Improving Food and Fluid Intake for Older Adults Living in Long-Term Care: A Research Agenda

Nursing Home Organization Mealtimes and Staff Attitude Toward Nutritional Care: A Multicenter Observational Study

OBJECTIVES

The aims of this study were to investigate the practices of registered nurses and nurse aides at mealtimes in nursing homes (NHs) and to evaluate the attitudes of health care staff toward the nutritional care of older people.

DESIGN

This is a multicenter cross-sectional study.

SETTING AND PARTICIPANTS

The study involved a convenience sample of NH health care staff: physicians, registered nurses, and nurse aides.

METHODS

Data were collected on characteristics of the dining environment, organizational and nutritional care practices, staff-resident ratio, and staff activities during meals, using 2 questionnaires and staff attitudes were assessed with Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G). Total score ranges from 18 to 90 points, with the following cutoffs: ≥72, positive attitude; ≤54, negative; and 55-71 points, neutral attitude.

RESULTS

A total of 1267 workers from 29 NHs in northern Italy participated in the study. The most common nutritional assessment tool used by nurses was the Malnutrition Universal Screening Tool. A median of 4.0 and 4.2 people (family caregivers, volunteers and staff) were present for feeding support, respectively, at lunch and dinner. A median of 2.5 and 2.0 staff members at lunch and at dinner, respectively, fed residents. Overall, 1024 health care workers responded to SANN-G of which 21.9% showed a negative attitude, 57.2% neutral, and 20.9% a positive attitude. Nurse aides (190/714) showed worse attitudes compared with registered nurses (20/204) and physicians (2/36); differences were statistically significant. Overall, the best attitudes were toward "habits," "interventions," and "individualization" of nutritional care. Staff who had received nutritional training (29.2%) had best attitudes.

CONCLUSIONS AND IMPLICATIONS

The results suggest that NHs should ensure adequate staff-resident ratio during meals, involving trained volunteers and relatives. Moreover, health professionals' knowledge and attitude toward nutritional care should be improved through continuous training.

Food, nutrition and the dining experience in aged care settings: Findings of a nationwide survey

OBJECTIVE

Previous research on food, nutrition and dining practices in Australian residential aged care (RAC) homes has been based on a limited sample of single-home or multiple-home providers, but a nationwide study has not been conducted. The aim of this study was to provide a preliminary overview of current food, nutrition and dining practices across Australian RAC facilities using a nationwide survey.

METHODS

A survey was distributed to Australian RAC homes in August-September 2020, as part of the National Congress on Food, Nutrition and the Dining Experience in Aged Care (February 2021). The survey, administered via an online portal, consisted of 38 semistructured questions including yes/no or multiple-choice responses, free text, frequency scales and number entry. Six key topics were explored, including 'food service system and environment', 'catering style', 'menu planning and evaluation', 'nutrition planning and requirements', 'nutrition-related screening and assessment' and 'training and additional information', which were informed by the Australian Government Department of Health and reflected the interests of the Congress.

RESULTS

The final sample included 292 respondents (204 individual homes and 88 multiple-home proprietors) representing 1152 homes and 125,393 residents, encompassing approximately 43% of RAC homes (of a possible 2671) and 57% of residents (of a possible 219,965) in Australia. Survey respondents representing RAC homes included service managers, catering managers, Chief Executive Officers, cooks, chefs, dietitians or staff from other roles within homes. A number of potential areas of need were identified, included increasing the autonomy of residents to select the foods they desire, increasing the variety and choice (including timing) of meals, enhancing the dining environments in homes to stimulate food intake and increasing staff training and the number of trained chefs in homes, so that meals are prepared which address diverse nutritional needs of residents.

CONCLUSIONS

This study provides insight into the food service and mealtime practices of over a third of Australian RAC homes. The findings of this survey may help to identify key targets for intervention to improve the food, nutrition and quality of life of aged care residents.

