Caregiver person-centeredness and behavioral symptoms during mealtime interactions: development and feasibility of a coding scheme

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.

An observational study protocol to capture, validate and characterise lucid episodes in people living with advanced dementia receiving hospice care

INTRODUCTION

Lucid episodes (LEs) in advanced neurodegenerative disease, characterised by a transient recovery of abilities, have been reported across neurological conditions, including Alzheimer's disease and related dementias. Evidence on LEs in dementia is extremely limited and draws predominantly from retrospective case reports. Lucidity in dementia has received growing attention given the clinical, caregiving and potential epidemiological implications of even a temporary return of abilities in advanced disease. Following a funding initiative by the National Institute on Aging, several new investigations are focused on establishing foundational evidence on lucidity in dementia. The objectives of this study are to capture, characterise and validate potential LEs via audiovisual observation, computational linguistic and timed-event coding of audiovisual data, and informant case review for face validation of LEs.

METHODS AND ANALYSIS

This prospective multifaceted observational study will investigate LEs in advanced dementia through longitudinal audiovisual observation within an inpatient hospice unit. Audiovisual data will be coded to generate variables of participant verbal output, verbal expressions, non-verbal communicative actions and functional behaviours to enable measurement of features that can be used to characterise LEs. Multiple methods will be used to identify potential LEs including field interviews with caregivers/clinicians who witness significant events during data collection, reports from research staff who witness significant events during data collection and detection by researchers during video data processing procedures. Potential LEs will undergo a structured case review with informants familiar with the participant to facilitate validation and enable triangulation across measures generated through coding.

ETHICS AND DISSEMINATION

This study will be conducted in accordance with all Federal Policies for the Protection of Human Subjects and the protocol (ID 2021-1243) has been approved by the University of Wisconsin-Madison Institutional Review Board. Findings will be disseminated via scientific conferences, journal publications and newsletters shared with participants and through dementia-focused and caregiver-focused networks.

Exploring resident experiences of person-centred care at mealtimes in long-term residential care: a rapid ethnography

INTRODUCTION

Poor nutrition is a common ongoing problem in long-term residential care, often resulting in reduced quality of life. Previous research has concluded that the content of the meal, dining environment, service style and general atmosphere all add to the mealtime experience, suggesting that person-centred mealtimes are optimal. However, knowledge about which elements of person-centred care can be achieved in a mealtime setting in a given context is currently lacking. We aimed to understand the mealtime experience in long-term residential care by exploring (missed) opportunities for person-centred care in different settings.

METHODS

As part of the TRANS-SENIOR research network, rapid ethnographies, were conducted across multiple sites (including interviews, observations and informal conversations), in a long-term residential care home in the UK, Switzerland and the Netherlands between October 2020 and December 2021.  RESULTS: Following analysis and interpretation of observations, interviews and informal conversations, the following themes were developed where either successfully achieved or missed opportunities for person-centred moments were observed: 1) considering the setting, 2) listening to and implementing resident choice, 3) enabling residents to help/care for themselves and others, 4) providing individualised care in a communal setting, and 5) knowing the person in the past and present. Residents experienced moments of participatory choice, interaction, independence and dignity, but opportunities for these were often missed due to organisational or policy constraints.

CONCLUSIONS

There are opportunities for person-centred moments during the mealtime, some of which are taken and some missed. This largely depended on the setting observed, which includes the overall environment (size of dining area, seating arrangements etc.) and allocation of staff resources, and the level of resident involvement in mealtimes, from preparation to the actual activity.

Verbal and Nonverbal Expressions of Persons Living With Dementia as Indicators of Person-Centered Caregiving

BACKGROUND AND OBJECTIVES

Improved measures capable of capturing the influence of person-centered caregiving by staff in formal care settings on people living with dementia beyond deficit-oriented outcomes such as absence or reduction of symptoms are important for measuring progress toward improvements in well-being. This exploratory ethnographic study aimed to identify verbal and nonverbal expressions evidenced by people living with dementia surrounding person-centered caregiving approaches and to consider their use in informing temporally specific observational measures.

RESEARCH DESIGN AND METHODS

This study adopted a microethnographic approach through secondary analysis of 5.3 h of audiovisual observations of people living with dementia (N = 9) in nursing home settings at mealtimes. We observed expressions surrounding person-centered caregiving approaches. A systematic review of audiovisual observations generated codes (observable indicators) of expressions that were characterized at their most discrete and unambiguous level.

RESULTS

Drawing from 82 observable verbal and nonverbal expressions by people living with dementia, 14 discrete observable indicators were identified, broadly evidencing shifts in engagement and communication. We found that people living with dementia's expressions served both responsive and initiatory communicative purposes.

