Feasibility of a web-based dementia feeding skills training program for nursing home staff

Family caregivers use a Hand-Under-Hand online course to improve the nutritional status of patients with severe dementia: A quasi-experimental study

AIM

In Taiwan, over 90% of dementia patients received home care. Severe dementia-linked food refusal significantly affects nutrition, thereby straining caregivers. Family caregivers can reduce their burden by learning feeding and dementia nutrition online, thus preserving patient oral feeding. The study aim for family caregivers learn online Hand-Under-Hand (UH) techniques to ease feeding in severe dementia, enhancing nutrition and reducing their burden.

METHODS

In this quasi-experimental study, participants in the experimental group received 2-h UH courses online, while the control group received their usual care. The primary outcome indicators were abnormal eating behavior, nutritional status, and caregiver burden, with outcomes tracked at 0, 1, and 3 months. At the neurology outpatient clinic of a medical center in Taipei, 65 dyads-comprising patients with severe dementia and their caregivers-were randomly assigned to groups.

RESULTS

The study participants comprised 36 female and 29 male caregivers, with an average age of 58.09 years. The patient group included 43 females and 22 males, with a mean age of 83.32 years. Patients in the experimental group exhibited reduced abnormal eating behavior, and caregiver burden was reduced at 1 and 3 months, patients demonstrated improved nutritional status by month 3.

CONCLUSIONS

The accessibility and convenience of online courses enabled family caregivers to use UH feeding techniques to effectively improve the nutritional status and correct the abnormal eating behavior of patients with dementia, while also decreasing caregiver burden. Geriatr Gerontol Int 2024; ••: ••-••.

Assessing eating ability and mealtime behaviors of persons living with dementia: A systematic review of instruments

This systematic review aimed to describe the characteristics of instruments that assess eating ability and/or mealtime behaviors in persons living with dementia, and evaluate their psychometric properties. Five databases were searched for relevant records between 1/1/1980 and 5/25/2023. Records included instruments assessing eating ability and/or mealtime behaviors of people with dementia. The psychometric quality of the instruments was evaluated using the Psychometric Assessment for Self-report and Observational Tools (PAT). 45 eligible instruments were identified from 115 records. While 38 instruments were scored as having low psychometric quality, 7 had moderate quality. Edinburgh Feeding Evaluation in Dementia (EdFED), Mealtime Difficulty Scale for older adults with Dementia (MDSD), and Dementia Hyperphagic Behavior Scale (DHBS) were scored as having the highest quality (total PAT score = 9). Further refinement of existing instruments and additional psychometric testing in larger, diverse samples will improve pragmatic use in dementia mealtime care research and practice.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Interventions to address mealtime support needs in dementia: A scoping review

The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.

Nonpharmacological Interventions for Management of Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities by Direct Caregivers: A Systematic Review

Behavioral and psychological symptoms of dementia (BPSD) are a worldwide problem. Estimates indicate approximately 96% of persons with dementia (PWD) exhibit BPSD that are directly associated with long-term care (LTC) placement and approximately one half of these persons experience symptoms classified as severe. BPSD are associated with lost days of work, high turnover, and poor job satisfaction for direct caregivers. Nonpharmacological interventions (NPIs) are effective for management of BPSD when used properly. NPIs are more likely to be used by direct caregivers who are knowledgeable about and have confidence in BPSD effectiveness. Various training techniques promote development of this self-efficacy. The current systematic review synthesizes evidence concerning the use of NPIs for management of BPSD by direct caregivers in LTC settings. Gaps in the literature include evaluation of positive impact of NPIs on PWD and behavior precedent factors. This review emphasizes the need for development and provision of quality NPI education for direct caregivers in LTC settings. [Journal of Gerontological Nursing, 48(7), 18-23.].