Individual-Level Variables Associated with Self-Efficacy in Nutritional Care for Older People among Italian Nurses: A Multicenter Cross-Sectional Study

Malnutrition in older people is still an unsolved issue. Clinical nurses have a key role in malnutrition prevention. This study aims to describe the individual-level variables associated with self-efficacy in nutrition care for older adults among nurses. A cross-sectional descriptive observational study was performed involving nurses from four northern Italy hospitals. The self-efficacy scale for nursing nutrition care (SE-NNC) and Multiple linear regression (MLR) models were used, enrolling 305 nurses. The mean SE-NNC total score was 53.3 ± 19.7. Considering the three dimensions of the SE-NNC, mean scores were 45.9 ± 21.7 for boosting knowledge, 55.4 ± SD = 20.3 for assessment and evidence utilization, and 57.7 ± 21.1 for care delivery. To be a younger nurse, working in a chronic care setting, and being male were associated with a higher level of self-efficacy, both considering the SE-NNC total score and its dimensions. Working in acute care settings and being an older nurse was associated with lower nursing self-efficacy in nutrition care for older adults.

Knowledge and Perceptions of Speech-Language Pathology Students Participating in a Feeding Training Program: A Pilot Study

This study examined the knowledge and perceptions of speech-language pathology students working with older adults before and after their participation in a feeding training program. A secondary objective evaluated the feeding training program in terms of improving students' knowledge and skills. A repeated measures design was used to assess changes in perceptions and knowledge over time of students participating in a feeding training program assisting older adults at a skilled nursing facility. Twenty-four students in the communication sciences and disorders department from a university were recruited. Data were collected on the perceptions of working with older adults, knowledge of feeding and swallowing, and the evaluation of the program. Participants reported feeling less fearful of assisting older adults with feeding issues and appeared to acquire a higher level of knowledge in certain areas post-training. Analysis of the evaluation forms revealed that students were positive about their experience. The findings provide additional support that perceptions become more favorable following early exposure to older adults through participation in service-learning experiences. This study supplements the literature about the knowledge and perceptions of speech-language pathology students working with older adults. This information may be used to improve the quality of care for older adults in various settings.

The unmet needs of older adults living in nursing homes in Mainland China: a nation-wide observational study

BACKGROUND

The unmet needs of older adults in nursing homes could result in their poor health status physically and psychologically. The aim of this study was to understand the characteristics of unmet needs of older adults residing in nursing homes in China, and to probe into the contributing factors.

METHODS

In this cross-sectional design, the demographic and health status questionnaire, Modified Barthel Index, the Numerical Rating Scale for pain assessment, Geriatric Depression Scale, Camberwell Assessment of Need for the elderly were employed to survey older adults living in 38 nursing homes in 13 cities in China from July 2017 to June 2018 through a multi-stage, stratified sampling scheme. The Short Portable Mental Status Questionnaire was adopted to exclude participants with severe cognitive impairment. Aside from descriptive analysis, a raft of hierarchical logistic regression models were run by sequentially controlling for the independent variables at 5 levels (demographic characteristics, health status, pain, ADL, and depression), aiming to identify the influencing factors of the unmet needs of the residents.

RESULTS

The effective sample size involved 2063 older adults (63.4% female versus 36.6% male), with a response rate of 98.5%. The median and inter-quartile range of the total needs and unmet needs of the sample was 3(1, 4) and 0(0, 1) respectively, with 122 older participants having more than 3 unmet needs (high unmet need category) versus 1922 older ones having ≤ 3 unmet needs (low unmet need category). The unmet needs of older adults in nursing homes mainly fell into social domains. Gender, religion, educational background, marital status, living condition before admission, room type, incomes, staffing, number of diseases, pain, Barthel Index, and depression were contributive to unmet needs of older adults in long-term care facilities in the final model that was adjusted for all levels of variables (all p < 0.05).

CONCLUSION

Understanding the influencing factors of the unmet needs of older adults in long term care provides clues for healthcare professionals to offer better care for this population. System-level support to nursing homes and training of staff are highlighted. Plus, taking measures to beef up social connections for the older adults to meet their social needs was suggested.

How are the mealtime experiences of people in residential aged care facilities informed by policy and best practice guidelines? A scoping review

BACKGROUND

Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impact their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Giddens' (The constitution of society: outline of the theory of structuration, 1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents' mealtime experiences.

