Health effect of improved meal ambiance in a Dutch nursing home: a 1-year intervention study

The Frailty Reduction via Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial: Study Protocol and Recruitment Results

INTRODUCTION

Virtually all adults in aged care facilities are frail, a condition which contributes to falls, cognitive decline, hospitalisation, and mortality. Polypharmacy, malnutrition, sedentariness, and sarcopenia are risk factors amenable to intervention. The Asia-Pacific Frailty Management Guidelines recommend anabolic exercise and the optimisation of medications and nutrition. However, no study has evaluated this best practice intervention triad in aged care.

METHODS

The Frailty Reduction via the Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial (ANZCTR No.ACTRN12622000926730p) is a staged 6-month translational trial evaluating resident outcomes, staff/caregiver knowledge, and institutional implementation in a Townsville aged care facility. Residents received high-intensity resistance exercise and balance training and medication and nutrition optimisation co-implemented by investigators (exercise physiologist, geriatrician, pharmacist, and nutritionist) and facility staff. Staff and caregivers completed comprehensive education modules and training. We report the trial protocol and recruitment results.

RESULTS

29 residents (21 female, age: 88.6 ± 6.3 years) were recruited. At baseline, the residents were frail (frailty scale nursing home (FRAIL-NH); 6.3 ± 2.4/14), cognitively impaired (Montreal Cognitive Assessment; 13.8 ± 6.8/30), functionally impaired (Short Physical Performance Battery; 4.9 ± 3.1/12, 6 min walk distance; 222.2 ± 104.4 m), and were prescribed numerous medications (15.5 ± 5.9). Two residents died and one withdrew before the intervention's commencement. Thirty family members and 19 staff (carers, allied health assistants, nurse managers, registered nurses, lifestyle-leisure officers, kitchen/hospitality staff, and senior leadership) were recruited to receive frailty education modules.

CONCLUSIONS

The FRIEND trial is currently being implemented with results expected in mid-2024. This is the first trial to evaluate the implementation of the best practice frailty guidelines including anabolic exercise and medication/nutritional optimisation in residential aged care.

Physical environmental designs in residential care to improve quality of life of older people

BACKGROUND

The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function.

OBJECTIVES

To assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched.

SELECTION CRITERIA

Non-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled.

MAIN RESULTS

Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).  The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.

Music Is Served: How Acoustic Interventions in Hospital Dining Environments Can Improve Patient Mealtime Wellbeing

Eating-related challenges and discomforts arising from moderately acquired brain injuries (ABI)—including physiological and cognitive difficulties—can interfere with patients’ eating experience and impede the recovery process. At the same time, external environmental factors have been proven to be influential in our mealtime experience. This experimental pilot study investigates whether redesigning the sonic environment in hospital dining areas can positively influence ABI patients’ (n = 17) nutritional state and mealtime experience. Using a three-phase between-subjects interventional design, we investigate the effects of installing sound proofing materials and playing music during the lunch meals at a specialised ABI hospital unit. Comprising both quantitative and qualitative research approaches and data acquisition methods, this project provides multidisciplinary and holistic insights into the importance of attending to sound in hospital surroundings. Our results demonstrate that improved acoustics and music playback during lunch meals might improve the mealtime atmosphere, the patient well-being, and social interaction, which potentially supports patient food intake and nutritional state. The results are discussed in terms of potential future implications for the healthcare sector.

Nutrition Assessment and Interventions for the Prevention and Treatment of Malnutrition in Older Adults: An Evidence Analysis Center Scoping Review

