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Koechl J, Banerjee A, Heckman G, Keller H. Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life. Int J Older People Nurs 2024; 19:e12634. [PMID: 39101230 DOI: 10.1111/opn.12634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 07/09/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context. METHODS Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order. RESULTS Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint. CONCLUSIONS Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options. IMPLICATIONS FOR PRACTICE Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.
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Affiliation(s)
- Jill Koechl
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Albert Banerjee
- Department of Gerontology, St. Thomas University, Fredericton, New Brunswick, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Heather Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
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Le HT, Dang AK, Le LTT, Nguyen HTT, Nguyen GT, Nguyen HTT, Phan HBT, Nguyen TA, Robinson L. Nutritional status, dietary quality and eating disturbance issues among people with dementia in Vietnam: evidence of a cross-sectional study. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:107. [PMID: 38987853 PMCID: PMC11238499 DOI: 10.1186/s41043-024-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/17/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Due to cognitive impairments, people with dementia (PWD) often have difficulties in eating and drinking. This study aimed to assess the nutritional status, dietary quality and eating disturbance issues among PWD in Vietnam. METHODS We conducted a cross-sectional study at the Vietnamese National Geriatric Hospital from April to December 2022. We used Mini-Mental State Exam (MMSE) to classify the severity levels of dementia. Mini Nutritional Assessment (MNA), 24-hour recall, eating disturbance questionnaires, and anthropometric indicators were used to evaluate the nutritional status, dietary quality, and eating disorders of study subjects. RESULTS Overall, among 63 study participants, 74.6 per cent of PWD were at risk of or having malnutrition. By dementia classification according to MMSE scale, people with moderate and severe dementia accounted for 53.3 per cent of those who met the recommended energy levels, compared to 42.4 per cent of people with mild dementia and normal people. In the above two groups, around three per cent of participants reached the recommended amount of fibre. Calcium (50-70%), vitamin A (80-90%), and D (90%) were found to be the most severe deficiency forms of minerals and vitamins in both male and female participants. The majority of participants (90.5%) had at least one form of eating disorders with the most frequent issue being appetite changes (76.2%) and swallowing issues (50.8%). CONCLUSIONS PWD in our sample frequently experienced malnutrition, a lack of essential nutrients, difficulties swallowing, changes in eating habits and appetite. It is neccesary to early screen and assess nutritional status and swallowing disturbance in PWD, and instruct their caregivers to prepare nutritious meals for them.
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Affiliation(s)
- Huong Thi Le
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam
| | - Anh Kim Dang
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, Australia
| | - Linh Thao Thi Le
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam.
| | - Ha Thu Thi Nguyen
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam
| | - Giang Thu Nguyen
- Population Health Sciences Institute, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Huong Thi Thu Nguyen
- Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam
| | - Hanh Bich Thi Phan
- Faculty of Dentistry, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Social Gerontology Division, National Ageing Research Institute, Melbourne, VIC, Australia
- Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
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Shen WC, Chang LH, Huang YC, Wang JJ. Psychological Distress, Multicare Needs and Social Resource Utilisation of Family Caregivers of People With Dementia: A Descriptive-Correlational Study. Int J Older People Nurs 2024; 19:e12624. [PMID: 38895917 DOI: 10.1111/opn.12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 04/08/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The population of people with dementia increases yearly, imposing a growing burden on family caregivers. Psychological distress impacts the mental health of family caregivers of people with dementia. Caregiver psychological distress can result in increased social resource utilisation and unmet multicare needs. PURPOSE The study explored the psychological distress of family caregivers of people with dementia and examined the impact on social resource utilisation and multicare needs. METHODS A descriptive-correlational study collected data in Taiwan from a cross-sectional sample of family caregivers of people with dementia using a self-report questionnaire. Data were analysed using linear and logistic regression. RESULTS A total of 301 caregivers provided data for analysis. Nearly two-thirds of caregivers were female with a mean age of 57 years old (SD = 12). Over half of the family caregivers of people with dementia experienced mild-to-moderate psychological distress. The greater the psychological distress, the greater the probability of using social resources (1.09 times per 1-point increase, p = 0.002). Psychological distress was positively associated with the number of caregivers' care needs (β = 0.371, p < 0.001). CONCLUSIONS Findings of this study can assist healthcare professionals in better understanding the psychological distress and care needs of caregivers. Services designed to meet the needs of family caregivers will improve psychological distress.