METHODS

Using Arksey and O'Malley's (Int J Soc Res Methodol 8:19-32, 2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.

RESULTS

Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.

CONCLUSIONS

Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.

Factors associated with perceptions of dignity and well-being among older people living in residential care facilities in Sweden. A national cross-sectional study

The care of older people living in residential care facilities (RCFs) should promote dignity and well-being, but research shows that these aspects are lacking in such facilities. To promote dignity and well-being, it is important to understand which associated factors to target. The aim of this study was to examine the associations between perceived dignity and well-being and factors related to the attitudes of staff, the care environment and individual issues among older people living in RCFs. A national retrospective cross-sectional study was conducted in all RCFs for older people within 290 municipalities in Sweden. All older people 65 years and older (n = 71,696) living in RCFs in 2018 were invited to respond to the survey. The response rate was 49%. The survey included the following areas: self-rated health, indoor-outdoor-mealtime environment, performance of care, attitudes of staff, safety, social activities, availability of staff and care in its entirety. Data were supplemented with additional data from two national databases regarding age, sex and diagnosed dementia. Descriptive statistics and ordinal logistic regression models were used to analyse the data. Respondents who had experienced disrespectful treatment, those who did not thrive in the indoor-outdoor-mealtime environment, those who rated their health as poor and those with dementia had higher odds of being dissatisfied with dignity and well-being. To promote dignity and well-being, there is a need to improve the prerequisites of staff regarding respectful attitudes and to improve the care environment. The person-centred practice framework can be used as a theoretical framework for improvements, as it targets the prerequisites of staff and the care environment. As dignity and well-being are central values in the care of older people worldwide, the results of this study can be generalised to other care settings for older people in countries outside of Sweden.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy

BACKGROUND

Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting.

METHODS

The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis.

RESULTS

The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group.

CONCLUSIONS

A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

Fidelity challenges while implementing an intervention aimed at increasing eating performance among nursing home residents with cognitive decline: A multicentre, qualitative descriptive study design

AIMS AND OBJECTIVES

To increase the knowledge on fidelity challenges in intervention studies promoting eating independence in residents with cognitive decline living in nursing homes (NHs).

BACKGROUND

A few studies have documented to date factors affecting fidelity in intervention studies performed in NH settings. Moreover, fidelity issues in intervention studies aimed at promoting eating independence among NH residents with cognitive decline have not been studied to date.

DESIGN

A hybrid study design was performed in 2018 and reported here according to the COnsolidated criteria for REporting Qualitative research.

METHODS

In a clustered multicentre before/after intervention study design, a nested, multicentre qualitative descriptive design was performed. Four researchers with a nursing background, who received appropriate training, implemented the designed intervention. This consisted in intentional rounds in the dining rooms during lunchtime and was based on supportive, prescriptive and informative prompts delivered to residents with cognitive decline aimed at stimulating eating independence. A momentary assessment method was used, based on daily diary filled in by participant researchers after every session of intervention delivery on the following five dimensions of fidelity: (a) adherence, (b) dose (or exposure), (c) intervention quality, (d) participant responsiveness and (e) programme differentiation. A direct content analysis of the narratives reported on the diaries was performed.

RESULTS

Factors increasing or hindering intervention fidelity during its implementation emerged at the NH, staff, family caregivers, resident, researchers and at the intervention itself levels.

CONCLUSIONS

Several factors emerged and all reported potentially both positive and negative influences on fidelity while implementing an intervention aimed at promoting eating independence among NH residents. Fidelity challenges should be considered as dynamic in NH intervention studies, where continuous adjustments of the intervention delivered are required.

RELEVANCE TO CLINICAL PRACTICE

A calm environment, with staff members showing a caring behaviour, and researchers having achieved good familiarity with the NH setting, the residents, their family carers and the staff members, can all increase intervention fidelity.

Enhancing independent eating among older adults with dementia: a scoping review of the state of the conceptual and research literature

Background

Addressing eating difficulties among older individuals with dementia living in nursing homes requires evidence-based interventions. However, to date, there is limited evidence of effective interventions designed to maintain and/or increase independent eating. In a field in which evidence is still lacking, a critical analysis of the state of research describing its main features can help identify methodological gaps that future studies should address. Hence, the aim of this study was to map the state of the research designed to maintain and/or promote independent eating in older individuals with dementia living in nursing homes.