Older adults living in the community or long-term residence such as a nursing home are at increased risk for malnutrition due to factors such as depression and isolation. The purpose of this scoping review is to identify the best available research that evaluates the validity and reliability of nutrition assessment tools, and the effectiveness of nutrition interventions to prevent or treat malnutrition among older adults. A literature search was conducted in Medline, Embase, CINAHL, and Cochrane Central databases to identify clinical trials, published in the English language, evaluating assessment and intervention methods aimed to treat or prevent malnutrition among older adults living in the community or their long-term residence such as nursing homes. Articles were screened by 2 reviewers, then data were extracted and narratively synthesized. The literature search retrieved 20,937 articles and 197 articles were included in narrative synthesis. A total of 73 assessment articles were identified, 36 of which were validity and reliability trials. A total of 122 intervention articles were identified, the majority of which were randomized controlled trials. A few of the most commonly evaluated interventions were oral nutrition supplements, medical nutrition therapy, fortification and enrichment, and nutrition education. Several systematic reviews were identified, however, that did not meet the criteria of this review. There is a need to conduct systematic reviews for nutrition assessment and intervention trials to guide development of evidence-based nutrition practice recommendations for older adults living in the community or their long-term residence.

Effect of communal dining and dining room enhancement interventions on nutritional, clinical and functional outcomes of patients in acute and sub-acute hospital, rehabilitation and aged-care settings: A systematic review

AIMS

This review aimed to synthesise evidence on the impact of communal dining and/or dining room enhancement interventions on nutritional, clinical and functional outcomes of patients in hospital (acute or subacute), rehabilitation and residential aged-care facility settings.

METHODS

Five electronic databases were searched in March 2020. Included studies considered the impact of communal dining and/or dining room enhancements on outcomes related to malnutrition in hospital (acute or subacute), rehabilitation and residential aged care facility settings. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality checklist. Overall quality was assessed using GRADEpro software. Outcome data were combined narratively for communal dining and dining room enhancements respectively.

RESULTS

Eighteen articles from 17 unique studies were identified. Of these studies, one was a randomised control trial (moderate quality) and 16 were observational studies (all low quality). Communal dining interventions (four studies, n = 490) were associated with greater energy and protein intake and higher measures of quality of life than non-communal mealtime settings. Dining room enhancement interventions (14 studies, n = 912), overall, contributed to increased intake of food, energy, protein and fluid.

CONCLUSIONS

Results indicate that communal dining and/or dining room enhancement has a positive impact on several outcomes of interest, however, most available evidence is of low quality. Therefore, there is a need for further large-scale, well-designed experimental studies to assess the potential impacts of these interventions.

Small is beautiful? Explaining resident satisfaction in Swedish nursing home care

BACKGROUND

Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood.

METHODS

A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences.

RESULTS

Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction.

CONCLUSIONS

The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis

BACKGROUND

Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality.

METHODS

A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment.

RESULTS

The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le.

CONCLUSIONS

The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Construct Validity of the Mealtime Scan: A Secondary Data Analysis of the Making Most of Mealtimes (M3) Study

Long-term care (LTC) physical and psychosocial mealtime environments have been inconsistently assessed due to the lack of a standardized measure. The purpose of this study was to examine the construct validity of a new standardized observational measure, the Mealtime Scan (MTS), using the Making Most of Mealtimes data collected on 639 residents in 82 dining rooms in 32 LTC homes. The MTS includes physical, social, and person-centered care summary scales scored from 1 to 8. Mean ratings on these summary scales were moderate for physical (5.6 SD 0.9), social (5.0 SD 0.9), and person-centered care (PCC; 5.5 SD 0.8). Regression analyses determined which items within the MTS were associated with these summary scales: physical - music (B = 0.27, p = 0.04), number of staff passing food (B = -0.11, p = 0.03), number of residents (B = -0.03, p = 0.01); social - social sound (B =  0.31 p < 0.0001), number of residents requiring eating assistance (B = 0.11, p = 0.02); PCC - lighting (B = 0.01 p = 0.04), and total excess noise (B = 0.05, p < 0.0001). The Mealtime Relational Care Checklist (M-RCC) was associated positively with ratings on all three summary scales. Correlations revealed that the MTS summary scales were associated with other constructs: Dining Environment Audit Protocol functionality scale, resident and dining room level M-RCC, Mini Nutritional Assessment- Short Form, and resident Cognitive Performance Scale. These results demonstrate that the MTS summary scales exhibit construct validity, as the ratings were associated with expected observed mealtime characteristics and correlated with dining room and resident level constructs in anticipated directions.

