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.

Evaluating a brief intervention for mealtime difficulty on older adults with dementia

AIMS AND OBJECTIVE

To test a spaced retrieval intervention using spaced retrieval to alleviate mealtime difficulties in older people with dementia.

DESIGN

A single-case study design.

SETTING

Nursing Homes in North Central England, United Kingdom.

PARTICIPANTS

Older people with Alzheimer's disease.

METHODS

A single-case study using an ABA design was used. Data were collected using the Edinburgh Feeding Evaluation in Dementia scale, Mini Nutritional Assessment, and Body Mass Index before intervention, postintervention and following 3 months of postintervention. Realist evaluation was used to identify for which participants the intervention was effective, and an economic evaluation was also carried out.

FINDING

Of 15 participants who entered the study, eight completed all phases of the study. A mean 104.4 h were needed to deliver the intervention. The number of sessions required ranged from 90-222. The length of time each participant retained information (for all sessions) ranged from 13-28 min. Participants had most difficulty with: "putting food into mouth and chewing it"; "realizing it was mealtime"; and "eating a whole meal continuously." A reduction in the difficulty with mealtimes occurred between phase A1-A2 for most participants. Six participants maintained this in phase A3. Similar patterns were evident for nutritional scores. For most participants, the effect size of the intervention was moderate or large.

CONCLUSIONS

Spaced retrieval is useful in reducing mealtime difficulties in older participants with dementia. While the results of this study are promising, further large and multicentre trials are needed to explore the effectiveness of the intervention in diverse populations.

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.

The Edinburgh Feeding Evaluation in Dementia Scale: A Longitudinal Study in Nursing Home Residents

AIMS/BACKGROUND

The Edinburgh Feeding Evaluation in Dementia (EdFED) scale has been shown to have good psychometric properties using a range of methods including Mokken scaling. We aimed to study the Italian version of the EdFED using Mokken scaling.

METHODS

Data were gathered at 7 time points from 401 nursing home residents affected by dementia in the course of a 6-month intervention study using analysis of variance, Mokken scaling, and person-item fit statistics.

RESULTS

The properties of the EdFED-I scale were stable over the course of the study with 4 items showing invariant item ordering at all time points. Some items behaved differently at different levels of difficulty in the scale and also depending on the mean level of feeding difficulty. The test information function showed a dip in the mid-range of difficulty scores.

Adaptation transculturelle en français du Edinburgh Feeding Evaluation in Dementia (EdFED) Scale : un questionnaire pour évaluer les difficultés à s'alimenter de personnes âgées présentant des troubles cognitifs en centre d'hébergement

ABSTRACTThe Edinburgh Feeding Evaluation in Dementia (EdFED) Scale was designed to identify feeding difficulties for people with moderate to severe dementia. Its Canadian-French cross-cultural adaptation was carried out, as part of an experimental study, whose secondary objective was to document its construct validity. A back-translation method was followed. The EdFED-f was used during a meal with 26 elderly residents who had cognitive disorders. There was a significant correlation between EdFED-f scores and energy intakes calculated using a visual estimation of plate wash method (r=-0,50, p=0,009). EdFED-f scores also showed a significant difference according to the percentage of food consumed at meals (p=0,015). These results support the validity of the EdFED-f to assess feeding difficulties among elderly French-speaking Canadians living in residential and long-term care centers.

The nutritional care of people living with dementia at home: A scoping review

There are an increasing number of people with dementia living in their own home for longer, often supported by a family member. The symptoms of dementia can affect an individual's nutritional status, which can lead to a reduced quality of life for the person with dementia and their family members. A scoping review was conducted from July 2016 until September 2016, using a recognised framework, to explore what is currently known, and identify any gaps in the research regarding the nutritional care of people living with dementia at home. This included any interventions that may have been trialled or implemented, and the views of those living with dementia, carers and clinicians. Six electronic databases were searched from inception to July 2016. A review team was involved in screening and data extraction for selected articles. Published qualitative and quantitative studies were included that explored the nutritional care of people living with dementia at home. Methods included data extraction and conventional content analysis. Stakeholders were involved in the development of final categories. Following screening, 61 studies reported in 63 articles were included. Most studies were cross-sectional (n = 24), cohort (n = 15) or qualitative (n = 9). Only three were randomised controlled trials. Three overarching categories represented the results: Timely identification of nutritional risk and subsequent regular monitoring of nutritional status, multi-component tailored interventions and the influence of the care-giving dyad on nutritional status. Many studies identify people living at home with dementia as a vulnerable group prone to malnutrition; however, a lack of interventions exists to address the increased risk. There is a lack of research exploring the role of home care providers and healthcare professionals in the provision of nutritional care. Further research is required to explore how the emotional aspect of the care-giving dyad influences nutritional care.