Methods

A scoping review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Reviews and conceptual analyses performed with different methodological approaches, published in indexed journals, and written in English were included. Keywords Were searched for in the MEDLINE, the Cumulative Index of Nursing and Allied Health, and in the Scopus databases to identify papers published up to 31 May 2018.

Results

17 reviews were included, assessing interventions’ effectiveness (n = 15) and providing conceptual frameworks for eating/mealtime difficulties (n = 2). Conceptual frameworks supporting interventions’ effectiveness have rarely been described in available studies. Moreover, interventions tested have been categorized according to non-homogeneous frameworks. Their effectiveness has been measured against (1) eating performance, (2) clinical outcomes, and (3) adverse event occurrence.

Conclusion

An increased use of conceptual frameworks in studies, as well as greater clarity in intervention categorization and outcomes, is necessary to enhance the reviews’ value in providing useful cumulative knowledge in this field. Interventions delivered should embody different components that integrate individual, social, cultural, and environmental factors, while when evaluating an intervention’s effectiveness, eating performance, clinical outcomes and adverse events should be considered. Together with more robust studies, involving clinicians could prove to be useful, as their knowledge of practice developed from direct experience can help develop innovative research questions.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

Adherence to a regulation that aims to prevent and treat malnutrition-The case of Swedish elderly care

Malnutrition constitutes a serious and challenging problem in elderly care. In 2015, a Swedish regulation that aims to prevent and treat malnutrition came into effect. This study set out to explore associations between level of adoption of the regulation reported as: no, started, yes, in a previous survey, and registrations in a national quality registry. Registry data on screening and actions extracted from the first trimester in 2014 (n=18967), 2016 (n=20318) and 2017 (n= 25669) represented 209, 197 and 199 of 290 Swedish municipalities respectively. A repeated measures ANOVA showed that there was no effect on screened nutritional status, Pearson's chi-square that there were minor differences in types of actions, and regression analysis that the number of actions increased on average by 0.3 due to a higher level of adoption of the regulation. Over the years studied, five actions were prominent regardless of level of adoption or screened nutritional status. Hence, to date, no firm conclusions regarding effects of the regulation can be drawn. Despite the regulatory nature, it appear as if the regulation and the level of adoption reported so far is routine in theory, although not yet leveraged to an implemented practice visible in the quality registry but instead decoupled from practice.

Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

CONCLUSIONS

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

Promoting mealtime function in people with dementia: A systematic review of studies undertaken in residential aged care

BACKGROUND

Dementia is one of the most prevalent conditions in older adults in residential aged care. Dementia has a significant impact on a person's ability to eat, drink and participate in mealtime activities. Dementia impacts memory, appetite, gross and fine motor skills, communication skills, mood and social behaviours, all of which can decrease the person's ability to engage in a meal.

OBJECTIVES

The objective was to review the literature on strategies to promote mealtime function in people with dementia living in residential aged care and assess their effectiveness. The review considered studies reporting outcome measures that related to nutritional status, communication, behaviour and eating skills and ability.

DESIGN

Systematic review using the Joanna Briggs Institute review methods.

DATA SOURCES

Seven databases (MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, Current Contents, PsycINFO and Allied and Complementary Medicine Database) were searched for research published 2000-2017 in English. Eligible studies included quantitative studies reporting a mealtime intervention delivered to people with dementia in residential aged care compared with standard care reporting nutritional, behavioural or functional outcomes, including observation studies with no comparator.

REVIEW METHODS

Studies were screened and independently appraised by two reviewers using Joanna Briggs Institute (JBI) critical appraisal tools based on study design. Data was extracted from eligible studies using JBI extraction tables that assess study design, population characteristics, intervention and comparator, outcome measures and findings. Results related to mealtime function were tabulated and reported in narrative format.

