Optimising nutrition for older people with dementia

This article explores interventions that can be undertaken to establish and maintain adequate nutritional intake in older people with dementia. This is often a problem, particularly in the later stages of the disease. A literature review was conducted, which identified 12 articles for inclusion. Most of these articles described interventions to maintain adequate nutritional intake in older adults with dementia. Although no standardised intervention was reported, some approaches did appear to be more successful than others. Further research is required on how nurses and nursing assistants can help older people with dementia to maintain adequate nutrition. Staff need more time and training to improve nutritional intake in this group of patients. In addition, enhanced vigilance with respect to eating difficulties and food consumption is necessary.     

The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2): convergent and discriminant validity

The increasing feeding difficulty of older people with dementia is well documented (Watson 1993, 1994). However, there is a paucity of validated instruments for the assessment of feeding difficulty in older people with dementia which can be used to guide practice. The scale properties, reliability (Watson 1996) and some aspects of the validity have previously been reported (Watson 1997). This short report describes continuing work on the Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2) and demonstrates the reliability of the EdFED #2 and its convergence with a scale measuring nutritional risk and discrimination from scales measuring unrelated aspects of feeding difficulty.     

The Factors Influencing Meal Satisfaction in Older Adults: A Systematic Review and Meta-analysis

PurposeThe aim of this study was to identify factors influencing meal satisfaction in older adults.MethodsAuthors searched four databases Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, and KoreaMed using the following key search terms: “(elderly-mp. OR aged), AND (meal OR food OR eating OR feeding), AND satisfaction.” Only articles published between January 1946 and May 2018 were considered. The preferred reporting items for systematic reviews and meta-analyses guidelines were adopted for quality assessment. The authors ultimately selected 7 of 1,695 references for review and meta-analysis.ResultsA meta-analysis was conducted to determine the factors influencing meal satisfaction in older adults aged more than 60 years. The results showed that meal satisfaction was low when age increased and the individual was served frozen meals. Satisfaction with meals was high when food choices were available and individuals were served high-quality food and when the food smelled and tasted good or was personally tailored. Satisfaction was also high when individuals ate with their families. Moreover, meal satisfaction seemed to be influenced by physical health, whereas it did not show a significant correlation with mental health.ConclusionIntending to improve the quality of life of older adults by increasing their meal satisfaction, the authors pointed out factors that institutions should attend to when providing meals to older adults. To contribute to the lack of any existing conceptual and theoretical framework in this field, further steps to be taken by the authors shall involve concept analysis that would assist in building a conceptual framework.     

Recognizing new perspectives in eating difficulties following stroke: a concept analysis

Purpose: To describe and identify various perspectives on eating difficulties following stroke to enable theory development and facilitate advancement of interventions. Methods: Concept analysis in line with Morse’s principles of exploring pragmatic utility was used throughout the data collection and analysis. Peer-reviewed research on eating difficulties was systematically and critically appraised. Literature included the bibliographic databases, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus and PsycInfo, published up until November 2011. A total of 33 key articles were included in the final analysis. Results: A conceptual model of eating difficulties is presented showing the multiple affecting factors, namely meaning-related, functional and contextual factors and the consequences of non-intervention, feeling of loss, social isolation, negative sensations and depression – all of which potentially increase the impact of disease severity, functional outcome and quality of life. Based upon the dimensions identified, the definition of eating difficulties was synthesized as “any activity and emotional requirement and relations, which alone or in combination interfere with the process of preparing food, transferring food into the mouth, chewing and swallowing”. Conclusion: Eating difficulties have profound effects on people. The conceptual model serves to guide health care professionals to assess and help stroke patients in facing a life with eating difficulties.

Implication for rehabilitation

• Eating difficulties is a complex concept that touches essential areas of life following stroke.

• Attending to eating difficulties in a structured way that encompasses meaning, functional and contextual issues might facilitate successful rehabilitation.

• The conceptual framework suggests a focus for developing effective, holistic interventions with initial screening and following assessment, so that appropriate interventions can commence and adverse consequences prevented. Items to consider in the assessment of eating difficulties are offered.