Construct validity of the Dining Environment Audit Protocol: a secondary data analysis of the Making Most of Mealtimes (M3) study

BACKGROUND

Research has demonstrated the importance of physical environments at mealtimes for residents in long term care (LTC). However, a lack of a standardized measurement to assess physical dining environments has resulted in inconsistent research with potentially invalid and unreliable conclusions. The development of a standardized, construct valid instrument that assesses dining rooms is imperative to systematically examine physical environments in LTC. The purpose of this study was to determine the construct validity of the new Dining Environment Audit Protocol (DEAP) tool.

METHODS

Secondary data collected from the Making Most of Mealtimes (M3) study was used for this analysis. Data were collected in 32 long term care homes, which included 82 dining rooms and 639 residents. A variety of resident and dining room level constructs were compared to the summative scales found on the DEAP using Spearman correlations and Student t-tests. A regression analysis identified individual characteristics assessed with DEAP that were associated with the summative scales of homelikeness and functionality.

RESULTS

Regression analysis (p < 0.05) identified that the DEAP homelikeness scale was positively associated with a view of the garden/green space, presence of a clock and a posted menu. The functionality scale was positively associated with number of chairs and lighting, while negatively associated with furniture with rounded edges and clutter. Additionally, the functionality scale was positively associated (p < 0.05) with the Mealtime Scan physical scale (ρ = 0.52), the dining room Mealtime-Relational Care Checklist (M-RCC) (ρ = 0.25), the DEAP total score (ρ = 0.56), and the Mini Nutritional Assessment- Short Form (ρ = 0.26). Homelikeness was positively associated (p < 0.05) with the DEAP total score (ρ = 0.53), staff Person Directed Care score (ρ = 0.49) and the resident Cognitive Performance Scale (t = 2.56), while negatively associated with energy (ρ = -0.26) and protein intake (ρ = -0.24). The homelikeness and functionality scales were also associated with one another (ρ = 0.26).

CONCLUSION

The construct validity of the DEAP was supported through significant correlations with a variety of measures that are theoretically related to the homelikeness and functionality of LTC dining rooms. This secondary analysis supports the use of the DEAP in future research to quantify the physical environment of LTC dining rooms. Protocol registered with ClinicalTrials.gov ID: NCT02800291; Registered retrospectively June 7, 2016.

"Leisurely Dining": Exploring How Work Organization, Informal Care, and Dining Spaces Shape Residents' Experiences of Eating in Long-Term Residential Care

Mealtimes are among the busiest times in nursing homes. Austerity measures resulting in insufficient staff with heavy workloads limit the amount of time available to assist residents with eating. Within a feminist political economy framework, rapid team-based ethnography was used for an international study involving six countries exploring promising practices and also for a study conducted in one Canadian province in which interrelationships between formal and informal care were investigated. Data collection methods included interviews and observations. In addition, dining maps were completed providing a cross-jurisdictional comparison of mealtime work organization, and illustrating the time spent assisting residents with meals. Dining maps highlight the reliance on unpaid care as well as how low staffing levels leave care providers rushing around, preventing a pleasurable resident dining experience, which is central to overall health and well-being.

Poor Appetite and Dietary Intake in Community-Dwelling Older Adults

BACKGROUND/OBJECTIVES

Poor appetite in older adults leads to sub-optimal food intake and increases the risk of undernutrition. The impact of poor appetite on food intake in older adults is unknown. The aim of this study was to examine the differences in food intake among older community-dwelling adults with different reported appetite levels.

DESIGN

Cross-sectional analysis of data from a longitudinal prospective study.

SETTING

Health, aging, and body composition study performed in the USA.

PARTICIPANTS

2,597 community-dwelling adults aged 70-79.

MEASUREMENTS

A semi-quantitative, interviewer-administered, 108-item food frequency questionnaire designed to estimate dietary intake. Poor appetite was defined as the report of a moderate, poor, or very poor appetite in the past month and was compared with good or very good appetite.