RESULTS

136 studies were identified, of which 20 were eligible for inclusion. Studies reported strategies related to: food presentation; meal styles; environment adaptations; skills training; music therapy and animal-assisted therapy. Outcomes included measures of nutritional status, communication and behavioural and psychological symptoms of dementia. Low quality evidence suggested that playing music and introducing fish to the dining room may improve the food intake of people with dementia by a small amount. Montessori and spaced retrieval programs also demonstrated some positive impact on eating skills and nutritional intake. Animal-assisted therapy also demonstrated small statistically significant improvements in weight and body mass index.

CONCLUSION

There is insufficient evidence to highly recommend any specific intervention to improve mealtime functional ability in people with dementia. Further research is required through robust study designs using valid and reliable outcome measures to demonstrate clinically significant effects for mealtime interventions.

Development and Inter-Rater Reliability of the Mealtime Scan for Long-Term Care

Background and Objectives

Poor food intake is common in long-term care (LTC). The mealtime experience has been identified as influential, yet, research has been limited by lack of quality, standardized measures. The purpose of this study was to develop and test for inter-rater reliability the Mealtime Scan (MTS), an observational measure.

Research Design and Methods

MTS was derived from the literature on ambiance, mealtime experience, social interactions at mealtimes, and social models of care. Three scales on person-centered care and physical and social environments are used to summarize key aspects observed with MTS. Two raters assessed MTS for reliability at 30 different meals conducted in 10 dining rooms, within three LTC residences. Intraclass correlation coefficient (ICC) was used to assess reliability.

Results

MTS demonstrated good to excellent reliability on the three summative scales (physical ICC = 0.73, social ICC = 0.81, person-centered care ICC = 0.83) and other scalable items had good to excellent reliability (e.g., background noise ICC = 0.65, Mealtime Relational Care checklist: negative interactions ICC = 0.85).

Discussion and Implications

MTS is reliable and face valid for assessing mealtime experience. Future work will explore construct validity of this measure. MTS can be used to support improving the mealtime experience for residents living in LTC.

Staff Self-Efficacy and Staff Outcome Expectations for Function-Focused Care: Rasch Testing

BACKGROUND AND PURPOSE

The purpose of this study was to test the reliability and validity for two new scales.

METHODS

We used baseline data from a worksite health promotion project with 98 long-term care staff and Pearson correlations and Rasch analysis testing.

RESULTS

For Staff Self-Efficacy for Function Focused Care and Staff Outcome Expectations for Function Focused Care item, reliability was .80 and .83, respectively. All items except one had acceptable INFIT and OUTFIT mean square statistics. Both new scales were significantly correlated (r = .342, p = .007), but neither of the scales were correlated with participants' baseline exercise levels (r = .014, p = .918; r = .092, p = .454, respectively).

CONCLUSIONS

There was some evidence of validity and internal consistency for both scales. Suggestions are provided to improve the measures for future use.

How Widely are Supportive and Flexible Food Service Systems and Mealtime Interventions Used for People in Residential Care Facilities? A Comparison of Dementia-Specific and Nonspecific Facilities

While improved mealtime practices can reduce agitation, improve quality of life, and increase food intake for people in aged care, the degree of implementation of these strategies is unknown. This study describes food service practices in residential aged care facilities, focusing on units caring for people with dementia. An online survey was distributed to residential aged care facilities for completion by the food service manager (n = 2057). Of the 204 responses to the survey, 63 (31%) contained a dementia-specific unit. Most facilities used adaptive equipment (90.2%) and commercial oral nutritional supplements (87.3%). A higher proportion of facilities with a dementia-specific service used high-contrast plates (39.7%) than those without (18.4%). The majority of facilities had residents make their choice for the meal more than 24 h prior to the meal (30.9%). Use of high contrast plates (n = 51, 25%) and molds to reform texture-modified meals (n = 41, 20.1%) were used by one-quarter or less of surveyed facilities. There is a relatively low use of environmental and social strategies to promote food intake and wellbeing in residents, with a focus instead on clinical interventions. Research should focus on strategies to support implementation of interventions to improve the mealtime experience for residents.