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

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

Facilitating ADLs by caregivers of persons with dementia: the C3P model

The purpose of this paper is to explicate a change model for caregivers of persons with dementia to assist them in facilitating meals in the home, at community-based programs and in institutional settings. Building on a Social Ecological Model, the C3P Model-Change the Person, Change the People, Change the Place offers a clear method to adapt care strategies to foster independence while providing appropriate support as the person with dementia cognitively and functionally declines. Meals are highly embedded within a culture and are ritualized events within a family requiring an individualized approach when modifications are needed.

Prevalence and factors associated with feeding difficulty in institutionalized elderly with dementia in Taiwan

OBJECTIVES

The purpose of this study was to establish the prevalence rate of feeding difficulty and to understand the factors associated with it among people with dementia.

DESIGN

A cross-sectional design was used.

SETTING

Five nursing homes in Taiwan.

PARTICIPANTS

Ninety-three residents with dementia were enrolled.

MEASUREMENTS

Feeding difficulty was measured by The Edinburgh Feeding Evaluation in Dementia (EdFED) scale. Data included demographics, nutritional data, cognition, and independence were also collected.

RESULTS

Residents with EdFED scores above five had significantly longer duration of dementia (56.3±27.4 vs 42.2±22.8, P<0.05), greater dependence (26.2±20.8 vs 57.4±25.7, P<0.0001), lower BMI (21.5±3.8 vs 23.2±4.6, P<0.05), and greater cognitive impairment (8.4±2.6 vs 6.4±3.3, P<0.001) than those with EdFED scores under five. Using 5 points as the EdFED cutoff score, the prevalence rate of feeding difficulties was 60.2%. Using multiple regression to examine the predictors of feeding difficulty, 35.1% of the variance was explained, with ADL, cognition and number of medications being significant (beta = .46,.23 and .19, respectively), while non-significant factors were age, gender, duration of dementia and eating time.

CONCLUSION

The prevalence of feeding difficulty was high among Taiwanese elderly with dementia. Training nurses or nursing assistants to notice feeding problems in order to provide adequate assistance is important for preventing malnutrition among residents with dementia in Taiwan nursing homes.

Item response theory: how Mokken scaling can be used in clinical practice

AIMS

To demonstrate the principles and application of Mokken scaling.

BACKGROUND

The history and development of Mokken scaling is described, some examples of applications are given, and some recent development of the method are summarised.

DESIGN

Secondary analysis of data obtained by cross-sectional survey methods, including self-report and observation.

METHODS

Data from the Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale were analysed using the Mokken scaling procedure within the 'R' statistical package. Specifically, invariant item ordering (the extent to which the order of the items in terms of difficulty was the same for all respondents whatever their total scale score) was studied.

RESULTS

The Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale showed no violations of invariant item ordering, although only the Townsend Functional Ability Scale showed a medium accuracy.

CONCLUSION

Mokken scaling is an established method for item response theory analysis with wide application in the social sciences. It provides psychometricians with an additional tool in the development of questionnaires and in the study of individuals and their responses to latent traits. Specifically, with regard to the analyses conducted in this study, the Edinburgh Feeding Evaluation in Dementia scale requires further development and study across different levels of severity of dementia and feeding difficulty.

RELEVANCE TO CLINICAL PRACTICE

Good scales are required for assessment in clinical practice and the present paper shows how a relatively recently developed method for analysing Mokken scales can contribute to this. The two scales used as examples for analysis are highly clinically relevant.

A Chinese Translation of the EdFED-Q and Assessment of Equivalence

The purpose of this study was to translate the Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q) from the original English into a Chinese language version and to assess the equivalence of the English and Chinese EdFED-Q versions. To use a directly translated instrument without minimal explanation of the procedures for determining the equivalence between the original and secondary language instrument is questionable. Ensuring equivalence of a translated Chinese version of the EdFED-Q for patients with dementia is an essential prerequisite for identifying culturally specific expressions of feeding difficulty under investigation. Phase 1 consisted of experts doing the initial translation into Chinese and then English back-translations of the questionnaire. Six experts determined the equality of the Chinese and English versions, and five monolingual nurses provided information for the C-EdFED-Q. In phase 2, two bilingual gerontological nurses rated 33 residents with dementia to determine equivalence across time. In phase 3, three groups of bilingual nurses used the Chinese, English, and finally both versions simultaneously to judge a model case's feeding behavior on the videotape. In phase 1, the rating on the equality of the items on the Chinese and English versions was 0.969. In phase 2, kappa coefficients for all items on the C-EdFED-Q and E-EdFED-Q ranged from 0.44 to 1.00. In determining the consistency of the scores for the C-EdFED-Q and E-EdFED-Q between the two raters across time, the intraclass correlation coefficient for the absolute agreement was found to range from 0.85 to 0.90. In phase 3, except for items 6 and 9, all items showed no significant difference among the three groups. Further studies to assess the relationship between constructs and to compare it with known and predicted relationships are recommended.