DISCUSSION AND IMPLICATIONS

Efforts to expand positive outcome measurement for people living with dementia should extend beyond characterizing them as passive respondents toward active participants in their lived experiences. Identified observable indicators can inform efforts to refine and validate measures of expressions among people living with dementia. Further research can extend this inquiry into different contexts and engage input from people living with dementia and caregivers.

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

Mealtime caregiving approaches and behavioral symptoms in persons living with dementia: a longitudinal, observational study

Background

Behavioral symptoms during mealtime can prohibit persons living with dementia from obtaining sufficient nutrition. However, little research has examined the relationship between behavioral symptoms and caregiving approaches. This study examines this relationship and further explores which specific caregiver behaviors were related to behavioral symptoms among persons living with dementia.

Methods

A secondary data analysis was performed using 86 mealtime videos from a longitudinal, observational study. The videos were repeatedly taken at months 0, 3, and 6 with 30 persons living with dementia in one of four long-term care facilities. Video coding was performed using coding schemes modified from the Cohen-Mansfield Agitation Inventory for behavioral symptoms and the Person-/Task-Centered Behavior Inventory for caregiving approaches. Coding schemes for behavioral symptoms consisted of four categories: total duration, aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Caregiving approaches consisted of ten-verbal/seven-nonverbal person-centered behavior codes, four-verbal/four-nonverbal task-centered behavior codes, and no-verbal/no-nonverbal interaction codes. A mixed-effect model was conducted using variables such as demographics, medical information, cognitive status, depression, function, and caregiving approaches as fixed effects, participant as a random effect, and four categories of behavioral symptoms as dependent variables.

Results

The total duration of the Cohen-Mansfield Agitation Inventory was associated with no verbal response (β = 9.09) and task-centered verbal behavior (β = 8.43), specifically verbal controlling (β = 7.87). Physically nonaggressive behavior was associated with no verbal response (β = 9.36). Verbally agitated behavior was associated with task-centered nonverbal behavior (β = 51.29), and specifically inappropriate touch (β = 59.05).

Conclusions

Mealtime is indispensable to dementia care for ensuring adequate nutrition and promoting personhood. Our findings revealed caregivers’ task-centered behaviors and no interaction were related to behavioral symptoms of persons living with dementia. When caregivers encounter behavioral symptoms during mealtime, it is recommended to avoid no response and task-centered behaviors, especially verbal controlling and inappropriate touch, and to promote person-centered behaviors.

Mealtime verbal interactions among nursing home staff and residents with dementia: A secondary behavioural analysis of videotaped observations

AIMS

To characterize dyadic mealtime verbal interactions and examine the associations with staff and resident characteristics.

DESIGN

A secondary analysis of 110 videotaped mealtime observations collected from a dementia communication trial during 2011-2014.

METHODS

Videos involved 25 residents with dementia and 29 staff in nine nursing homes. Verbal behaviours (utterances) were coded during 2018-2019 using the Cue Utilization and Engagement in Dementia mealtime video-coding scheme, addressing eight positive behaviours and four negative behaviours. Bivariate analyses and multivariate regression models were used.

RESULTS

Staff spoke three times more frequently (76.5%) than residents (23.5%). Nearly all staff utterances were positive (99.2%); 85.1% of residents' utterances were positive and 14.9% negative. Staff positive utterances were correlated with their negative utterances and resident positive and negative utterances. Staff negative utterances were correlated with resident negative utterances. Resident positive and negative utterances were correlated. Resident positive utterances were significantly associated with staff care-giving length in the current nursing home (OR = 1.430, 95% CI = 1.008, 2.027). Resident negative utterances were significantly associated with resident gender (female versus male, OR = 11.892, 95% CI = 1.237, 114.289) and staff years worked as a caregiver (OR = 0.838, 95% CI = 0.710, 0.989). Staff positive and negative utterances were not associated significantly with any participant characteristics.

CONCLUSIONS

Staff engage residents using primarily positive verbal strategies. Staff-resident mealtime verbal interactions were dynamic, interactive, and complex and related to multiple individual characteristics.

IMPACT

Positive dyadic mealtime interactions are critical to engage residents in eating. Little work has characterized dyadic mealtime interactions, limiting the development of effective interventions. Findings showed staff-resident mealtime verbal interactions were primarily positive, inter-related, and associated with multiple individual characteristics. Findings inform directions to improve mealtime care practice and develop person-centred mealtime interventions targeting modifiable factors, including staff care-giving experiences.

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.