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Affiliation(s)
- Wan-Ching Shen
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Ling-Hui Chang
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Ying-Che Huang
- Department of Neurology, Tainan Hospital, Ministry of Health and Welfare, Tainan City, Taiwan
| | - Jing-Jy Wang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
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Davies N, Aker N, West E, Rait G, Sampson EL. Acceptability of Using a Decision Aid to Support Family Carers of People With Dementia Towards the End of Life: A Qualitative Study. Health Expect 2024; 27:e14123. [PMID: 38896012 PMCID: PMC11187896 DOI: 10.1111/hex.14123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/13/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES To explore the experiences, acceptability and utility of a decision aid for family carers of people with dementia towards the end of life. METHODS We conducted semi-structured interviews with a sample of family carers enroled into a 6-month feasibility study in England, sampling to gain a range of experiences and views, based on relationship to person they cared for (e.g., spouse, adult child), age, gender, and self-reported use of the decision aid during the feasibility study. Interviews were conducted in March 2021-July 2021 and analysed using reflexive thematic analysis. We used COREQ checklist to report our methods and results. RESULTS Family carers found the decision aid acceptable, describing it as comprehensive, accessible with relevant information and its presentation enabled good engagement. Experiences of the decision aid covered four main themes which demonstrated the perceived acceptability and utility: 1. A source of support and reassurance; 2. Empowering conversations and confidence; 3. Including the person living with dementia; and 4. Breaking down complexity. CONCLUSIONS An aid focussing on decisions about dementia end of life care supported family carers break down complex and emotive decisions, not only with making decisions in the moment but also in future planning. PATIENT OR PUBLIC CONTRIBUTION Our three Patient and Public Involvement (PPI) members (all former family carers) were crucial throughout the wider study. PPI supported development of the topic guides, supported trialling the topic guide and interview procedures and finally supported the development of themes as part of the analysis.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care and Population Health, Centre for Ageing Population StudiesUniversity College LondonLondonUK
| | - Narin Aker
- Research Department of Primary Care and Population Health, Centre for Ageing Population StudiesUniversity College LondonLondonUK
| | - Emily West
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population HealthUniversity College LondonLondonUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological Medicine, Royal London HospitalEast London NHS Foundation TrustLondonUK
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Durlach O, Tripoz-Dit-Masson S, Massé-Deragon N, Subtil F, Niasse-Sy Z, Herledan C, Guittard L, Goldet K, Merazga S, Chabert M, Suel A, Dayde D, Merdinian M, Falandry C. Feasibility of a screening and prevention procedure for risks associated with dysphagia in older patients in geriatric units: the DYSPHAGING pilot study protocol. BMJ Open 2024; 14:e081333. [PMID: 38642998 PMCID: PMC11033636 DOI: 10.1136/bmjopen-2023-081333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/24/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Dysphagia, particularly sarcopenic dysphagia, is frequent in frail older patients. Sarcopenic dysphagia is a swallowing disorder caused by sarcopenia, corresponding to a loss of muscle mass and strength. It frequently leads to inhalation and to the decrease of food intake, leading the patient to enter a vicious circle of chronic malnutrition and frailty. The awareness of the major health impacts of sarcopenic dysphagia is recent, explaining a low rate of screening in the population at risk. In this context, methods of prevention, evaluation and intervention of sarcopenic dysphagia adapted to the most at-risk population are necessary. METHODS The DYSPHAGING (dysphagia & aging) pilot study is a prospective, multicentre, non-comparative study aiming to estimate the feasibility of an intervention on allied health professionals using the DYSPHAGING educational sheet designed to implement a two-step procedure 'screen-prevent' to mitigate swallowing disorders related to sarcopenic dysphagia. After obtaining oral consent, patients are screened using Eating Assessment Tool-10 Score. In case of a score≥2, procedures including positional manoeuvres during mealtimes, food and texture adaptation should be implemented. The primary endpoint of the study is the feasibility of this two-step procedure (screening-prevention measures) in the first 3 days after patient's consent.The study will include 102 patients, with an expected 10% rate of non-analysable patients. Participants will be recruited from acute geriatric wards, rehabilitation centres and long-term care units, with the hypothesis to reach a feasibility rate of 50% and reject a rate lower than 35%. ETHICS AND DISSEMINATION The study protocol was approved according to French legislation (CPP Ile-de-France VII) on 15 February 2023. The results of the primary and secondary objectives will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05734586.