Eating Difficulties among Older Adults with Dementia in Long-Term Care Facilities: A Scoping Review

This paper reports a scoping review of the literature on eating difficulties among older adults with dementia in long-term care facilities to identify key concepts, methods of measuring outcomes, interventions, and related factors. A scoping review was performed using the bibliographic databases PubMed, CINAHL, PsycINFO, and Cochrane Library. A combination of keywords and subject headings related to eating or feeding difficulties was used. Inclusion criteria were limited to materials published in English. A total of 1070 references were retrieved, of which 39 articles were selected after applying the inclusion and exclusion criteria. Articles that met the criteria were published between 1987 and 2020. “Eating disabilities” have been defined as problems related to choosing food and/or the ability to get food to one’s mouth, chew, and swallow. Interventions for eating difficulties described in the literature include spaced retrieval training, Montessori training, and feeding skill training. Intrapersonal, interpersonal, and environmental factors related to eating difficulties were identified. This scoping review will provide direct care workers, nursing educators, and administrators with an overview of eating performance and a broad understanding of eating difficulties for older adults with dementia in long-term care facilities.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

BACKGROUND

As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.

OBJECTIVE

To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.

DESIGN

A systematic review of qualitative research.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.

REVIEW METHODS

Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.

FINDINGS

A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, a social worker, a professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.

CONCLUSIONS

Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients' preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.

Assessing Caregivers' Skills in Assisting People with Dementia during Mealtime: Portuguese Cultural Adaptation of the Feeding Skills Checklist

In advanced dementia, individuals usually develop feeding difficulties. The Feeding Skills Checklist (FSC) is an instrument to assess caregivers’ skills when assisting people with dementia (PwD) at mealtimes. This study aimed to adapt and culturally validate a European Portuguese version of the FSC (FSC-PT) and test its reliability. Initially, translation and cultural validation of the FSC, with estimation of the content validity index (CVI), was conducted. Then, the FSC was applied to 23 female nursing assistants (mean age 44.73 ± 10.42 years) while offering lunch (n = 41 meals) to institutionalized PwD. Inter-rater reliability was determining using Cohen’s Kappa. FSC-PT showed excellent content validity, with item-content validity index ranging from 0.85 to 1, scale level average CVI = 0.94 and universal agreement CVI = 0.54. It also showed very satisfactory inter-observer reliability, with Cohen’s Kappa = 0.844. Of the 41 meals analyzed, only 37.7% of the actions/good practices in feeding PwD were observed. A positive and moderate correlation was found between the length of time working as nursing assistance and the FSC environment dimension (r_s = 0.435; p = 0.038). The results supported the content validity of the FSC-PT, which shows considerable potential to be an instrument for verifying caregivers’ skills when helping PWD to eat and should be increasingly studied.

Ease of use, feasibility and inter-rater reliability of the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme

AIMS

To refine the Cue Utilization and Engagement in Dementia mealtime video-coding scheme and examine its ease of use, feasibility, and inter-rater reliability in assessing the food intake process and dyadic verbal and nonverbal interactions.

DESIGN

This study was a secondary analysis of 110 videotaped observations of mealtime interactions collected under usual care conditions from a dementia communication trial during 2011-2014.

METHODS

The videos involved 29 staff and 25 residents with dementia (42 unique staff-resident dyads) in nine nursing homes. Data coding and analysis were performed in 2018-2019. Logs of coding challenges with matched solutions and coding time were collected. Inter-rater reliability was examined through rating of randomly selected 22 videos across four trained coders.

RESULTS

It took a mean of 10.81 hr to code a one-hour video using the refined coding scheme. Coding challenges, including identification of key intake process characteristics and differentiation of similar verbal or nonverbal behaviours, were identified with appropriate solutions. The refined coding scheme had good inter-rater reliability (Cohen's Kappa range = 0.93 - 0.99, 95% CI = 0.92 - 0.99).

CONCLUSION

Findings supported preliminary evidence on feasibility, usability and inter-rater reliability of the refined coding scheme. Future psychometric testing is needed in diverse populations with dementia across different care settings.