     

Measuring feeding difficulty in patients with dementia: developing a scale

Feeding difficulty in elderly people with dementia is well documented and the need for research in this area of nursing care has been raised by several authors. One hundred and twelve elderly people with dementia were entered into a study of feeding difficulty. Data were gathered by means of a questionnaire administered to the nurses caring for the patients. The aspects of feehg difficulty which were investigated were based on reports of relevant behaviour in the literature and included refusal to eat, turning the head away, refusing to open the mouth, spitting, allowing food to drop out of the mouth and not swallowing. It was possible to arrange these different aspects of feeding difficulty under three headings: (a) refusal to eat, (b) spitting, and (c) inability to swallow, and to analyse the pattern of accumulation of these feeding difficulties by means of Guttman scale analysis. According to this analysis, the feeding Uculties investigated form a cumulative and unidimensional pattern. The implications of this pattern and the possibilities for further research are discussed.     

Interventions on mealtime difficulties in older adults with dementia: A systematic review

Objectives

To evaluate the effects of interventions on mealtime difficulties in older adults with dementia.

Design

A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement.

Data sources

Pubmed, Medline (OVID), CINAHL (EBSCOHost), EBM Reviews (OVID) and PsychINFO (OVID) were searched between January 2004 and September 2012 by using keywords as dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, nutrition, intervention, experimental, quasi-experimental and any matched terms. Other sources included Google Scholar and relevant bibliographies.

Review methods

Eligibility criteria were established by defining the population, intervention, comparator, outcomes, timing and setting of interest. Studies were reviewed by title and abstract screening, and full-text assessing for eligibility. Data were abstracted from eligible studies using a self-made structured tool. Eligible studies were classified by intervention, accessed for quality using the Quality Assessment Tool for Quantitative Studies, and graded for evidence using the Grading of Recommendations, Assessment, Development and Evaluation Working Group criteria.

Results

Twenty-two intervention studies (9 RCTs), including a total of 2082 older adults with dementia and 95 professionals from more than 85 long-term care facilities, were selected, and classified into five types: nutritional supplements, training/education programs, environment/routine modification, feeding assistance and mixed interventions. Eight studies were strong, eleven moderate and three weak in quality. Limitations of body of research included lack of randomization and/or control group, small sample size without power analysis, lack of theory-based interventions and blinding, inadequate statistical analysis and plausible confounding bias. “Nutritional supplements” showed moderate evidence to increase food intake, body weight and BMI. “Training/education programs” demonstrated moderate evidence to increase eating time and decrease feeding difficulty. Both “training/education programs” and “feeding assistance” were insufficient to increase food intake. “Environment/routine modification” indicated low evidence to increase food intake, and insufficient to decrease agitation. Evidence was sparse on nutritional status, eating ability, behavior disturbance, behavioral and cognitive function, or level of dependence.

Conclusions

This review provides updated evidence for clinical practice and points out priorities for nursing research. Current evidence is based on a body of research with moderate quality and existing limitations, and needs to be further explored with more rigorous studies.     

Cultural Perspectives in Feeding Difficulty in Taiwanese Elderly With Dementia

Objective: To investigate factors related to feeding difficulty that is shown in the interaction between nursing assistants and elderly residents with dementia.
Methods: Forty-eight residents and 31 nursing assistants were observed during meal times in a congregate dining room of a Taiwanese nursing home specializing in dementia care. Residents' eating behaviors, the dining environment, interactions between the nursing assistant and the residents, and feeding strategies used by nursing assistants were observed. Nutritional data for residents were collected from medical charts. The EdFED Scale #2 and interviews of nursing assistants provided information about feeding difficulty. Interviews also provided data on strategies used to address feeding difficulties.
Findings: The most frequent feeding difficulty was refusal to eat (37.5%). The strategies used by nursing assistants were limited. Nursing assistants stated they needed more training to address feeding difficulty in residents with dementia.
Conclusions: Future research should be focused on the interface between the residents and nursing assistants who must identify various feeding difficulties and select appropriate interventions.
Clinical Relevance: Results might provide information that can be used to develop effective interventions and promote high-quality mealtime care in patients with dementia.     

Strategies for feeding patients with dementia

OVERVIEW: Despite the high prevalence of dementia among elderly patients in hospitals and nursing homes and the strong association between dementia and feeding difficulty, few sources adequately address effective feeding interventions. Basing their discussion on the conceptual model that grew out of a previously published systematic literature review, the authors address a wide range of assessment and intervention practices specific to various observed behaviors that may aid in feeding patients with dementia.     

