Effects of a feeding skills training programme on nursing assistants and dementia patients

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.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Interventions to address mealtime support needs in dementia: A scoping review

The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.

Impact of COVID-19 pandemic on mortality and cognitive function of dementia patients: Tochigi Dementia Cohort Study

OBJECTIVES

The coronavirus disease 2019 pandemic significantly affected Japanese society and the health of its population. Despite this, few studies have evaluated the influence of the pandemic on patients with neurological diseases or dementia, which we assessed through the Tochigi Dementia Cohort Study.

METHODS

Participants were divided into two groups. The pre-pandemic group included patients who were enrolled from December 1, 2016 to November 30, 2018, and were followed up until November 30, 2019 (i.e., before the pandemic). The post-pandemic group included patients who were enrolled from December 1, 2019 to November 30, 2021, and were followed up until November 30, 2022 (i.e., during the pandemic). We recorded their age, sex, mortality, and treatment withdrawal during the follow-up period. Furthermore, we examined their cognitive function at the baseline, and after 6 and 12 months.

RESULTS

A total of 384 patients were enrolled in this study, including 199 patients in the pre-pandemic group and 185 in the post-pandemic group. The mortality of dementia patients was significantly higher in the post-pandemic group than in the pre-pandemic group" (5.3% vs. 18.5%, p < 0.05*). The cognitive function scores at 12 months were also significantly lower in the dementia patients of the post-pandemic group than in those of the pre-pandemic group (p < 0.05*).

CONCLUSIONS

This longitudinal cohort study conducted in a local Japanese area revealed that mortality rate and cognitive function worsened in dementia patients during the pandemic.

Effective nursing interventions in ADL care affecting independence and comfort - a systematic review

Despite its frequent provision, evidence of nursing interventions in Activities of Daily Living (ADL) remains unclear. Hence, we addressed the research question: What are the effects of ADL nursing interventions on independence and comfort in adults across all care settings? We conducted a systematic review of randomized controlled trials and quasi-experimental studies described in systematic reviews. In three databases, we searched for systematic reviews that we used as a portal to select (quasi) experimental studies. After narratively summarizing the studies on characteristics, effects, and interventions, we assessed the risk of bias. Among the 31 included studies, 14 studies evaluated independence, 14 studies measured comfort, and three studies assessed both outcomes. Seven interventions significantly improved independence and seven interventions significantly improved comfort. The studies varied highly in intervention components, outcome measures, and quality. Evidence on ADL nursing interventions affecting independence and comfort remains fragmented and inconclusive, limiting guidance for nursing professionals.

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.

Montessori mealtimes for dementia: A pathway to person-centred care

PURPOSE

This study examined the impact of a Montessori mealtime intervention for people living with dementia to support the mealtime experience of residents and mealtime care practices of staff in a memory support unit. The mealtime intervention was part of a broader culture change project.

METHOD

An observational research design was used to evaluate changes in the mealtime experience and care practices across three time points (baseline, post-implementation, maintenance), spanning 30 months. Five video recordings of the lunch time service (range: 19-32 min) were analysed. The coding protocol comprised pre-determined indicators related to accepted dimensions of person-centred care. Resident and staff behaviours were quantified across four categories: providing choice and preferences, promoting the social side of eating, supporting independence and showing respect towards residents. Staff behaviours that reflected personal enhancing actions and personal detractors were also coded during each mealtime service.

RESULTS

A significant increase in staff providing residents with the opportunity for choice and a subsequent significant increase in residents demonstrating choice behaviours was evident. Staff and residents both significantly increased their interactional behaviours, with greater social interaction between staff and residents. Staff further demonstrated greater support for mealtime independence that reached and maintained significance during the final two sampling points. Significant gains observed post implementation were largely maintained and, on specific measures, further increased over time. A significant increase in staff use of personal enhancing actions during mealtime care was also evident. Variability in individual staff and resident behaviour highlighted the complexity of mealtime care and culture change processes.

IMPLICATIONS

The study provides novel evidence to support the use of a Montessori mealtime intervention to achieve more person-centred mealtime care, and which resulted in a more respectful, enabling and social dining experience. Clinical implications and direction for future research are presented to build on these findings.