IMPACT

Existing tools assessing the food intake process and dyadic interactions are few and have limited feasibility and/or reliability and fail to capture the complexity and dynamics of mealtime care. The refined coding scheme showed preliminary feasibility, usability, and inter-rater reliability. In consideration of the balance between time intensity and the richness of data obtained, the tool may be appropriate and useful in addressing certain research inquires (e.g., characterizing and clustering dyadic behaviours, temporal relationship between behaviours and intake) pertaining older adults with or without dementia and their formal or informal caregivers.

Mealtime caregiving knowledge, attitudes, and behaviors for persons living with dementia: A systematic review of psychometric properties of instruments

BACKGROUND

Using valid instruments to assess caregiving knowledge, attitudes, skills, and behaviors in mealtime care for people living with dementia is critical to evaluate the process and effects of mealtime assistance interventions. Yet, the quantity and psychometric quality of such instruments are unknown.

OBJECTIVES

This systematic review described and evaluated psychometric properties of instruments that were developed and used to assess mealtime caregiving knowledge, attitudes, skills, and behaviors for people with dementia.

METHODS

We searched Pubmed, CINAHL, AgeLine, PsychINFO, and Cochrane Library for records published between January 1st, 1980 and June 31st, 2019, with follow-up searches by December 20th, 2019. Records were eligible if they included any instrument developed, tested, and/or used to measure the concepts of interest, including mealtime caregiving knowledge, attitudes, skills, and/or behaviors. After eligible records were identified, instruments that were reported in the eligible records were identified and extracted. Instruments were eligible if they were originally developed to measure the concepts of interest or developed in non-mealtime activities and later used or tested to measure the concepts of interest. From eligible records, eight characteristics of eligible instruments were extracted: (1) development process, (2) the concept/construct the instrument operationalizes, (3) sample and setting the instrument was used/tested in, (4) administration method, (5) description of items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric quality of eligible instruments was evaluated using a newly developed psychometric quality assessment tool.

RESULTS

A total of 9438 records were retrieved and 19 eligible instruments were identified. Ten instruments assessed mealtime caregiving skills or behaviors; 5 assessed attitudes, intention, self-efficacy, empathy; and 4 assessed knowledge. All instruments were scored as having low psychometric quality, except for Mealtime Engagement Scale with moderate psychometric quality in assessing mealtime engagement toward people with dementia. Reasons for low psychometric quality included limited psychometric testing, inadequate estimates of psychometric properties, and use of small sample size.

CONCLUSIONS

While all instruments warrant further testing, Mealtime Engagement Scale demonstrated moderate psychometric quality with preliminary evidence of reliability and validity to assess mealtime engagement toward people with dementia. Future testing of Mealtime Engagement Scale is needed in larger diverse samples in different care settings to accumulate psychometric evidence and expand the use.

Feasibility of a Mobile Meal Assistance Program for Direct Care Workers in Long-Term Care Facilities in South Korea

Purpose

The purpose of this study was to assess the feasibility and examine the preliminary effectiveness of a mobile application-based meal assistant training program (APP) for use by direct care workers (CAs) assisting residents with dementia in long-term care facilities in South Korea.

Methods

We adopted a mixed methods research design, which included a pre- and post-intervention study and focus group interviews for the feasibility assessment. Participants included 23 dyads of older adults with dementia and their CAs from a long-term care facility in South Korea. Upon completion of the APP intervention, focused group interviews were conducted with six CAs and five nurses.

Results

The results of paired t-tests showed that the effects of the APP intervention on the older adults with dementia and their CAs were not significant; however, the results of the focused group interviews support the potential usefulness of the APP for CAs.

Conclusion

The APP may be applicable to long-term care workers who need meal assistant skills education.

Dysphagia and mealtime difficulties in dementia: Speech and language therapists' practices and perspectives

BACKGROUND

There is increasing recognition of the impact that dementia has upon swallowing and at mealtimes, and the significant effect this can have on people with dementia's health and well-being. However, there remains a paucity of evidence for assessment and intervention practices for dysphagia and mealtime difficulties. Furthermore, there is a limited understanding of how speech and language therapists (SLTs) support people with these dementia-related issues and what are the barriers and facilitators to practice. Further research is therefore needed to guide policy as well as service guideline and delivery development.

