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

The Impact of Modifiable Preoral Factors on Swallowing and Nutritional Outcomes in Healthy Adults: A Scoping Review

PURPOSE

Swallowing has previously been characterized as consisting of four phases; however, it has become apparent that these four phases are not truly discrete and may be influenced by factors occurring prior to bolus entrance into the oral cavity (i.e., preoral factors). Still, the relationship between these factors and swallowing remains poorly understood. The aim of this review was to synthesize and characterize the literature pertaining to the influence of preoral factors on swallowing and nutritional outcomes in healthy individuals.

METHOD

We performed a scoping review, searching the databases of PubMed, CINAHL, Cochrane, and Scopus. Search terms included those related to swallowing, experience of preoral factors, and exclusionary terminology to reduce animal and pediatric literature. Our initial search revealed 5,560 unique articles, of which 153 met our inclusionary criteria and were accepted into the review.

RESULTS

Of the accepted articles, 78% were focused exclusively on nutritional outcomes, 17% were focused on both swallowing and nutritional outcomes, and 5% were focused on solely swallowing outcomes. Of the preoral factors examined, 99% were exteroceptive in nature (17% olfactory, 44% visual, 21% auditory, 7% tactile, 11% other), while 1% were proprioceptive in nature.

CONCLUSIONS

This review supports the influence of preoral factors on swallowing and nutritional outcomes. However, there is a large emphasis on the visual modality and on nutritional outcomes. Nearly none of the literature found in this review directly measured swallowing safety, efficiency, or physiology. Future work will benefit from a larger focus on proprioceptive preoral factors as they relate to swallowing outcomes.

Nutritional Care for Institutionalized Persons with Dementia: An Integrative Review

BACKGROUND

Older people are at risk of malnutrition, especially when they suffer from cognitive impairment. Guidelines that orient nursing care in this regard need to be updated. The aim of this review is to address the best available evidence on interventions that can benefit nutritional nursing care for institutionalized older adults with dementia.

METHODS

Integrative review using the Dimensions and Eureka search engines, and the PubMed, Embase, Scielo, CINAHL, and ScienceDirect databases. We searched from the year 2015 through to 2021. We employed the MMAT guidelines for mixed, qualitative, and quantitative studies, and the PRISMA, CASP, and JBI guidelines to value the reviews.

RESULTS

A total of 55 studies met the inclusion criteria. The best available evidence to support nutritional nursing care for institutionalized older adults with dementia highlights several aspects related to the assessment and caring interventions that are focused on people with dementia, their caregivers, and their context.

CONCLUSIONS

Both the assessment and nutritional care interventions for older people with dementia should consider the patient-caregiver dyad as the subject of care and understand the context as a fundamental part of it. The analysis of the context should look further than the immediate environment.

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents' nutrition and well-being is required.

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.

Predictors of incident malnutrition-a nutritionDay analysis in 11,923 nursing home residents

Background/Objectives

Malnutrition (MN) in nursing home (NH) residents is associated with poor outcome. In order to identify those with a high risk of incident MN, the knowledge of predictors is crucial. Therefore, we investigated predictors of incident MN in older NH-residents.

Subjects/Methods

NH-residents participating in the nutritionDay-project (nD) between 2007 and 2018, aged ≥65 years, with complete data on nutritional status at nD and after 6 months and without MN at nD. The association of 17 variables (general characteristics (n = 3), function (n = 4), nutrition (n = 1), diseases (n = 5) and medication (n = 4)) with incident MN (weight loss ≥ 10% between nD and follow-up (FU) or BMI (kg/m²) < 20 at FU) was analyzed in univariate generalized estimated equation (GEE) models. Significant (p < 0.1) variables were selected for multivariate GEE-analyses. Effect estimates are presented as odds ratios and their respective 99.5%-confidence intervals.

Results

Of 11,923 non-malnourished residents, 10.5% developed MN at FU. No intake at lunch (OR 2.79 [1.56–4.98]), a quarter (2.15 [1.56–2.97]) or half of the meal eaten (1.72 [1.40–2.11]) (vs. three-quarter to complete intake), the lowest BMI-quartile (20.0–23.0) (1.86 [1.44–2.40]) (vs. highest (≥29.1)), being between the ages of 85 and 94 years (1.46 [1.05; 2.03]) (vs. the youngest age-group 65–74 years)), severe cognitive impairment (1.38 [1.04; 1.84]) (vs. none) and being immobile (1.28 [1.00–1.62]) (vs. mobile) predicted incident MN in the final model.

Conclusion

10.5% of non-malnourished NH-residents develop MN within 6 months. Attention should be paid to high-risk groups, namely residents with poor meal intake, low BMI, severe cognitive impairment, immobility, and older age.

Is Weight Loss More Severe in Older People with Dementia?

Weight loss, a hallmark feature of dementia, is associated with higher mortality in older people. However, there is a lack of consensus in the literature as to whether the weight loss commonly observed in older people with dementia results from reduced energy intake and/or increased energy expenditure. Understanding the cause of energy imbalance in older people with dementia would allow more targeted interventions to avoid detrimental health effects in this vulnerable group. In this paper, we review studies that have considered weight change, energy intake, and energy expenditure in older people with and without dementia. We critically assess the studies' methodology and outline the various factors which may decrease and increase energy intake and expenditure respectively in older people with and without dementia. Current available literature does not support the view that there is a lower energy intake and/or a higher energy expenditure in older people with dementia when compared to those without dementia. The need for more high-quality studies is also highlighted in order to shed more light towards this issue which continues to elude researchers and clinicians alike.

Energy Intake and Severity of Dementia Are Both Associated with Health-Related Quality of Life among Older Long-Term Care Residents

Our aim was to investigate how energy intake modifies the association of the stage of dementia with health related quality of life (HRQoL) among institutionalized older people. A cross-sectional sample of 538 older long-term care residents with dementia in Helsinki, Finland were assessed with HRQoL (15D), energy intake (from one to two days), and the stage of dementia by the clinical dementia rating (CDR) scale. The energy intakes were standardized by z-scores to include both men and women in the same analyses. Severity of dementia was associated with HRQoL (15D index in CDR 0.5–1: 0.65 (0.11), CDR 2: 0.60 (0.10), CDR 3: 0.52 (0.10)). When the three groups of dementia severity were divided according to their energy intake quartiles, there was an association between the HRQoL and the stage of dementia (p < 0.001) and energy intake (p = 0.013); however, no interaction was observed (p = 0.30). While partial correlation analysis showed that energy intake correlated with HRQoL among residents with very mild/mild or moderate dementia, this was not observed among those with severe dementia. In moderate dementia, the dimensions of mobility and usual activities correlated significantly with higher energy intake. Both energy intake and severity of dementia are associated with HRQoL.