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.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

BACKGROUND

As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.

OBJECTIVE

To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.

DESIGN

A systematic review of qualitative research.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.

REVIEW METHODS

Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.

FINDINGS

A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, a social worker, a professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.

CONCLUSIONS

Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients' preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.

Expanding role of nurses in management of dementia in geriatrics: improving well-being of geriatric patients through quality nursing care

The potential nurses role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. However, treatment of geriatric dementia has become difficult owing to co-morbidities and cognitive and physical deterioration of these patients. Thus, geriatric dementia patients require special attention during care in homes and clinical settings. In modern medical practice, the role of nurse has become dynamic, ranging from education and personal care. The profession of nursing is considered as critical to meets the needs of the elderly population with dementia and ensure the delivery of high-quality care. Since nurses play such an important role in caring for these individuals, comprehensive reviews lack on their role and experience in geriatric dementia treatment and issues. This review summarizes the expanding role of nurses in the management of geriatric dementia in terms of nurse's knowledge, role, communication, attitude and maintaining patient's quality of life through diverse activities. Furthermore, we also explain the future direction for improving the nursing care to treat dementia in elderly population.

The role of non-dietetic healthcare professionals in managing interventions among adults at risk of malnutrition: A systematic review

BACKGROUND

Malnutrition is estimated to affect over three million people in the UK resulting in serious consequences on both the individuals' health and healthcare system. While dietitians are uniquely qualified to provide nutritional interventions, they have one of the lowest workforce numbers in the NHS making it difficult to tackle the malnutrition burden alone. Thus, innovative ways of working are needed. Non-dietetic health care professionals are often involved in the identification, assessment and treatment of malnutrition and research has shown benefits of their involvement in identification and management of nutritional issues, however their role in delivering nutritional interventions has not yet been evaluated. The aim of this systematic review is to collate evidence on the potential roles and effectiveness of non-dietetic healthcare professionals in providing nutritional interventions and their impact on patient-centred outcomes in malnourished or at-risk individuals.

METHODS

Three electronic databases were searched on 10th October 2019. Titles and abstracts were initially screened, followed by full texts, against inclusion criteria and included/excluded studies by two authors independently. Data were extracted and tabulated where possible and grouped according to type of intervention and outcomes. Risk of bias and quality of evidence was assessed using the GRADE approach. Data were combined in the form of a narrative synthesis.

RESULTS

Eighteen eligible studies were included; five involved feeding assistance, 10 involved implementing individualised nutrition monitoring or care plans and three were multi-factorial interventions. Interventions took place in a range of settings including hospital and long term care facilities. Very low and low quality evidence suggests that non-dietetic HCP interventions may improve weight, percent of patients reaching estimated energy requirements, quality of life, falls and frailty rate and patient satisfaction. Very low quality evidence suggests that non-dietetic HCP interventions may not improve mid-arm circumference, energy or protein intake, activities of daily living, handgrip strength or length of hospital stay. Low quality evidence suggests that non-dietetic HCP interventions have no effect on mortality.

CONCLUSIONS

A lack of good quality evidence on the effectiveness of non-dietetic HCP delivered interventions on the management of malnutrition in adults makes it difficult to draw conclusions. However, this review has highlighted the types of interventions and potential roles of non-dietetic HCPs, providing a groundwork for further high-quality research such as feasibility studies in this area, for the effective management of malnutrition within clinical and community practice.

Staff Perceptions of a Mealtime Management Educational Video for Training in Long-Term Care Homes

The purpose of this study was to determine if staff perceive a mealtime management video to be a beneficial and useful training tool in long-term care (LTC) homes. An email invitation was sent to the Dietitians of Canada Gerontology Network inviting dietitians working in LTC homes to participate. A previously used and reliable 25-item questionnaire was used to assess sustained attention/mental effort, learner satisfaction, clinical experience/relevance, and information processing of the video. Dietitians were asked to show the video to LTC staff and distribute the questionnaire to staff after viewing the video. A total of 769 surveys were completed at 28 LTC homes across Canada. Eighty-seven percent (n = 637/736) of participants felt more knowledgeable after viewing the video and 91% (n = 669/738) found the video format easy for learning. Managers had a higher Likert scores (mean = 6.2 out of 7) than continuing care assistant (mean = 5.7, P = 0.02) and food service workers (mean = 5.5, P = 0.001) for the clinical relevance scales. No differences were found for age (χ² = 5.52, P = 0.60), gender (χ² = 2.65, P = 0.10), and size of home (χ² = 3.34, P = 0.34). Staff perceived the video to be useful for their work with residents living in LTC homes and it raised awareness of the importance of their roles at mealtimes.