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Affiliation(s)
- Olivier Durlach
- Institut du Vieillissement, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Stéphanie Tripoz-Dit-Masson
- Centre de Recherche Clinique Vieillissement, Cerveau, Fragilité, Hôpital des Charpennes, Hospices Civils de Lyon, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Nicolas Massé-Deragon
- Institut du Vieillissement, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Fabien Subtil
- CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Lyon, Universite Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Zeinabou Niasse-Sy
- Institut du Vieillissement, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- Geriatrics, Université Lyon 1 Faculte de Medecine et de Maieutique Lyon-Sud Charles Merieux, Oullins, Rhône-Alpes, France
- Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Chloé Herledan
- Unité de Pharmacie clinique oncologique, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- EA 3738 CICLY, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Laure Guittard
- Pôle de Santé Publique, Service Recherche et Epidémiologie cliniques, Hospices Civils de Lyon, 69008 Lyon, France
- Research on Healthcare Performance (RESHAPE), Inserm U1290, Université Claude Bernard Lyon 1, 69008 Lyon, Auvergne-Rhône-Alpes, France
| | - Karine Goldet
- Centre de Recherche Clinique Vieillissement, Cerveau, Fragilité, Hôpital des Charpennes, Hospices Civils de Lyon, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Salima Merazga
- Direction à la Recherche en Santé, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Margaux Chabert
- Direction à la Recherche en Santé, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Anne Suel
- Direction à la Recherche en Santé, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - David Dayde
- Plateforme Transversale de Recherche de l'ICHCL, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Marion Merdinian
- Institut du Vieillissement, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- Service de Gériatrie, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Claire Falandry
- Institut du Vieillissement, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- Service de Gériatrie, Centre Hospitalier de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- CarMeN Laboratory, Inserm U1060, INRA U1397, Université Claude Bernard Lyon 1, INSA Lyon, Charles Mérieux Medical School, University of Lyon, Oullins, France
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O'Neill M, Duffy O, Henderson M, Kernohan WG. Identification of eating, drinking and swallowing difficulties for people living with early-stage dementia: A systematic review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2023; 58:1994-2007. [PMID: 37483095 DOI: 10.1111/1460-6984.12924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The prevalence of dementia is increasing, bringing a range of challenges, such as eating, drinking and swallowing (EDS) difficulties, that are associated with aspiration, which can be fatal. Early identification of EDS difficulty in early-stage dementia could prevent complications, but reliable indicators are needed to help develop pathways to support the diagnosis. Previous reviews of this area require updating. AIMS To identify reliable and clinically measurable indicators of EDS difficulty used in early-stage dementia. METHODS & PROCEDURES A systematic search was conducted using common databases (MEDLINE, EMBASE and PsychInfo). Articles reporting indicators of EDS difficulty in early-stage dementia or mild cognitive impairment were included. The reliability of included studies was critically appraised using the risk of bias tools. Study outcomes were narratively reviewed by considering the reliability, clinical measurability and applicability of EDS indicators to early-stage dementia. OUTCOMES & RESULTS Initial searches returned 2443 articles. After removing duplicates, limiting to English language and human studies, 1589 articles remained. After reviewing titles, 60 abstracts were reviewed, yielding 18 full-text articles. A total of 12 articles were excluded that did not report at least one indicator of EDS difficulty in early-stage dementia, or where the reported association was not strong. Six included studies that reported eight indicators of EDS difficulty in early-stage dementia (four studies including people with Alzheimer's disease). On the balance of measurability, reliability and applicability, the most promising indicators of EDS difficulty were: delayed oral transit, rinsing ability, sarcopenia and polypharmacy. Additional, less reliable and applicable indicators included: always opened lips and non-amnestic mild cognitive impairment, especially in men. The delayed pharyngeal response is subjectively measured when instrumental assessment is not available and the 'candy sucking test' cannot be recommended because there is an inherent choking risk. CONCLUSIONS & IMPLICATIONS EDS difficulty in early-stage dementia can be highlighted by indicators that could be combined to create enhanced pathways to support the early identification of EDS difficulties for people living with early-stage dementia with a view to preventing complications and facilitating informed discussions regarding wishes in the event of further deterioration. Exploring the experiences of people living with dementia and their families' perspectives on potential indicators of EDS difficulty may add to the existing evidence base. WHAT THIS PAPER ADDS What is already known on the subject Early identification of EDS difficulty in early-stage dementia may prevent complications, but more reliable and clinically measurable indicators of EDS difficulty are needed to help develop pathways to support diagnosis. What this paper adds to existing knowledge A comprehensive range of studies related to EDS identification in early-stage dementia have been selected and reviewed. Across six included studies, the most promising indicators of EDS difficulty in early-stage dementia included delayed oral transit, poor rinsing ability, presence of sarcopenia and polypharmacy. What are the potential or actual clinical implications of this work? This study could help to develop pathways to support the early identification of EDS difficulties for people living with early-stage dementia with a view to preventing complications and facilitating informed discussions regarding wishes in the event of further deterioration.