Dehydration and Malnutrition in Residential Care: Recommendations for Strategies for Improving Practice Derived from a Scoping Review of Existing Policies and Guidelines

Preventing malnutrition and dehydration in older care home residents is a complex task, with both conditions remaining prevalent, despite numerous guidelines spanning several decades. This policy-mapping scoping review used snowballing search methods to locate publicly-available policies, reports and best practice guidelines relating to hydration and nutrition in UK residential care homes, to describe the existing knowledge base and pinpoint gaps in practice, interpretation and further investigation. The findings were synthesised narratively to identify solutions. Strategies for improvements to nutritional and hydration care include the development of age and population-specific nutrient and fluid intake guidelines, statutory regulation, contractual obligations for commissioners, appropriate menu-planning, the implementation and auditing of care, acknowledgment of residents' eating and drinking experiences, effective screening, monitoring and treatment and staff training. The considerable body of existing knowledge is failing to influence practice, relating to translational issues of implementing knowledge into care at the point of delivery, and this is where future research and actions should focus.

Engaging food service providers to change food service practices in aged care facilities

AIM

The present study describes the impact of a novel education program for food service staff from Australian aged care facilities (ACF) to facilitate improvements in food service practices. The purpose was to explore; (i) the impact of the intervention (ii) barriers and facilitators of the program from food service providers' perspectives and (iii) make program planning and practice recommendations.

METHODS

Participants completed pre- and post-program questionnaires, attended two focus groups on program process and impact and 4 months later reported through individual interviews on changes they had implemented. Results were triangulated between the questionnaires, focus groups and interviews and impacts and outcomes identified through directed content analysis.

RESULTS

Thirty senior-level chefs and a cook participated from 27 ACF from Victoria, Australia. Participation impacted on the menu, dining experiences and food service practices. All of the participants were enacting changes in their workplace 4 months later as change agents. A focus on skilling the participants as 'change agents', brokering ongoing peer-support and the celebrity and/or expert status of the facilitators were attributed to the success of the intervention.

CONCLUSIONS

This novel intervention empowered Victorian food service providers to make positive changes in ACF. Further research is required to measure if these self-reported changes are sustainable and relevant to other facilities and to establish the effect on food experience, satisfaction and well-being of residents.

Nutritional Needs of the Older Adult

Older adults are particularly vulnerable to compromised nutritional status. With advancing age, the consumption of a high-quality, nutritionally dense diet is increasingly essential to optimize health and well-being. Proportionally, macronutrient needs for older adults are similar to younger adults, however overall calorie requirements tend to decline with age. Unique factors influencing food intake should be considered and individualized guidance should be designed to help overcome medical, physical, and social barriers to a healthy diet. The goal for nutrition intervention should ultimately be to promote health and quality of life across the continuum of the aging process.

The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial

RATIONALE

Suboptimal nutritional practices in elderly care settings may be resolved by an efficient introduction of nutritional guidelines.

AIMS

To compare two different implementation strategies, external facilitation (EF) and educational outreach visits (EOVs), when introducing nutritional guidelines in nursing homes (NHs), and study the impact on staff performance.

METHODOLOGICAL DESIGN

A quasi-experimental study with baseline and follow-up measurements.

OUTCOME MEASURES

The primary outcome was staff performance as a function of mealtime ambience and food service routines.

INTERVENTIONS/RESEARCH METHODS

The EF strategy was a 1-year, multifaceted intervention that included support, guidance, practice audit and feedback in two NH units. The EOV strategy comprised one-three-hour lecture about nutritional guidelines in two other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Mealtime ambience was evaluated by 47 observations using a structured mealtime instrument. Food service routines were evaluated by 109 food records performed by the staff.

RESULTS

Mealtime ambience was more strongly improved in the EF group than in the EOV group after the implementation. Factors improved were laying a table (p = 0.03), offering a choice of beverage (p = 0.02), the serving of the meal (p = 0.02), interactions between staff and residents (p = 0.02) and less noise from the kitchen (p = 0.01). Food service routines remained unchanged in both groups.

CONCLUSIONS

An EF strategy that included guidance, audit and feedback improved mealtime ambience when nutritional guidelines were introduced in a nursing home setting, whereas food service routines were unchanged by the EF strategy.