Effects of nursing nutrition interventions on outcomes in malnourished hospital inpatients and nursing home residents: A systematic review

CONTEXT

Malnutrition in institutionalized patients is associated with adverse outcomes and increased costs. Nurses have a crucial role in the recognition and treatment of malnutrition and empowering patients in nutritional care.

OBJECTIVE

This systematic review provides an overview of the effectiveness of nursing nutritional interventions to counteract malnutrition.

DATA SOURCES

Data were obtained through a systematic search in MEDLINE/PubMed, Cochrane, CINAHL, EMBASE and ISI Web of Science databases from inception to February 15^th 2018.

DATA EXTRACTION

Studies were eligible for inclusion when published in English, Spanish or German. Primary outcome parameters were nutritional status and dietary intake.

DATA ANALYSIS

The Evidence analysis checklist from the American Dietetic Association and GRADE were used to evaluate the methodological quality of the studies.

RESULTS

Out of 8162 studies, fifteen studies were included in the study, representing nine hospitals and six long-term care facilities. Two main categories of nursing nutrition interventions were identified; the implementation of 1) a nursing nutrition plan focusing on nursing actions in nutritional care or 2) nursing assistance in feeding support, mostly during mealtimes. Studies were heterogeneous and of most of them of low quality. This hampered drawing conclusions on effectiveness of nursing nutrition interventions on malnutrition related outcomes in clinical care. Nevertheless, six out of 15 studies reported a slightly improved nutritional status and/or clinical outcomes as a result of the interventions.

CONCLUSION

This review identified two categories of nursing nutrition interventions to counteract malnutrition. Their effectiveness needs to be further evaluated in future studies. Tweetable abstract: Systematic review of effective Nursing Nutrition Interventions in the management of malnutrition in hospital and nursing home care.

Ease of use, feasibility and inter-rater reliability of the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme

AIMS

To refine the Cue Utilization and Engagement in Dementia mealtime video-coding scheme and examine its ease of use, feasibility, and inter-rater reliability in assessing the food intake process and dyadic verbal and nonverbal interactions.

DESIGN

This study was a secondary analysis of 110 videotaped observations of mealtime interactions collected under usual care conditions from a dementia communication trial during 2011-2014.

METHODS

The videos involved 29 staff and 25 residents with dementia (42 unique staff-resident dyads) in nine nursing homes. Data coding and analysis were performed in 2018-2019. Logs of coding challenges with matched solutions and coding time were collected. Inter-rater reliability was examined through rating of randomly selected 22 videos across four trained coders.

RESULTS

It took a mean of 10.81 hr to code a one-hour video using the refined coding scheme. Coding challenges, including identification of key intake process characteristics and differentiation of similar verbal or nonverbal behaviours, were identified with appropriate solutions. The refined coding scheme had good inter-rater reliability (Cohen's Kappa range = 0.93 - 0.99, 95% CI = 0.92 - 0.99).

CONCLUSION

Findings supported preliminary evidence on feasibility, usability and inter-rater reliability of the refined coding scheme. Future psychometric testing is needed in diverse populations with dementia across different care settings.

IMPACT

Existing tools assessing the food intake process and dyadic interactions are few and have limited feasibility and/or reliability and fail to capture the complexity and dynamics of mealtime care. The refined coding scheme showed preliminary feasibility, usability, and inter-rater reliability. In consideration of the balance between time intensity and the richness of data obtained, the tool may be appropriate and useful in addressing certain research inquires (e.g., characterizing and clustering dyadic behaviours, temporal relationship between behaviours and intake) pertaining older adults with or without dementia and their formal or informal caregivers.