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Affiliation(s)
- Michelle O'Neill
- Speech and Language Therapy, School of Health Sciences, Ulster University, Londonderry, UK
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
| | - Orla Duffy
- Speech and Language Therapy, School of Health Sciences, Ulster University, Londonderry, UK
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
| | - Mo Henderson
- Northern Health and Social Care Trust, Antrim, UK
| | - W George Kernohan
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
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O'Neill M, Duffy O, Henderson M, Davis A, Kernohan WG. Exploring the connection between dementia and eating, drinking and swallowing difficulty: Findings from home-based semi-structured interviews. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2023; 58:1738-1751. [PMID: 37219383 DOI: 10.1111/1460-6984.12899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/26/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Eating, drinking and swallowing (EDS) difficulties are important to identify early. Awareness of EDS changes starts with those living with dementia or their family carers. However, little is known about early identification from the perspective of people with dementia. AIM The aim of this study was to understand the experience of EDS by people living with dementia in their own home. METHODS Published evidence pertaining to EDS difficulties in dementia was used to inform an online semi-structured interview guide. Four people living with dementia and a third-sector Empowerment Lead were invited to become co-researchers. People living with dementia and their carers were invited to be interviewed. We enquired about their past and present experiences, and future expected changes in EDS, information needs, opinions on early problem identification, and lifestyle modifications following onset of EDS difficulty. Narrative concepts of heroes and villains in their 'stories' were identified. Responses were subjected to framework analysis informed by narrative enquiry. RESULTS Seven people living with dementia and five family carers were interviewed. The overarching theme was a 'missed connection' between EDS difficulty and dementia. Where EDS difficulties were identified, 'compensatory changes' and a need for 'access to information' were noted. CONCLUSIONS The connection between potential EDS difficulties and a dementia diagnosis may not be made, even though EDS changes were recognised by people living with dementia and their family carers. This may be explained by behaviours that mask problems or allow individuals to cope or compensate. Reduced awareness may also be due to inadequate access to information and lack of specialist services. If the connection between dementia and EDS difficulty is missed it could further delay access to support services. WHAT THIS PAPER ADDS What is already known on the subject The prevalence of dementia is increasing and is expected to affect 9% of the population by 2040. EDS difficulties are common in people living with dementia and predispose to poorer outcomes. Better awareness of EDS changes early in the disease process of dementia or at preclinical stages can identify individuals at risk and allow for intervention prior to advanced EDS difficulties developing. What this paper adds to existing knowledge This paper reports the perspective of people living with dementia and family carers and provides insights into experiences of EDS and the challenges faced and identifies commonalities. The connection between potential EDS difficulties and dementia is missed despite various changes reported by both people living with dementia and their family carers, who tend to make compensatory lifestyle changes without support. What are the potential or actual clinical implications of this work? Lack of awareness of the connection between potential EDS difficulties and dementia may arise due to inadequate access to information to support people living with dementia and their family carers. Access to such information is needed and the quality assurance of information from reputable sources is important to people living with dementia. There is a need for greater service user awareness of signs of EDS difficulty and how to access specialist services.