A Dedicated Nutritional Care Program (NUTRICARE) to reduce malnutrition in institutionalised dysphagic older people: A quasi-experimental study

AIMS AND OBJECTIVES

To assess the effects of a texture-modified food program for dysphagia on the nutritional, biochemical and functional profile in a cohort of institutionalised older people in Italy.

BACKGROUND

Dysphagic institutionalised older people, often also affected by dementia, are frequently exposed to malnutrition. Malnutrition in older people has negative effects on mortality, days of hospitalisation, infection, wound healing and risk of pressure injuries. Therefore, it is very important to prevent malnutrition in this frail population.

DESIGN

A pre-post study without a control group.

METHODS

The study included 479 dysphagic institutionalised older people from 20 nursing homes. Anthropometrical, biochemical, nutritional and functional parameters were collected retrospectively, 6 months before the study intervention, at time zero and, prospectively for 6 months after implementing the NUTRICARE food programme, for a total of nine evaluations. The NUTRICARE programme includes meals without nutritional supplementation, and personalised levels of density, viscosity, texture and particle size.

RESULTS

The total mean body mass index of our sample passed from 17.88-19.00; body weight averagely improved by 7.19%, as well as their nutritional and biochemical profiles. There was a progressive improvement of total protein and serum albumin values. Nutritional parameters (serum transferrin and lymphocytes) displayed similar changes. Plasma lymphocytes reached normal levels in 98.23% of the sample. Plasma creatinine levels remained steady throughout the study and within the normal range. No side effects were reported.

CONCLUSION

The NUTRICARE food programme with a adequate proteins, calories, balanced nutritional and bromatological properties, and appropriate texture and palatability significantly improved the nutritional, biochemical and functional profile in a cohort of institutionalised dysphagic older people.

RELEVANCE TO CLINICAL PRACTICE

The introduction of a balanced nutritional programme, using high-quality natural ingredients, appropriate texture and palatability can significantly improve health and quality of life in dysphagic older people.

Dietary Service Staffing Impact Nutritional Quality in Nursing Homes

Objective: To examine the relationship between dietary service staff and dietary deficiency citations in nursing homes (NHs). Method: 2007-2011 Online Survey and Certification and Reporting data for 14,881 freestanding NHs were used to examine the relationship between dietary service staff and the probability of receiving a dietary service–related deficiency citation. An unconditional logit model with random effects was employed. Results: Findings suggest that higher staffing levels for dietitians (odds ratio [OR] = .955; p < .01), dietary service personnel (OR = .996; p < .01), and certified nursing assistants (CNAs; OR = .981; p < .05) decrease the likelihood of receiving a dietary service deficiency citation. Conclusion: Higher levels of dietary service and CNA staffing levels have the potential to improve the quality of nutritional care in NHs. Findings help substantiate the Centers for Medicare and Medicaid Services’ proposed rules for more stringent Food and Nutrition Services in the NH setting and signify the need for further research relative to the impact of dietary service staff on nutritional and clinical outcomes.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Quality Indicators of Nutritional Care Practice in Elderly Care

OBJECTIVES

The aim is to explore the effects of antecedent, structural and process quality indicators of nutritional care practice on meal satisfaction and screened nutritional status among older adults in residential care homes.

DESIGN

Data for this Swedish cross-sectional study regarding older adults living in residential care homes were collected by i) a national questionnaire, ii) records from the quality registry Senior Alert, iii) data from an Open Comparison survey of elderly care in 2013/2014. The data represented 1154 individuals in 117 of 290 Swedish municipalities.

MEASUREMENTS

Meal satisfaction (%) and adequate nutritional status, screened by the Mini Nutritional Assessment Short Form (MNA-SF), were the two outcome variables assessed through their association with population density of municipalities and residents' age, together with 12 quality indicators pertaining to structure and process domains in the Donabedian model of care.

