health and functional status among older nursing home residents.SettingsParticipants were recruited from 91 nursing homes.ParticipantsA total of 1447 older adults were included for final analysis and they were randomly selected from a nationally representative sample of people 65 years and older at the sampled nursing homes.MethodsPresence of aggressive behaviors was identified when participants showed at least one of the five symptoms in the Korean interRAI Long-Term Care Facility Assessment Tool such as physical abuse, verbal abuse, socially inappropriate or destructive behaviors, and resistance to care. Theory-based contributing factors were selected and examined. Multivariate logistic regression analyses were performed.ResultsAbout 19% of older nursing homes residents had aggressive behaviors, and several health and social factors including social engagement are associated with aggressive behaviors.ConclusionsAggressive behavior is prevalent in older nursing home residents with and without dementia in South Korea and individual and institutional level interventions are necessary.     

The association of eating performance and environmental stimulation among older adults with dementia in nursing homes: A secondary analysis

BackgroundNursing home residents with dementia experience increased risk for compromised eating performance due to intrapersonal, interpersonal, and environmental factors. Environmental stimulation is physical, social, and/or sensory stimulation present in the environment that can potentially trigger individuals’ emotion or motivate physical reactions. Beyond the personal factors, there is a lack of evidence on how environmental stimulation influences individuals’ eating performance at mealtimes.ObjectivesThis study examined the association between environmental stimulation and eating performance among nursing home residents with dementia.DesignThis study was a secondary analysis using baseline videos selected from a communication intervention study, where videos were recorded to capture staff-resident interactions during care activities for nursing home residents with dementia. Videos were included in this study only if residents demonstrated eating activities at mealtimes.Sample and settingA total of 36 videos were selected (mean length = 4 min). The sample included 15 residents with dementia (mean age = 86), and 19 certified nursing assistants (mean age = 36) in 8 nursing homes.MethodsThe dependent variable was eating performance as measured by the Level of Eating Independence scale (range: 15–36, with higher scores indicating better eating performance). The independent variables were characteristics of environmental stimulation measured by the Person-Environment Apathy Rating-Environment subscale (stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback). Each characteristic was rated on a 1–4 scale with higher scores indicating more desirable environmental stimulation. Multilevel models were used to examine the association between eating performance and environmental stimulation, adjusting for resident characteristics (i.e., age, gender, dementia stage, function, comorbidity, psychoactive medication use) and nesting effects of residents and staff.ResultsResident participants demonstrated moderate levels of eating performance (M = 27.08, SD = 5.16). Eating performance was significantly lower among older residents, those with more advanced dementia, and higher comorbidity. After controlling for resident characteristics, eating performance was significantly associated with stimulation specificity (how the stimulation is delivered and tailored to the resident), and was not associated with other environmental stimulation characteristics. For each 1 point increase in stimulation specificity, eating performance increased by 8.78 points (95% CI=0.59, 16.97).ConclusionsEnvironmental stimulation that is personally tailored to a resident’ needs and preferences and directly offered to a resident contributed to better eating performance among residents with dementia. The findings will direct future development and implementation of person-directed mealtime care programs and dining environment arrangements for residents with dementia in nursing homes.