AIMS

To establish the current practices of SLTs managing dementia-related dysphagia and mealtime difficulties in the UK and Republic of Ireland (ROI), and to establish their opinions and experiences of what challenges or supports to practice they have encountered.

METHODS & PROCEDURES

An anonymous, cross-sectional web-based survey was developed and distributed to SLTs working in the UK and ROI. Respondents completed a questionnaire that consisted of open and closed questions across nine topic areas. Closed responses were evaluated using descriptive statistics; open-ended questions were analysed using conventional content analysis.

OUTCOMES & RESULTS

A total of 310 people accessed the survey, and 125 respondents completed it fully. While respondents agreed on their role in dysphagia management, they varied in their views on the extent of their role in managing mealtime difficulties. Additionally, their self-rated knowledge of mealtime difficulties in dementia was lower than their dysphagia knowledge. The respondents predominantly based their management decisions on their clinical experience of working with people with dementia. They primarily used compensatory strategies and frequently cited the need for family and care staff training. Respondents also highlighted barriers to effective management and training provision such as inefficient referral systems, a lack of carer knowledge and lack of SLT resources.

CONCLUSIONS & IMPLICATIONS

The results provide valuable insight into the issues facing SLTs practising in this area. The SLTs surveyed considered dysphagia a core part of their role when supporting people with dementia; however, respondents' views on mealtime difficulties varied. This highlights the need to establish consensus guidelines on the SLT's role in order to avoid variations in service delivery that could negatively impact the health and well-being of people with dementia. Moreover, further research to develop efficient and effective training for care staff supporting mealtime difficulties and dysphagia is essential. What this paper adds What is already known on the subject Research indicates that people with dementia develop dysphagia and mealtime difficulties as dementia progresses. SLTs often manage these, but there is no research on the effective assessment and management procedures, or guidance on best practice. What this paper adds to existing knowledge This paper provides an understanding of the variation in practice across the UK and ROI. Respondents described barriers to delivering an effective service and frequently linked these to the SLTs' resources as well as service constraints. What are the potential or actual clinical implications of this work? These findings support the need for future research to develop guidelines for SLT practice in this area. They also support the need to examine resource allocation and workforce management to enable SLTs to manage dementia-related dysphagia and mealtime difficulties effectively.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Equipping Nurses and Care Staff to Manage Mealtime Difficulties in People With Dementia: A Systematic Scoping Review of Training Needs and Interventions

Purpose Mealtime difficulties are prevalent in dementia, posing major challenges to people with dementia (PWD), carers, and clinical services. Speech-language pathologists have a recognized role in providing training to carers of PWD who have mealtime difficulties. The aims of this study are (a) to identify the training needs of nurses and care staff with regard to managing mealtime difficulties in PWD, (b) to describe existing training interventions on this topic, and (c) to investigate the extent to which these interventions are relevant to the needs of nurses and care staff. Method A systematic search was carried out to identify studies relevant to the aims of the review. Data were extracted and then synthesized using thematic analysis and a synthesis matrix. Study quality was appraised using a validated appraisal tool. Results Various themes were identified in relation to the training needs of nurses and other care staff who manage mealtime difficulties in PWD. These were as follows: person-centered care; dealing with uncertainty; strategies, skills, and knowledge; and creating the right environment. Existing training interventions were described and compared against the training needs. The review found some correspondence between interventions and staff needs, but also some gaps. Conclusions Training interventions on this topic should be more systematically developed and better reported to facilitate effective implementation. Evidence to date indicates that training should do more to help staff deal with uncertainty. Further research assessing the benefits of speech-language pathologists' involvement in the development of training interventions is recommended because of this profession's specialist skills and knowledge with regard to both dysphagia and communication.