Mealtime caregiving knowledge, attitudes, and behaviors for persons living with dementia: A systematic review of psychometric properties of instruments

BACKGROUND

Using valid instruments to assess caregiving knowledge, attitudes, skills, and behaviors in mealtime care for people living with dementia is critical to evaluate the process and effects of mealtime assistance interventions. Yet, the quantity and psychometric quality of such instruments are unknown.

OBJECTIVES

This systematic review described and evaluated psychometric properties of instruments that were developed and used to assess mealtime caregiving knowledge, attitudes, skills, and behaviors for people with dementia.

METHODS

We searched Pubmed, CINAHL, AgeLine, PsychINFO, and Cochrane Library for records published between January 1st, 1980 and June 31st, 2019, with follow-up searches by December 20th, 2019. Records were eligible if they included any instrument developed, tested, and/or used to measure the concepts of interest, including mealtime caregiving knowledge, attitudes, skills, and/or behaviors. After eligible records were identified, instruments that were reported in the eligible records were identified and extracted. Instruments were eligible if they were originally developed to measure the concepts of interest or developed in non-mealtime activities and later used or tested to measure the concepts of interest. From eligible records, eight characteristics of eligible instruments were extracted: (1) development process, (2) the concept/construct the instrument operationalizes, (3) sample and setting the instrument was used/tested in, (4) administration method, (5) description of items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric quality of eligible instruments was evaluated using a newly developed psychometric quality assessment tool.

RESULTS

A total of 9438 records were retrieved and 19 eligible instruments were identified. Ten instruments assessed mealtime caregiving skills or behaviors; 5 assessed attitudes, intention, self-efficacy, empathy; and 4 assessed knowledge. All instruments were scored as having low psychometric quality, except for Mealtime Engagement Scale with moderate psychometric quality in assessing mealtime engagement toward people with dementia. Reasons for low psychometric quality included limited psychometric testing, inadequate estimates of psychometric properties, and use of small sample size.

CONCLUSIONS

While all instruments warrant further testing, Mealtime Engagement Scale demonstrated moderate psychometric quality with preliminary evidence of reliability and validity to assess mealtime engagement toward people with dementia. Future testing of Mealtime Engagement Scale is needed in larger diverse samples in different care settings to accumulate psychometric evidence and expand the use.

Feasibility of a Mobile Meal Assistance Program for Direct Care Workers in Long-Term Care Facilities in South Korea

Purpose

The purpose of this study was to assess the feasibility and examine the preliminary effectiveness of a mobile application-based meal assistant training program (APP) for use by direct care workers (CAs) assisting residents with dementia in long-term care facilities in South Korea.

Methods

We adopted a mixed methods research design, which included a pre- and post-intervention study and focus group interviews for the feasibility assessment. Participants included 23 dyads of older adults with dementia and their CAs from a long-term care facility in South Korea. Upon completion of the APP intervention, focused group interviews were conducted with six CAs and five nurses.

Results

The results of paired t-tests showed that the effects of the APP intervention on the older adults with dementia and their CAs were not significant; however, the results of the focused group interviews support the potential usefulness of the APP for CAs.

Conclusion

The APP may be applicable to long-term care workers who need meal assistant skills education.

Development and Psychometric Testing of the Mealtime Engagement Scale in Direct Care Providers of Nursing Home Residents with Dementia

BACKGROUND AND OBJECTIVES

Mealtime engagement is defined as verbal and nonverbal assistance provided by caregivers to guide and motivate care-recipients in eating. Quality mealtime engagement is critical to improve mealtime difficulties and intake among older adults with dementia requiring eating assistance. Few tools are feasible and valid to measure mealtime engagement. This study developed and tested the Mealtime Engagement Scale (MES).

RESEARCH DESIGN AND METHODS

Items were developed based on literature review and expert review and finalized based on content validity and corrected item-total correlation. A secondary analysis of 87 videotaped observations capturing 18 nursing home staff providing mealtime care to residents with dementia was conducted. Internal consistency, inter-rater reliability, and intra-rater reliability were assessed. Concurrent and convergent validity were examined through correlation (rs) with the Relational Behavior Scale (RBS) and the Mealtime Relational-Care Checklist (M-RCC), respectively.