RESULTS

The mean age of the study sample was 74.5 ± 2.8 years; 48.2% were men, 37.7% were black, and 21.8% reported a poor appetite. After adjustment for total energy intake and potential confounders (including biting/chewing problems), participants with a poor appetite had a significantly lower consumption of protein and dietary fiber, solid foods, protein rich foods, whole grains, fruits, and vegetables, but a higher consumption of dairy foods, fats, oils, sweets, and sodas compared to participants with very good appetite. In addition, they were less likely to report consumption of significant larger portion sizes.

CONCLUSION

Older adults reporting a poor appetite showed a different dietary intake pattern compared to those with (very) good appetite. Better understanding of the specific dietary intake pattern related to a poor appetite in older adults can be used for nutrition interventions to enhance food intake, diet variety, and diet quality.

Goal-Directed Drinking Behaviors Can Be Modified Through Behavioral Mimicry

PURPOSE

This study tested whether behavioral mimicry can alter drinking behavior. It was hypothesized that participants would increase drinking behaviors given increased confederate drinking but not cup touching.

METHODS

Nineteen healthy adults (Mage = 20.32 years) completed 2 picture description tasks; during 1 task, a confederate frequently sipped water (complete drinking gesture), and during the other, the confederate touched her cup but did not drink (partial gesture). Outcome measures included number of drinks per minute, number of cup touches per minute, percentage of time spent drinking, and percentage of time spent touching the cup.

RESULTS

Participants spent more time drinking and had an increased drinking rate during the drinking condition versus the cup-touching condition. For a majority of participants, drinking rate increased during the drinking condition versus baseline. Drinking, but not cup touching, rate also increased given increased confederate cup touching for many.

CONCLUSIONS

Mimicry likely contributes to social modeling of drinking behaviors. This effect appears more robust given a complete target gesture (full drink); however, a partial goal-directed drinking gesture may also yield a mimicked response. Beyond the theoretical implications, these results provide directions for research investigating more naturalistic mechanisms for increasing dietary intake in various patient populations (e.g., individuals with dysphagia).

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Clinical nursing leaders' perceptions of nutrition quality indicators in Swedish stroke wards: a national survey

AIM

To describe nursing leaders' perceptions of nutrition quality in Swedish stroke wards.

BACKGROUND

A high risk of undernutrition places great demand on nutritional care in stroke wards. Evidence-based guidelines exist, but healthcare professionals have reported low interest in nutritional care. The Donabedian framework of structure, process and outcome is recommended to monitor and improve nutrition quality.

METHOD

Using a descriptive cross-sectional design, a web-based questionnaire regarding nutritional care quality was delivered to eligible participants.

RESULT

Most clinical nursing leaders reported structure indicators, e.g. access to dieticians. Among process indicators, regular assessment of patients' swallowing was most frequently reported in comprehensive stroke wards compared with other stroke wards. Use of outcomes to monitor nutrition quality was not routine. Wards using standard care plans showed significantly better results.

CONCLUSION

Using the structure, process and outcome framework to examine nutrition quality, quality-improvement needs became visible. To provide high-quality nutrition, all three structure, process and outcome components must be addressed.

IMPLICATIONS FOR NURSING MANAGEMENT

The use of care pathways, standard care plans, the Senior Alert registry, as well as systematic use of outcome measures could improve nutrition quality. To assist clinical nursing leaders in managing all aspects of quality, structure, process and outcome can be a valuable framework.