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Affiliation(s)
- Michelle O'Neill
- Speech and Language Therapy, School of Health Sciences, Ulster University, Londonderry, UK
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
| | - Orla Duffy
- Speech and Language Therapy, School of Health Sciences, Ulster University, Londonderry, UK
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
| | - Mo Henderson
- Northern Health and Social Care Trust, Antrim, UK
| | | | - W George Kernohan
- Institute of Nursing and Health Research, Ulster University, Londonderry, UK
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Anantapong K, Bruun A, Walford A, Smith CH, Manthorpe J, Sampson EL, Davies N. Co-design development of a decision guide on eating and drinking for people with severe dementia during acute hospital admissions. Health Expect 2023; 26:613-629. [PMID: 36647692 PMCID: PMC10010093 DOI: 10.1111/hex.13672] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Using co-design processes, we aimed to develop an evidence-based decision guide for family carers and hospital professionals to support decision-making about eating and drinking for hospital patients with severe dementia. METHODS Following a systematic review, we interviewed people with mild dementia, family carers and hospital professionals in England. We then held co-design workshops with family carers and hospital professionals. In parallel with the workshops, we used a matrix to synthesize data from all studies and to develop a decision guide prototype. The prototype was iteratively refined through further co-design workshops and discussions among researchers and Patient and Public Involvement (PPI) representatives. We conducted user testing for final feedback and to finalize the decision guide. RESULTS Most participants acknowledged the limited benefits of tube feeding and would not use or want it for someone with severe dementia. However, they found decision-making processes and communication about nutrition and hydration were emotionally demanding and poorly supported in acute hospitals. The co-design groups developed the aims of the decision guide to support conversations and shared decision-making processes in acute hospitals, and help people reach evidence-based decisions. It was designed to clarify decision-making stages, provide information and elicit the values/preferences of everyone involved. It encouraged person-centred care, best-interests decision-making and multidisciplinary team working. From user testing, family carers and hospital professionals thought the decision guide could help initiate conversations and inform decisions. The final decision guide was disseminated and is being used in clinical practice in England. CONCLUSION We used rigorous and transparent processes to co-design the decision guide with everyone involved. The decision guide may facilitate conversations about nutrition and hydration and help people reach shared decisions that meet the needs and preferences of people with severe dementia. Future evaluation is required to test its real-world impacts. PATIENT OR PUBLIC CONTRIBUTION People with mild dementia, family carers and hospital professionals contributed to the design of the decision guide through the interviews and co-design workshops. PPI members helped design study procedures and materials and prepare this manuscript.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Andrea Bruun
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Faculty of Health, Science, Social Care and Education, Kingston University, London, UK
| | - Anne Walford
- Family Carer, Patient and Public Involvement Panel, London, UK
| | - Christina H Smith
- Language and Cognition, Division of Psychology and Language Sciences, University College London, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health & Social Care Workforce, King's College London, London, UK.,NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Department of Psychological Medicine, Royal London Hospital, East London NHS Foundation Trust, London, UK
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Research Department of Primary Care and Population Health, Centre for Ageing Population Studies, University College London, London, UK
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Anantapong K, Sampson EL, Davies N. A shared decision-making model about care for people with severe dementia: A qualitative study based on nutrition and hydration decisions in acute hospitals. Int J Geriatr Psychiatry 2023; 38:e5884. [PMID: 36750227 PMCID: PMC10108087 DOI: 10.1002/gps.5884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To understand the decision-making processes regarding eating and drinking for hospital patients with severe dementia and use this data to modify a decision-making model about care for people with severe dementia. METHODS From January to May 2021, qualitative semi-structured interviews were conducted with 29 family carers and hospital staff in England who cared for people with severe dementia during hospital admissions. Interviews were transcribed verbatim and analysed using codebook thematic analysis. RESULTS We demonstrated a modified decision-making model consisting of six stages of the decision-making process: (i) identify a decision to be made; (ii) exchange information and recognise emotions; (iii) clarify values and preferences of all involved; (iv) consider feasibility of each choice; (v) share preferred choice and make a final decision; and (vi) deliver the decision, monitor outcomes and renegotiation. From this study, decision-making needed to be shared among all people involved and address holistic needs and personal values of people with dementia and family carers. However, hospital staff often made assumptions about the persons' ability to eat and drink without adequate consultation with family carers. The process was impacted by ward culture, professional practice, and legal framework, which might overlook cultural and personal beliefs of the persons and families. Treatment escalation plans could help inform stepwise treatments, create realistic expectations, and guide future decisions. CONCLUSIONS Our decision-making model provides clear stages of decision-making processes and can be used to guide clinical practice and policy around care decisions for eating and drinking, which is often poorly supported.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Department of PsychiatryFaculty of MedicinePrince of Songkla UniversityHat YaiThailand
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological MedicineRoyal London HospitalEast London NHS Foundation TrustLondonUK
| | - Nathan Davies
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Centre for Ageing Population StudiesResearch Department of Primary Care and Population HealthUniversity College LondonLondonUK
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Stöhr D, Mayer H, Soom Ammann E. 'After mealtime is before mealtime' - an ethnographic exploration of nursing home residents' practices of dealing with meal requirements. BMC Geriatr 2022; 22:992. [PMID: 36550407 PMCID: PMC9783982 DOI: 10.1186/s12877-022-03595-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In nursing homes, food is part of the care provided to residents, causing it to be strictly organised within the institutional framework. Moreover, once food has been integrated into the institutional logic, structural and economic aspects regarding organisation of food and eating may dictate individual and social needs, as a theoretical perspective informed by Goffman's notion of the 'total social institution' suggests. This paper describes nursing home residents' practices of dealing with meal requirements in two Austrian nursing homes, to understand how food integrates into the daily routine and how the institutional setting influences the social and material arrangement of food. METHODS An ethnographic design was chosen to gain an in-depth understanding. Two urban nursing homes were studied over 21 months (approx. 800 h of participant observation and ethnographic interviews collected). Data analysis took place iteratively, following Grounded Theory strategies. RESULTS As the thick descriptions resulting from this procedure show, observing everyday practices of eating in nursing homes reveals complex dimensions of residents being subject to institutional logics, and also demonstrates that residents develop elaborate strategies to deal with the institutional circumstances. CONCLUSION A better understanding of the resulting tensions between the restrictions of living in a formal organisation and the agencies of residents described, may contribute to better understanding the effects of structural constraints and to designing more flexible processes.