RESULTS

The 18-item MES was developed with adequate content validity (Scale-CVI=1.00; Scale-CVI/Average=0.962-0.987). Each item is scored from 0 (never) to 3 (always). The total scale score ranges from 0 to 54. Higher scores indicate greater mealtime engagement. The MES had very good internal consistency (Cronbach's alpha=0.837), outstanding inter-rater reliability (Interclass Correlation=0.920), outstanding intra-rater reliability (Interclass Correlation =0.956), adequate concurrent validity based on strong correlation with the RBS (rs=0.821, p&.001), and fair convergent validity based on weak correlation with the M-RCC (rs=0.219, p=.042).

DISCUSSION AND IMPLICATIONS

Findings provide preliminary psychometric evidence of MES to measure mealtime engagement. Future testing is needed among more and diverse samples in different care settings to accumulate psychometric evidence.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Factors influencing the pace of food intake for nursing home residents with dementia: Resident characteristics, staff mealtime assistance and environmental stimulation

AIM

To examine the association of resident characteristics, staff mealtime assistance and environmental stimulation with the pace of food intake.

DESIGN

A secondary analysis of 36 baseline eating videos involving 19 nursing assistants and 15 residents with dementia in eight nursing homes from a communication intervention study.

METHODS

The outcome variable was the pace of food intake (the number of bites and drinks per minute). The exploratory variables were resident characteristics (age, gender, dementia stage and eating performance), staff mealtime assistance (frequency of verbal, visual, partial and full physical assistance) and environmental stimulation. Multi-level models were used to examine the association.

RESULTS

A faster pace of food intake is associated with being male, better eating performance, staff provision of visual and physical assistance and better quality of environmental stimulation that involved interaction. The pace of food intake was not associated with resident age, staff verbal assistance or partial physical assistance.

Equipping Nurses and Care Staff to Manage Mealtime Difficulties in People With Dementia: A Systematic Scoping Review of Training Needs and Interventions

Purpose Mealtime difficulties are prevalent in dementia, posing major challenges to people with dementia (PWD), carers, and clinical services. Speech-language pathologists have a recognized role in providing training to carers of PWD who have mealtime difficulties. The aims of this study are (a) to identify the training needs of nurses and care staff with regard to managing mealtime difficulties in PWD, (b) to describe existing training interventions on this topic, and (c) to investigate the extent to which these interventions are relevant to the needs of nurses and care staff. Method A systematic search was carried out to identify studies relevant to the aims of the review. Data were extracted and then synthesized using thematic analysis and a synthesis matrix. Study quality was appraised using a validated appraisal tool. Results Various themes were identified in relation to the training needs of nurses and other care staff who manage mealtime difficulties in PWD. These were as follows: person-centered care; dealing with uncertainty; strategies, skills, and knowledge; and creating the right environment. Existing training interventions were described and compared against the training needs. The review found some correspondence between interventions and staff needs, but also some gaps. Conclusions Training interventions on this topic should be more systematically developed and better reported to facilitate effective implementation. Evidence to date indicates that training should do more to help staff deal with uncertainty. Further research assessing the benefits of speech-language pathologists' involvement in the development of training interventions is recommended because of this profession's specialist skills and knowledge with regard to both dysphagia and communication.

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.

Progressive Support for Activities of Daily Living for Persons Living With Dementia

Background and Objectives

Dementia is accompanied by increasing need for support in activities of daily living (ADLs). This brief report/literature review summarizes the practices to care for early stage, middle stage, and late stage ADL needs (dressing, toileting, and eating/nutrition), and examines commonalities across ADL needs and the extent to which practices are reflected in guidelines and/or evidence.

Research Design and Methods

A review of the grey and peer-reviewed literature, using some but not all procedures of a systematic review. Key terms were identified for ADLs overall and for each of the 3 ADLs, and a search was conducted using these words in combination with (a) dementia, Alzheimer's disease, and similar terms, and (b) practices, interventions, guidelines, recommendations, and similar terms. Searches were conducted using databases of peer-reviewed literature as well as the Grey Literature Reports and Google search engine. Sources were included if they provided evidence or recommendations on interventions to address ADL functioning for dressing, toileting, and feeding for persons living with dementia.