Environmental Considerations for Improving Nutritional Status in Older Adults with Dementia: A Narrative Review

As the number of older adults in the United States continues to grow, the American health care system will face the unique challenge of providing care for these individuals, including many who will be diagnosed with some form of dementia. As dementia progresses, patients require increasing amounts of care and nutrient intake usually declines. This tends to result in weight loss, malnutrition, and increased morbidity and mortality. Various interventions have been developed with the goal of improving meal intake and reducing unintentional weight loss in patients with dementia. Several studies have shown that meal intake improves with the provision of adequate assistance, either from staff members or from volunteer feeding assistants. Some studies have focused on the method of meal service and its influence on meal intake and nutrition status. Both buffet-style and family-style dining have shown promising results in terms of improving meal intake and quality of life among older adults in long-term-care settings. Other environment-related interventions include improving lighting and visual contrast, altering the dining room to more closely resemble a home-style setting, using the aroma of food to stimulate appetite, using routine seating arrangements, and using relaxing or familiar music in the dining room to provide a calmer environment. The purpose of this review is to evaluate the research on environment-based interventions to improve nutritional status among older adults with dementia, to describe potential for practical applications, and to identify gaps in the existing literature whereon further research is warranted.

Geriatric rehabilitation patients' perceptions of unit dining locations

Background

Eating together is promoted among hospitalized seniors to improve their nutrition. This study aimed to understand geriatric patients’ perceptions regarding meals in a common dining area versus at the bedside.

Methods

An exploratory qualitative study was conducted. Open-ended questions were asked of eight patients recruited from a geriatric rehabilitation unit where patients had a choice of meal location.

Results

Eating location was influenced by compliance with the perceived rules of the unit, physical and emotional well-being, and quarantine orders. Certain participants preferred eating in the common dining room where they had more assistance from hospital staff, a more attractive physical environment, and the opportunity to socialize. However, other participants preferred eating at their bedsides, feeling the quality of social interaction was poor in the dining room.

Conclusions

Participants’ experiences of, and preferences for, communal dining differed. If the benefits of communal dining are to be maximized, different experiences of this practice must be considered.

The effect of interventions to prevent and treat malnutrition in patients admitted for rehabilitation: a systematic review with meta-analysis

BACKGROUND

Malnutrition occurs frequently among patients in rehabilitation, leading to poorer outcomes. Evidence of the effects of interventions to prevent or treat malnutrition is required to guide clinical practice in this setting. This systematic review aimed to determine the effect of oral nutrition interventions implemented in rehabilitation on nutritional and functional outcomes.

METHODS

Five databases were searched to identify relevant publications; intervention trials of oral nutrition interventions (such as oral nutrition supplements, foodservice interventions, clinical care processes, enhanced eating environments) conducted with patients admitted for rehabilitation, reporting dietary intake, anthropometric, biochemical or functional outcomes. The reviewers determined study eligibility and assessed the included studies for risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS

From 1765 publications, 10 studies trialling oral nutrition supplements, foodservice interventions and clinical care processes (of neutral or positive quality) were identified. Compared to meals alone, oral nutritional supplements significantly improved energy and protein intake, with some evidence for improvements in anthropometry and length of stay. There was little evidence that speciality supplements were beneficial compared to standard versions. Meta-analyses demonstrated significantly greater energy [weighted mean difference (WMD) = 324 kcal, 212-436 kcal 95% confidence interval (CI)] and protein (WMD = 9.1 g, 0.2-17.9 g 95% CI) intake with energy dense meals. Opposing results were reported in studies investigating enhanced clinical care processes.

CONCLUSIONS

The provision of oral nutrition supplements and energy dense meals improved energy and protein intake and therefore may comprise effective strategies for addressing malnutrition in rehabilitation. The effect of these strategies on other nutritional and functional outcomes should be explored further.

Interventions for improving mealtime experiences in long-term care

Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.

Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis

The need to improve the nutrition of the elderly living in long term care has long been recognised, but how this can best be achieved, and whether (and which) intervention is successful in reducing morbidity is less well understood. The aim of this systematic review was to determine the effectiveness of mealtime interventions for the elderly living in residential care. Mealtime interventions were considered as those that aimed to change/improve the mealtime routine, practice, experience or environment. Following comprehensive searches, review and appraisal, 37 articles were included. Inadequate reporting in over half of the articles limited data quality appraisal. Mealtime interventions were categorised into five types: changes to food service, food improvement, dining environment alteration, staff training and feeding assistance. Meta-analysis found inconsistent evidence of effects on body weight of changes to food service (0.5 kg; 95% CI: -1.1 to 2.2; p=0.51), food improvement interventions (0.4 kg; 95% CI: -0.8 to 1.7; p=0.50) or alterations to dining environment (1.5 kg; 95% CI: -0.7 to 2.8; p=0.23). Findings from observational studies within these intervention types were mixed, but generally positive. Observational studies also found positive effects on food/caloric intake across all intervention types, though meta-analyses of randomised studies showed little evidence of any effects on food/caloric intake in food improvement studies (-5 kcal; 95% CI: -36 to 26; p=0.74). There was some evidence of an effect on daily energy intakes within dining environment studies (181 kcal/day, 95% CI: -5 to 367, p=0.06). The need to improve the nutrition of the elderly living in residential long term care is well recognised. This review found some evidence that simple intervention around various aspects of mealtime practices and the mealtime environment can result in favourable nutritional outcomes. Further large scale pragmatic trials, however, are still required to establish full efficacy of such interventions.

Physiological and psychosocial age-related changes associated with reduced food intake in older persons

Dietary intake changes during the course of aging. Normally an increase in food intake is observed around 55 years of age, which is followed by a reduction in food intake in individuals over 65 years of age. This reduction in dietary intake results in lowered levels of body fat and body weight, a phenomenon known as anorexia of aging. Anorexia of aging has a variety of consequences, including a decline in functional status, impaired muscle function, decreased bone mass, micronutrient deficiencies, reduced cognitive functions, increased hospital admission and even premature death. Several changes during lifetime have been implicated to play a role in the reduction in food intake and the development of anorexia of aging. These changes are both physiological, involving peripheral hormones, senses and central brain regulation and non-physiological, with differences in psychological and social factors. In the present review, we will focus on age-related changes in physiological and especially non-physiological factors, that play a role in the age-related changes in food intake and in the etiology of anorexia of aging. At the end we conclude with suggestions for future nutritional research to gain greater understanding of the development of anorexia of aging which could lead to earlier detection and better prevention.

A theoretically based Behavioral Nutrition Intervention for Community Elders at high risk: the B-NICE randomized controlled clinical trial

We conducted a study designed to evaluate the efficacy and feasibility of a multilevel self-management intervention to improve nutritional intake in a group of older adults receiving Medicare home health services who were at especially high risk for experiencing undernutrition. The Behavioral Nutrition Intervention for Community Elders (B-NICE) trial used a prospective randomized controlled design to determine whether individually tailored counseling focused on social and behavioral aspects of eating resulted in increased caloric intake and improved nutrition-related health outcomes in a high-risk population of older adults. The study was guided by the theoretical approaches of the Ecological Model and Social Cognitive Theory. The development and implementation of the B-NICE protocol, including the theoretical framework, methodology, specific elements of the behavioral intervention, and assurances of the treatment fidelity, as well as the health policy implications of the trial results, are presented in this article.

‘The Taste Buddies’: participation and empowerment in a residential home for older people

The active participation and autonomy of older people living in residential homes is considered to be problematic. However, in our action research project conducted in a Dutch residential care organisation we found ways to enhance residents' direct participation. This form of participation is grounded in deliberative and participatory approaches to democracy. In this article we describe how a group of seven residents (all female), calling themselves ‘The Taste Buddies’, developed a joint vision on how meals could be improved. The facilitation of this process enhanced this group's empowerment, building interpersonal trust, social identity and joint purpose. We will take the reader through this process and discuss the developments of these older women against the background of relational empowerment. We argue that resident participation as partnership with employees and managers starts with relational empowerment among residents themselves (enclave deliberation). This process is non-linear and requires time and constructive facilitation.

Mealtimes in nursing homes: striving for person-centered care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.