Disability & aging: an evolutionary concept analysis

The idealized image of successful aging as living independently and autonomously does not convey reality for many adults in the United States and globally who are living with a disability. There have been inconsistencies throughout the literature in defining disability and aging. A concept analysis using Rodgers' method was undertaken to define the concept of disability and aging, understand its antecedents and consequences, and determine the implications for nursing practice and research. Four attributes were defined: limitation in physical, sensory, and/or mental function; universal human experience; difficulties in activities of daily living (ADLs)/instrumental ADLs; and social construction. Exemplars were identified to provide a representation of the attributes in context, and a model of disability and aging was created. This concept analysis provides a better understanding of disability and aging, which can enable nurses to provide education and advocacy to older adults and their families.     

The Edinburgh Feeding Evaluation in Dementia Scale: determining how much help people with dementia need at mealtime

OVERVIEW: The Edinburgh Feeding Evaluation in Dementia scale is an 11-item instrument developed to assess eating and feeding problems in people with late-stage dementia. By looking for certain behaviors--spilling food while eating or turning the head when prompted to eat, for example--a nurse can identify a patient's needs and build an effective care plan. The scale takes as little as five minutes to complete. Watch an online video of nurses demonstrating the use of the scale: http://links.lww.com/A281.     

The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2): inter- and intra-rater reliability

Difficulty with feeding increases in older people as the condition of dementia progresses (Watson 1997a). The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2) has been designed to measure the level of feeding difficulty associated with dementia, and its scale properties, internal consistency (Watson 1996) and some aspects of the validity have previously been reported (Watson 1997b; Watson et al. 2001). The present report describes the inter- and intra-rater reliability of the EdFED #2.     

Improving the nutritional status of people with dementia

The attention given to the nutritional needs of older adults receiving hospital care has been the subject of research over recent years. It has been suggested that older people are suffering from malnutrition as a result of poor nursing care. Those involved in care of persons with dementia are faced with considerable difficulty when trying to respond to their nutritional care needs and there is concern that there may come a time when the care team will withdraw food and fluid. However, in Southern Derbyshire we believe that we now have a set of standards for nutritional care of older adults with dementia that can ensure adequate and good nutrition despite the numerous and complex problems posed by dementia. This article discusses the progress of a sample of 20 residents of a long-stay ward over a period of 6 years and shows how a multidisciplinary team accessed, developed and applied an evidence base to practice to the benefit of the sample group. The outcomes show that malnutrition can be reversed, and that people who are considered to be in the final stages of dementia can improve their nutritional status.     

Poorly served? Eating and dementia

BACKGROUND: People with dementia encounter problems in eating and these have been reported in various studies. Many of these studies focus on individual difficulties and neglect the social, environmental and cultural aspects of meals and eating. Studies often centre on the problems of providing food instead of the experience of those receiving food. Less is known of the perspectives of family carers and residential or domiciliary care staff than of nurses' perceptions. Only recently are the perspectives of family carers and people with dementia joining nurses' discussions. AIM: The present paper considers feeding and eating in the context of enhancing support of life for people with dementia. Drawing on a range of literature, it highlights themes that are well developed and aims to identify areas of little knowledge and potential investigation. CONCLUSIONS: In the United Kingdom, the areas of feeding and eating are likely to assume greater importance in attempts to promote rehabilitation, in moves to offer training to unqualified staff and in enhanced vigilance of the experience of people with dementia. Their problems with respect to food and its consumption need to be interrogated and informed by interventions that are ethical, socially inclusive and acknowledge the importance of food to well-being.     

Effects of a nutrition education program for urban, low-income, older adults: a collaborative program among nurses and nursing students

Nutrition education programs can be effective in reducing risks of cardiovascular disease in older adults. The objective of the Eat and Learn Nutrition Program was to increase knowledge of nutrition and promote healthy eating among the residents of an older adult, low-income, urban housing community. The program was a series of 3 discussions on nutrition topics, based on a community needs assessment, that were presented in the common room of the participants' residence over a heart-healthy lunch. On average, participants were able to increase their nutrition knowledge learning 1 major point per session. In addition, participants discussed alternative methods for healthy eating and shared culturally diverse nutritious recipes with each other. The collaborative nursing effort in designing the program served to facilitate learning about community program implementation for all nursing students involved. Collaboration between nurses and nursing students from a variety of educational backgrounds may enhance learning and program success.     