Results

As cognitive and functional impairment increases, the number of care practices and themes that embody care practices increases. The majority of practices are evidence-based, and most evidence is incorporated into guidelines.

Discussion and Implications

Virtually all practices reflect person-centered care principles. Five recommendations summarize the evidence and recommendations related to providing support to persons living with dementia in relation to dressing, toileting, and eating/nutrition.

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 impact of nurse and care staff education on the functional ability and quality of life of people living with dementia in aged care: A systematic review

OBJECTIVES

Educational initiatives can improve care delivery and the experience of living in residential aged care for people with dementia. This review aimed to determine the impact of nurse and care staff education on measures of functional ability and quality of life for older people with dementia living in care homes.

DESIGN

Systematic review.

DATA SOURCES

Search of on-line databases in English between January 2000 and January 2017.

REVIEW METHODS

Three reviewers used data extraction and critical appraisal tools of the Joanna Briggs Institute to determine methodological quality of research.

RESULTS AND CONCLUSION

Thirty-two studies met the initial inclusion criteria and 13 were retrieved for full appraisal. There was limited impact of nurse and care staff education on residents' agitation, anxiety, mood and quality of life. The most consistent improvement in functional ability due to education may be in the execution of activities of daily living. More successful programs included multi-faceted components (e.g. hands on support, clinical auditing) in conjunction with didactic teaching. There is a need for more rigorous and well-designed studies to test interventions.

Environmental and behavioural modifications for improving food and fluid intake in people with dementia

BACKGROUND

Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia.

OBJECTIVES

Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions.

SEARCH METHODS

We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low.One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention.The remaining eight studies implemented behavioural modifications.Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) -0.01 to 0.23; n = 78, 1 study; low-quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD -0.26 kg/m² favouring control, 95% CI -0.70 to 0.19; n = 734, 2 studies; moderate-quality evidence), body weight (MD -1.60 kg favouring control, 95% CI -3.47 to 0.27; n = 656, 1 study; moderate-quality evidence), or score on Mini Nutritional Assessment (MNA) (MD -0.10 favouring control, 95% CI -0.67 to 0.47; n = 656, 1 study; low-quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD -1.79 kg/m² favouring control, 95% CI -1.28 to -2.30; n = 52, 1 study; moderate-quality evidence) and body weight (MD -8.11 kg favouring control, 95% CI -2.06 to -12.56; n = 52, 1 study; moderate-quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status.Two studies compared self-feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self-feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect.One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect.Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low-quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low-quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed.

AUTHORS' CONCLUSIONS

Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.

Comparison of Patient Food Intake, Satisfaction and Meal Quality Between Two Meal Service Styles in a Geriatric Inpatient Unit

This pilot study evaluated the introduction of a bistro evening meal service in a geriatric inpatient unit by comparing patient intake, satisfaction and meal quality of this new service to the usual central preplated service. Ten meals were observed under each condition (n = 30; mean age 79 years, 47% male). Data were collected on intake of each meal component (none, ¼, ½, ¾, all; converted to energy and protein using known food composition data), patient satisfaction with meals (meal flavor/taste, appearance, quality, staff demeanor; seven-point scale) and meal quality (sensory properties, temperature; five-point scale). Independent t-tests were used to compare energy and protein intakes between bistro and preplated services. There was no difference in mean energy or protein intake (energy: 2524 ± 927 kJ vs. 2692 ± 857 kJ, p = 0.612; protein: 29 ± 12 g vs. 27 ± 11 g, p = 0.699) patient satisfaction or meal quality between the bistro and preplated meal services. Patients were provided with fewer meal items during the bistro service, but ate a higher proportion of what was provided to them. Implementing a bistro service did not increase intake, satisfaction or meal quality in this study, suggesting that meal plating may be only one of many factors influencing intake and satisfaction of older inpatients.