Innovation in medical education: a culinary coaching tele-nutrition training program

BACKGROUND

Nutrition medical education training programs that are focused on home cooking are emerging.

OBJECTIVE

This short communication describes the first synchronous tele-nutrition medical education training program using a novel Culinary Coaching (CC) model.

DESIGN

Seven health coaches were trained and each coach delivered CC programs to four patients (28 total). Evaluations included:1) two questionnaires before, immediately after, and six months post training program; and 2) one questionnaire after each patient program.

RESULTS

CC training significantly improved coaches' attitudes about and confidence to deliver CC from pre-program means of 3.61 and 3.65 (out of 5), respectively, to post-program means, 3.77 (p<0.01) and 3.86 (p<0.05), respectively, and remained higher 6 months after the training program (3.93, p<0.01; 3.93, p<0.05). Health coaches described a high usage of CC principles and tools through the patient programs.

CONCLUSIONS

This early evidence suggests that the CC model can be successfully expanded to health coaches, thus improving nutritional care.

Environmental and behavioural modifications for improving food and fluid intake in people with dementia

BACKGROUND

Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia.

OBJECTIVES

Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions.

SEARCH METHODS

We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low.One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention.The remaining eight studies implemented behavioural modifications.Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) -0.01 to 0.23; n = 78, 1 study; low-quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD -0.26 kg/m² favouring control, 95% CI -0.70 to 0.19; n = 734, 2 studies; moderate-quality evidence), body weight (MD -1.60 kg favouring control, 95% CI -3.47 to 0.27; n = 656, 1 study; moderate-quality evidence), or score on Mini Nutritional Assessment (MNA) (MD -0.10 favouring control, 95% CI -0.67 to 0.47; n = 656, 1 study; low-quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD -1.79 kg/m² favouring control, 95% CI -1.28 to -2.30; n = 52, 1 study; moderate-quality evidence) and body weight (MD -8.11 kg favouring control, 95% CI -2.06 to -12.56; n = 52, 1 study; moderate-quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status.Two studies compared self-feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self-feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect.One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect.Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low-quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low-quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed.

AUTHORS' CONCLUSIONS

Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.

Health Workers' Knowledge and Perceptions on Dementia in Skilled Nursing Homes: A Pilot Implementation of Teepa Snow's Positive Approach to Care Certification Course

INTRODUCTION

A knowledge gap on caring for people with dementia exists among health workers employed in skilled nursing facilities. This article reports on knowledge gained and perceptions changed among 24 skilled nursing facility health workers who completed Teepa Snow's innovative Positive Approach to Care Certification course as a regional initiative.

METHODS

This pilot study used a quasi-experiment with a one-group pretest-posttest design to assess the dementia knowledge and perceptions of health workers who participated in the course. Paired responses (n = 22) for the 54-item dementia knowledge and training/coaching perceptions survey were compared using the McNemar test, Paired t test, and Wilcoxon signed-rank test to analyze the improvement in knowledge and perceptions of dementia.

RESULTS

Significant knowledge gain was found among health workers after completing the program (t(21) = -7.46, P < .001). Statistical differences (P < .05) were present in eight knowledge items (ie, working memory, mental health, temporal lobe, "sapphire", "space and awareness", personal space, binocular vision, and hippocampus) and four perception areas (ie, approaching, understanding, calming, and instructing) about dementia. Significant changes were also found in four areas of health workers' perceptions about dementia (P < .05).

DISCUSSION

The certification course can improve knowledge and facilitate perceptual change on dementia. Implementing this program as a novel regional initiative has robust potential in ensuring continuing workforce development in health care settings challenged with ever-changing people living with dementia needs and high staff turnover.

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia

BACKGROUND

Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake.

OBJECTIVES

To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH).

DESIGN

A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences.

SETTING AND PARTICIPANTS

30 residents living with advanced dementia in 11 U.S. NHs.

MEASUREMENTS

Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale.

INTERVENTION

Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days.

RESULTS

Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8).

CONCLUSION

All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.