Improving the dietary intake of frail older people

As a population subgroup, older people are more vulnerable to malnutrition especially those who are institutionalised. Recognition of deteriorating or poor nutritional status is key in reversing the effects of undernutrition and reinforces the value of regular weight checks and/or the use of screening tools. Commercially produced supplements are often the first option used to address undernutrition in both acute and community settings. They can be expensive and, although regularly prescribed, have undergone only limited evaluation of their effectiveness in community settings. An alternative but less researched approach to improve the nutritional status of undernourished people is food fortification. This approach may be particularly useful for older people, given their often small appetites. The ability to eat independently has been significantly related to decreased risk of undernutrition. Assisting people who have difficulty feeding themselves independently should become a designated duty and may be crucial in optimising nutritional status. Lack of nutrition knowledge has been identified as the greatest barrier to the provision of good nutritional care. Education and training of care staff are pivotal for the success of any intervention to address undernutrition. The development of undernutrition is a multi-factorial process and a package of approaches may be required to prevent or treat undernutrition. Nutrition must be at the forefront of care if national care standards are to be met.

The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents

OBJECTIVE

Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well-being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non-demented residents.

METHODS

Prospective cohort study of a stratified random sample of 326 AL residents living in 21 AL facilities. Measures included the Therapeutic Environmental Screening Scale for Nursing Homes and Residential Care (TESS-NH/RC) to rate facilities and in-person assessment of residents for diagnosis (and assessment of treatment) of dementia, ratings on standardized clinical, cognitive, and QOL measures. Regression models compared environmental measures with outcomes. TESS-NH/RC is modified into a scale for rating the AL physical environment AL-EQS.

RESULTS

The AL Environmental Quality Score (AL-EQS) was strongly negatively associated with Neuropsychiatric Inventory (NPI) total score (p < 0.001), positively associated with Alzheimer Disease Related Quality of Life (ADRQL) score (p = 0.010), and negatively correlated with fall risk (p = 0.042). Factor analysis revealed an excellent two-factor solution, Dignity and Sensory. Both were strongly associated with NPI and associated with ADRQL.

CONCLUSION

The physical environment of AL facilities likely affects NPS and QOL in AL residents, and the effect may be stronger for residents without dementia than for residents with dementia. Environmental manipulations that increase resident privacy, as well as implementing call buttons and telephones, may improve resident well-being.

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data.

This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication.

There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Malnutrition and mealtime ambiance in nursing homes

Inadequate nutritional intake is the predominant cause of malnutrition in older persons. It is one of the most common and devastating conditions in nursing home residents. It is multifactorial and treatment or nutrition care plans should try to address the main causes. Such plans often include means to stimulate appetite to prevent or treat anorexia. One important stimulus, which can be modulated easily, is the meal ambiance. This article deals with the theory or mechanism behind this meal ambiance stimulus, discusses some study results, and makes practical recommendations.

Evaluation of strategies to improve nutrition in people with dementia in an assessment unit

OBJECTIVES

To evaluate strategies designed to improve nutrition in elderly hospitalised patients with dementia.

DESIGN

Observation phase followed by sequential interventions.

SETTING

A Short stay assessment unit.

PARTICIPANTS

Hospital Inpatients with a variety of conditions causing dementia.

INTERVENTIONS

Phase 1: Observation. Phase 2: Encouraging dietary, 'Grazing'. Phase 3: Using volunteers to feed patients. Phase 4: Improving dining room ambience by playing soothing music.

MEASUREMENTS

Body Mass Index (BMI), mid arm circumference, mini nutrition index and caloric intake by plate waste measurement.

RESULTS

BMI fell in the Observation phase 0.6 +/- 0.68 kg/m2 (p < 0.001), but increased in each of the Intervention phases. Phase2 0.3 +/- 0.86 kg/m2 (p < 0.04), Phase 3 0.37 +/- 0.4 kg/m2 (p < 0.04), Phase 4 0.39 +/- 0.7 kg/m2 (p < 0.007). Caloric intake increased in the intervention phases.

CONCLUSIONS

Simple, inexpensive and easy to implement strategies can improve nutrition in hospital inpatients with dementia.