Intake and Factors Associated with Consumption of Pureed Food in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Residents living in long term care (LTC) who consume a pureed diet tend to have inadequate intake; understanding factors associated with poor intake in this group of residents is not well established. This study examined the adequacy of nutrient intake among LTC residents consuming a pureed diet and the factors associated with this intake (n = 67). Data was collected as part of a cross-sectional study conducted in 32 LTC homes. Weighed food intake was measured on three non-consecutive days and analyzed using Food Processor software. Intake of nutrients were adjusted for intra-individual variability and compared to the Estimated Average Requirement or Adequate Intake for women only. Consumers of a pureed diet had low micronutrient intakes. Multivariate analysis found that the average number of staff assisting with a meal was associated with energy and protein intake. Overcoming eating challenges, careful menu planning and nutrient-dense options for pureed diets in LTC are recommended.

Validation of the Spanish version of the Edinburgh Feeding Evaluation in Dementia Scale for older people with dementia

AIMS

To adapt the Edinburgh Feeding Evaluation in Dementia Scale (EdFED) for use in a Spanish-speaking population and to assess its validity and reliability in patients with dementia.

METHOD

A cross-sectional study was carried out in two stages: 1. Cross-cultural adaptation (translation, back-translation, review by committee of experts, pilot test and weighting of results); 2. Clinimetric validation comprising interobserver reliability assessment, test-retest reliability and internal consistency. To determine construct validity, confirmatory factorial analysis and principal components analysis were performed by oblique rotations. Criteria validity was analysed using the Pearson correlation (p<0.05) with the BMI, MNA and analytical values of albumin, transferrin, cholesterol, absolute lymphocytes and total proteins. Data collection was carried out for six months in 2016 in nursing homes and Alzheimer's day centers in the province of Málaga (Spain), at nine centers, with 262 patients (aged over 60 years and presenting feeding difficulties), 20 nurses, 20 professional caregivers and 103 family caregivers.

RESULTS

A version of EdFED culturally adapted to Spanish was obtained. The sample presented the following characteristics: 76.3% women, mean age 82.3 years (SD: 7.9); MNA 18.73 (SD: 4.44); BMI 23.99 (SD: 4.72); serum albumin 3.79 mg/dl (SD: 0.36). A Cronbach's alpha of 0.88 was obtained, with an inter-item global correlation of 0.43 and a homogeneity index ranging from 0.42 to 0.73. The exploratory factor analysis reproduced the three-factor model identified by the original authors, explaining 62.32% of the total variance. The criterion validity showed a good inverse correlation with MNA and a moderate one with albumin, total proteins, transferrin and BMI.

DISCUSSION

The Spanish version of EdFED is reliable and valid for use in elderly people with dementia. The most appropriate for our environment is the three-factor model, which maintains the original factors, with a slight redistribution of the items.

Interdisciplinary development and implementation of a dementia skills training program in a VA community living center: a pilot study

This pilot study investigates the usefulness of a dementia care training program developed by an interdisciplinary team to address problem behaviors associated with dementia. Staff members of a VA Community Living Center completed an 8-hour workshop covering fundamental knowledge about dementia and instruction in skills to use with patients through video, lecture, and role-plays. Measures on dementia knowledge and perceived self-efficacy were completed by staff members before and after the workshop. Results revealed increases in self-efficacy and knowledge, with particular gains in general knowledge of dementia and communicating with patients. Younger staff members scored higher on tests of knowledge at pre- and post-test, whereas staff members with more years of work experience rated their self-efficacy higher at post-test only. There was an associated decrease in assaultive behaviors by patients with dementia in the year this workshop was implemented. Results highlight the benefit of interdisciplinary collaboration in developing educational content and the value of providing staff training on managing dementia-related behaviors. Adjustments to this training program are discussed.