A communication model for nursing staff working in dementia care: Results of a scoping review

BACKGROUND

Communication between nursing staff and people with dementia can be challenging. According to the literature, communication is seen as a process of social- and/or informational exchange between a sender and a receiver in a context. Factors related to these elements determine the quality of communication. Insight into the factors involved in the communication process between nursing staff and people with dementia is limited and a comprehensive model of communication in dementia care is lacking.

OBJECTIVES

To identify and visualize factors associated with communication between nursing staff and people with dementia.

DESIGN

A scoping review of scientific literature.

DATA SOURCES

Scientific articles were retrieved from the bibliographic databases of PubMed, CINAHL and PsycINFO.

REVIEW METHODS

The reviewing process was directed by the Joanna Briggs guidelines for scoping reviews. Full-text articles describing the communication process between nursing staff and people with dementia were eligible for inclusion. A data extraction form was used to identify factors associated with communication. Following a directed content analysis approach, factors were categorized in one of three categories: nursing staff; people with dementia; or context. Each category was thematically analysed to identify themes and subthemes. Results were visualized into a communication model.

RESULTS

The review included 31 articles; in total, 115 factors were extracted. Thematic analysis of nursing staff factors (n = 78) showed that communication is associated with professional characteristics, individual experiences, verbal- and non-verbal communication skills, communication approach and values. Factors attributed to people with dementia (n = 22) concerned client characteristics, functional status, behaviour, verbal communication skills and values. Contextual factors (n = 15) related to organization of care, time and situation. Based on these results, the Contac-d model was constructed.

CONCLUSIONS

The Contac-d model gives a comprehensive overview of factors involved in the communication process between nursing staff and people with dementia, providing insight in potential starting points for communication improvement, e.g. respect for needs, identity and privacy of people with dementia, a flexible and adapted communication approach and matching language. Additionally, results suggest that an appealing location, longer duration of the interaction, and music in the surrounding may improve communication in certain situations. However, it was not feasible based on current literature to recommend what works to improve communication in which situations. Future studies should study factors and their interrelatedness in specific care situations. Authors further believe that more attention should be paid to strengths and capabilities of people with dementia and to non-modifiable factors that influence communication.

Understanding Interactions Between Caregivers and Care Recipients in Person-Centered Dementia Care: A Rapid Review

Background

Good interactions are essential in caring for people with dementia. There is a lack of knowledge about interaction approaches used by caregivers in person-centered dementia care. This study aimed to understand interactions in person-centered dementia care.

Methods

A search for relevant publications was undertaken in 2020 on two electronic databases, MEDLINE with full text and CINAHL Plus with full text. This was supplemented by manual searching of the reference lists of relevant articles. Inclusion and exclusion criteria were applied to determine the relevance of the articles. Data extraction included publication year, country, study setting, aim, design, definition of person-centered dementia care, elements of person-centered dementia care and interaction approaches used by caregivers. A Donabedian quality framework was used to group the elements of person-centered dementia care into three categories: structure, process and outcome.

Results

A total of 25 articles were included in the review, all from developed countries. A conceptual framework was developed for the delivery of person-centered dementia care. It includes the organizational structure, ie, management and resources, a competent workforce and physical environment; the dementia care process, ie, respectful interaction underpinned by good knowledge about the care recipients in a calm, peaceful environment; and care outcome, ie, the social, psychological, and physical well-being of the care recipients. Interaction approaches used by caregivers in providing person-centered dementia care were classified according to the six purposes of interaction: to know and understand the care recipient, to keep the person happy and satisfied, to make the person feel safe and secure, to calm the person, to support self-identity, and to guide the person in conducting daily activities.

Conclusion

The delivery of person-centered dementia care needs to consider organizational structure, the dementia care process, and care outcome which together foster a positive environment for meaningful interactions between caregivers and care recipients. The identified interaction approaches could be used by dementia care trainers to develop training materials.

Eating performance in relation to intake of solid and liquid food in nursing home residents with dementia: A secondary behavioral analysis of mealtime videos

BACKGROUND

Persons with dementia commonly experience low food intake leading to negative nutritional and functional outcomes. While multilevel personal and environmental factors that influence intake are implicated, evidence is lacking on the role of characteristics of dynamic eating performance cycles. An eating performance cycle is defined as the process of getting food from the plate or container, transporting it into the mouth, and chewing and swallowing it.

OBJECTIVE

This study aimed to examine the association between intake and characteristics of eating performance cycles among nursing home residents with dementia.

METHODS

A secondary analysis of 111 mealtime video clips from a nursing home communication training study was conducted. The 111 videos involved 25 residents and 29 staff (N = 42 unique staff-resident dyads) in 9 nursing homes. The Cue Utilization and Engagement in Dementia Mealtime video-coding scheme was used to code the characteristics of eating performance cycles, including eating technique (resident-completed, staff-facilitated), type of food (solid, liquid), duration of each eating performance cycle, and intake outcome (intake, no intake). The Generalized Linear Mixed Model was used to examine the interaction effects of eating technique by type of food, eating technique by duration, and type of food by duration on intake outcome.