RESULTS

Meal satisfaction was associated with rural and urban municipalities, with the structure quality indicators: local food policies, private meal providers, on-site cooking, availability of clinical/community dietitians, food service dietitians, and with the process quality indicators: meal choice, satisfaction surveys, and 'meal councils'. Adequate nutritional status was positively associated with availability of clinical/community dietitians, and energy and nutrient calculated menus, and negatively associated with chilled food production systems.

CONCLUSION

Municipality characteristics and structure quality indicators had the strongest associations with meal satisfaction, and quality indicators with local characteristics emerge as important for meal satisfaction. Nutritional competence appears vital for residents to be well-nourished.

Anorexia of aging and its role for frailty

PURPOSE OF REVIEW

The purpose of this review is to examine the concept of anorexia of aging, including its complex pathophysiology and the multifaceted interventions required to prevent adverse health consequences from this geriatric syndrome.

RECENT FINDINGS

Anorexia of aging is extremely common, occurring in up to 30% of elderly individuals; however, this diagnosis is frequently missed or erroneously attributed to a normal part of the aging process. With aging, impairments in smell and taste can limit the desire to eat. Alterations in stress hormones and inflammatory mediators can lead to excess catabolism, cachexia, and reduced appetite. In addition, mood disorders, such as anxiety and depression, are powerful inhibitors of appetite. Anorexia of aging, with its negative consequences on weight and muscle mass, is a risk factor for the development of frailty and is important to screen for, as early intervention is key to reversing this debilitating condition.

SUMMARY

Anorexia of aging is a complex geriatric syndrome and a direct risk factor for frailty and thus should not be accepted as normal consequence of aging. Early diagnosis and formulating a plan for targeted interventions is critical to prevent disability and preserve function in elderly patients.

Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well IN dementiA (EDWINA) systematic review

Background

Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service or dining environment modification, education, exercise or behavioural interventions in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia).

Methods

We comprehensively searched Medline and twelve further databases, plus bibliographies, for intervention studies with ≥3 cognitively impaired adult participants (any type/stage). The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data. Meta-analysis (statistical pooling) was not appropriate so data were tabulated and synthesised narratively.

Results

We included 56 interventions (reported in 51 studies). Studies were small and there were no clearly effective, or clearly ineffective, interventions. Promising interventions included: eating meals with care-givers, family style meals, soothing mealtime music, constantly accessible snacks and longer mealtimes, education and support for formal and informal care-givers, spaced retrieval and Montessori activities, facilitated breakfast clubs, multisensory exercise and multicomponent interventions.

Conclusions

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. A variety of promising indirect interventions need to be tested in large, high-quality RCTs, and may be approaches that people with dementia and their formal or informal care-givers would wish to try.

Trial registration

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007611).

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0256-8) contains supplementary material, which is available to authorized users.

Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis

BACKGROUND

Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.

METHODS

We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis.

RESULTS

Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions.

CONCLUSIONS

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero.

Improving food intake in persons living with dementia

Persons living with dementia have many health concerns, including poor nutritional states. This narrative review provides an overview of the literature on nutritional status in persons diagnosed with a dementing illness or condition. Poor food intake is a primary mechanism for malnutrition, and there are many reasons why poor food intake occurs, especially in the middle and later stages of the dementing illness. Research suggests a variety of interventions to improve food intake, and thus nutritional status and quality of life, in persons with dementia. For family care partners, education programs have been the focus, while a range of intervention activities have been the focus in residential care, from tableware changes to retraining of self-feeding. It is likely that complex interventions are required to more fully address the issue of poor food intake, and future research needs to focus on diverse components. Specifically, modifying the psychosocial aspects of mealtimes is proposed as a means of improving food intake and quality of life and, to date, is a neglected area of intervention development and research.

The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi

Background

Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation.

Methods

A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel.

Results

80 % of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators.

Conclusions

This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.

Dehydration, Hypernatremia, and Hyponatremia

Disturbances of serum sodium are one of the most common findings in older persons. They are also a major cause of hospital admissions and delirium and are associated with frailty, falls, and hip fractures. Both hypernatremia and hyponatremia are potentially preventable. Treatment involves treating the underlying cause and restoring sodium and volume status to normal. The arginine vasopressin antagonists, vaptans, have increased the therapeutic armamentarium available to physicians.