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Affiliation(s)
- Doreen Stöhr
- grid.10420.370000 0001 2286 1424Institute of Nursing Science, University of Vienna, Alser Straße 23/12, A-1080 Wien, Austria
| | - Hanna Mayer
- grid.459693.4Department of General Health Studies, Division Nursing Science with focus on Person-Centred Care Research, Karl Landsteiner University of Health Sciences, Dr.-Karl-Dorrek-Straße 30, A-3500 Krems, Austria
| | - Eva Soom Ammann
- grid.424060.40000 0001 0688 6779Health Department, aR&D Nursing, Bern University of Applied Sciences, Murtenstrasse 10, CH-3008 Bern, Switzerland
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Anantapong K, Davies N, Sampson EL. Communication between the multidisciplinary team and families regarding nutrition and hydration for people with severe dementia in acute hospitals: a qualitative study. Age Ageing 2022; 51:6834151. [PMID: 36434801 PMCID: PMC9701106 DOI: 10.1093/ageing/afac230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND When a person with severe dementia is in hospital and has eating and drinking difficulties, communication between the multidisciplinary team and families can be challenging and lead to suboptimal care. OBJECTIVE To gain in-depth understanding about the experiences, views and needs of family carers and hospital staff, regarding communication and conversations about nutrition and hydration, for hospital patients with severe dementia. DESIGN Qualitative semi-structured interview study. SETTING Acute hospital in England. METHODS From January to May 2021, semi-structured interviews were conducted with 29 family carers and hospital staff. Interviews were transcribed verbatim and analysed using reflexive thematic methods. RESULTS Four overarching themes were developed: (i) prerequisites to initiating communication about eating and drinking; (ii) communication aiming to develop agreed care plans; (iii) difficulty discussing palliative and end-of-life care; and (iv) needs of information and plans about future eating and drinking difficulties. Families tended to wait for hospital staff to initiate discussions but usually experienced frustration with delays and repeated conversations with different staff. Some staff felt unprepared to manage these conversations and found it challenging to work across the multidisciplinary team. During discharge processes, key information and care plans about eating and drinking were not regularly passed on to people involved to avoid unnecessary readmissions. CONCLUSIONS In acute hospitals, family carers and hospital staff can have disjointed communications and conversations about nutrition and hydration for persons with severe dementia. Timely reassurance, ongoing discussions and clear information sharing will support communication between those involved.
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Affiliation(s)
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK,Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK,Department of Psychological Medicine, Royal London Hospital, East London NHS Foundation Trust, London, UK
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Davies N, Barrado-Martín Y, Vickerstaff V, Rait G, Fukui A, Candy B, Smith CH, Manthorpe J, Moore KJ, Sampson EL. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev 2021; 8:CD013503. [PMID: 34387363 PMCID: PMC8407048 DOI: 10.1002/14651858.cd013503.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. OBJECTIVES To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. DATA COLLECTION AND ANALYSIS Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. MAIN RESULTS We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. AUTHORS' CONCLUSIONS We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Yolanda Barrado-Martín
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Akiko Fukui
- Medical School, St George's, University of London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, Policy Institute at King's, King's College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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