RESULTS

Totally 1122 eating performance cycles were coded from 111 video clips. The majority of the cycles (85.7%) resulted in intake. There were significant interactions for eating technique by duration, and type of food by duration. As the duration of the eating performance cycle increased, staff-facilitated cycles resulted in greater odds of intake than resident-completed cycles (OR = 17.80 vs. 2.73); and cycles involving liquid food resulted in greater odds of intake than cycles involving solid food (OR = 15.42 vs. 3.15). Though the interaction between eating technique and type of food was not significant, the odds of intake were greater for resident-completed cycles than for staff-facilitated cycles regardless of the type of food being involved in the cycle (OR = 3.60 for liquid food, OR = 10.69 for solid food).

CONCLUSIONS

The findings pointed out the importance of supporting resident independence in eating performance, providing liquid food when residents struggle with solid food, and provision of longer and continuous facilitation at mealtimes to improve intake. The findings inform the development and implementation of innovative mealtime assistance and staff training to promote eating performance and intake.

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.

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship

Purpose of Study

To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions.

Design and Methods

In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification.

Results

The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review.

Implications

The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Temporal Associations between Caregiving Approach, Behavioral Symptoms and Observable Indicators of Aspiration in Nursing Home Residents with Dementia

OBJECTIVES

Dysphagia, or impaired swallowing, is common in nursing home (NH) residents with dementia and contributes to malnutrition and diminished quality of life. Dysphagia also commonly leads to aspiration or passage of food or fluids into the airway, which can result in aspiration pneumonia-a leading cause of death for people with dementia. Currently available interventions for dysphagia aim to modify the risk of aspiration events primarily by modifying diet and positioning to improve the safety of an individual's swallow. However other potentially modifiable contextual factors relevant to mealtime care within NH settings that may influence the occurrence of aspiration events, such as the nature of caregiving interactions or occurrence of dementia-related behavioral symptoms, have not been examined. To address this gap, we examined the temporal associations between caregiving approach and behavioral symptoms as antecedents to observable indicators of aspiration among nursing home (NH) residents with dementia.

DESIGN

Secondary analysis of coded, timed-event behavioral data from 33 video-recorded observations of mealtime interactions between NH residents with dementia and caregivers.

SETTING/PARTICIPANTS

Residents with dementia who required assistance with mealtime care (n=12) and nursing assistants (n=8) from Memory Care Units (MCU) in 2 Midwestern NHs.

RESULTS

Observable indicators of aspiration were significantly more likely to occur during or following task-centered caregiver actions than person-centered actions (12% likelihood; Yule's Q 0.89; OR 95% CI 12.70-23.75) and 15-30 seconds after a behavioral symptom (5% likelihood; Yule's Q 0.65; OR 95% CI 4.18-8.57).

CONCLUSIONS

These findings provide compelling preliminary evidence that caregiver approach may influence the occurrence of aspiration. Provided the urgent need for more approaches to mitigate the complications associated with dysphagia in people with dementia, even a moderate reduction in aspiration events may be clinically meaningful. Further, well-designed observational studies with individuals with well-characterized dysphagia are needed to better understand and characterize these relationships, their temporal structures and their impacts on other relevant outcomes such as eating performance and malnutrition.

A qualitative study of professional caregivers' perceptions of processes contributing to mealtime agitation in persons with dementia in nursing home wards and strategies to attain calmness

Aim

Describe professional caregivers' perceptions of factors and processes contributing to mealtime agitation and strategies for attaining and maintaining calm mealtimes.

Design

Qualitative and descriptive.

Methods

A convenience sample of professional caregivers working in two wards for residents with dementia was used. Data were collected during two focus‐group interviews and supplemented with field notes from six reflection groups. Thematic content analysis was conducted. Data collection occurred from 2010–2011.

Results

Professional caregivers perceived agitation during mealtime as resulting from negative feelings in residents triggered by a lack of or negative social interaction, too much or ambiguous stimuli or demands exceeding residents' capacity. Strategies for attaining calm mealtimes involved thorough planning beforehand. During mealtime, professional caregivers focused on establishing a positive community around the table, helping residents focus on eating and continuously observing residents for subtle signals indicating that agitation was about to develop. The prerequisites to succeed with the strategies were knowledge of the residents' preferences and abilities, knowledge sharing within the team and awareness of one's own communication style. Thus, the professional caregivers operationalized person‐centred care in a mealtime context.