Effects of a feeding skills training programme on nursing assistants and dementia patients

Aims and objectives. The purposes of this study were to develop a comprehensive feeding skills training programme for nursing assistants and to test the effects of this training programme on their knowledge, attitude and behaviour and the outcome of dementia patients including total eating time, food intake and feeding difficulty. Background. Dementia patients have a high probability of feeding problems that result in a substantial risk of malnutrition. Assisting residents with eating is a major task for nursing assistants and they require better training to provide adequate quality of nutritional care. Design methods. A quasi‐experimental study was conducted. Two convenience‐chosen dementia‐specialized long‐term care facilities in North Taiwan were randomly assigned into either a control or a treatment group. Sixty‐seven nursing assistants were enrolled (treatment: 31; control: 36). Twenty nursing assistants and the same number of dementia patients were observed during mealtime. The treatment group participated in a feeding skills training programme including three hours of in‐service classes and one hour of hands‐on training, whereas the control group did not receive any training. Results. The treatment group had significantly more knowledge (F = 47·7, P < 0·001), more positive attitude (F = 15·75, P = 0·001) and better behaviours (t = 6·0, P < 0·001) than the control group after the intervention. Dementia patients in the treatment group had significantly longer total eating time (t = 2·7, P < 0·05) and higher Edinburgh Feeding Evaluation in Dementia scores (more feeding difficulty) (t = 2·1, P < 0·05) than the control group. There was no significant difference on food intake between the two groups (t = 0·8, P = 0·49). Conclusion. This feeding skills training programme has been found to change nursing assistants’ knowledge, attitude, and behaviour as well as increasing the eating time for the dementia patients. Relevance to clinical practice. This study raises attention regarding on‐the‐job training for nursing assistants. Furthermore, the feeding problems among dementia patients should be further explored as well as the nutritional care.     

Adapting the family management style framework for families caring for older adults with dementia

This article presents an adaptation of the Family Management Style Framework (FMSF)-a well-established framework of family response to chronic condition care of children-to families caring for older adults with dementia. Using the FMSF to better understand how families manage dementia care can provide clinicians with insights on how to work effectively with families. Using data from interviews with eight female caregivers of older adults with dementia, this secondary analysis adapts the FMSF, and identifies new dimensions that apply specifically to families caring for older adults with dementia. The discussion draws comparisons between the family management of a child with chronic condition to management of an older adult with dementia. The article concludes with a discussion of how understanding how families manage care of an older adult with dementia informs assessment for management styles and the tailoring of interventions specific to family, caregiver, and older adult needs.     

Social isolation in older adults: an evolutionary concept analysis

Title.  Social isolation in older adults: an evolutionary concept analysis.
Aim.  This paper is a report of an analysis of the concept of social isolation as experienced by older adults.
Background.  Social isolation is a serious problem with older adults that is expected to increase in the future. Although strong correlations exist between social isolation and negative health consequences, few interventions exist. One contributing factor to this is a lack of conceptual clarity.
Data sources.  The CINAHL, PsycINFO and Medline databases and the Web of Science were searched using the key terms social isolation, social networks, older adults, elderly and social integration for publications between 1983 and 2007.
Review methods.  An evolutionary concept analysis was undertaken. References were read in their entirety and analysed based on the summary of surrogate terms, related concepts, attributes, antecedents and consequences.
Findings.  Five attributes were identified: number of contacts, feeling of belonging, fulfilling relationships, engagement with others and quality of network members. Antecedents included: lack of relationships, psychological barriers, physical barriers, low financial and resource exchange, and prohibitive environment. Roy's Adaptation Model is proposed as a theoretical context into which social isolation fits.
Conclusion.  Numerous definitions are used to describe social isolation, but they lack uniformity, consistency and clarity; this impairs the further development and refinement of the concept. This concept analysis can offer additional understanding and a starting point for future research related to social isolation.     

Informal support for older adults is negatively associated with walking and eating during hospitalization

Processes related to daily care of older adults during hospitalization, such as mobility and nutrition, have long-term consequences for their health and functioning. Although instrumental support provided by family members during hospitalization is highly prevalent, its relationship to older adults’ actual walking and eating is unknown.Data on walking level (walking outside vs. inside the room) and nutritional intake were collected from 493 independent older adults admitted to internal medicine wards through up to three daily interviews using validated questionnaires. Informal support with walking and eating was assessed with the modified Informal Caregiving for Hospitalized Older Adults scale. Multivariate regression showed that informal support with walking and eating was associated with greater likelihood of walking inside the room and with lower nutritional intake. This association between informal support and less walking and eating call for routine functional assessments and tailored counseling of informal caregivers to meet older patients’ support needs.