The effect of nutrition training for health care staff on learner and patient outcomes in adults: a systematic review and meta-analysis

Background: Nutrition training for health care staff has been prioritized internationally as a key means of tackling malnutrition; however, there is a lack of clear evidence to support its implementation. Systematic reviews in other fields of training for health care staff indicate that training strategies may have a beneficial impact on learner and patient outcomes.Objectives: We assessed whether nutrition training for health care staff caring for nutritionally vulnerable adults resulted in improved learner and patient outcomes and evaluated the effectiveness of different training strategies.Design: A systematic review of trials of nutrition training for health care staff was conducted. Six databases were searched with key terms relating to malnutrition and nutrition training. Studies were categorized according to cognitive (didactic teaching), behavioral (practical implementation of skills), and psychological (individualized or group feedback and reflection) training strategies. Where sufficient data were available, meta-analysis was performed according to study design and training strategy. All study designs were eligible. The risk of bias was evaluated in accordance with Cochrane guidance.Results: Twenty-four studies met the eligibility criteria: 1 randomized controlled trial, 4 nonrandomized controlled trials, 3 quasi-experimental trials, 13 longitudinal pre-post trials, 2 qualitative studies, and 1 cross-sectional survey. Results from a number of low-quality studies suggest that nutrition training for health care staff may have a beneficial effect on staff nutrition knowledge, practice, and attitude as well as patient nutritional intake. There were insufficient data to determine whether any particular training strategy was more effective than the others.Conclusions: In the absence of high-quality evidence, low-quality studies suggest that nutrition training for health care staff has some positive effects. However, further randomized controlled trials are required to confirm overall efficacy and to explore the impact of training strategies on learner and patient outcomes.

The association of eating performance and environmental stimulation among older adults with dementia in nursing homes: A secondary analysis

BACKGROUND

Nursing home residents with dementia experience increased risk for compromised eating performance due to intrapersonal, interpersonal, and environmental factors. Environmental stimulation is physical, social, and/or sensory stimulation present in the environment that can potentially trigger individuals' emotion or motivate physical reactions. Beyond the personal factors, there is a lack of evidence on how environmental stimulation influences individuals' eating performance at mealtimes.

OBJECTIVES

This study examined the association between environmental stimulation and eating performance among nursing home residents with dementia.

DESIGN

This study was a secondary analysis using baseline videos selected from a communication intervention study, where videos were recorded to capture staff-resident interactions during care activities for nursing home residents with dementia. Videos were included in this study only if residents demonstrated eating activities at mealtimes.

SAMPLE AND SETTING

A total of 36 videos were selected (mean length=4min). The sample included 15 residents with dementia (mean age=86), and 19 certified nursing assistants (mean age=36) in 8 nursing homes.

METHODS

The dependent variable was eating performance as measured by the Level of Eating Independence scale (range: 15-36, with higher scores indicating better eating performance). The independent variables were characteristics of environmental stimulation measured by the Person-Environment Apathy Rating-Environment subscale (stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback). Each characteristic was rated on a 1-4 scale with higher scores indicating more desirable environmental stimulation. Multilevel models were used to examine the association between eating performance and environmental stimulation, adjusting for resident characteristics (i.e., age, gender, dementia stage, function, comorbidity, psychoactive medication use) and nesting effects of residents and staff.

RESULTS

Resident participants demonstrated moderate levels of eating performance (M=27.08, SD=5.16). Eating performance was significantly lower among older residents, those with more advanced dementia, and higher comorbidity. After controlling for resident characteristics, eating performance was significantly associated with stimulation specificity (how the stimulation is delivered and tailored to the resident), and was not associated with other environmental stimulation characteristics. For each 1 point increase in stimulation specificity, eating performance increased by 8.78 points (95% CI=0.59, 16.97).

CONCLUSIONS

Environmental stimulation that is personally tailored to a resident' needs and preferences and directly offered to a resident contributed to better eating performance among residents with dementia. The findings will direct future development and implementation of person-directed mealtime care programs and dining environment arrangements for residents with dementia in nursing homes.

[Nutrition in dementia]

BACKGROUND

In the course of dementia sooner or later nutritional problems appear, and the question arises which interventions are effective in ensuring adequate nutrition and thus may contribute to the maintenance of health, functionality and independence.

OBJECTIVE

This overview presents the state of knowledge regarding nutrition in dementia.

METHODS

This work is based on the present guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) on nutrition in dementia, which systematically investigated relevant available evidence.

RESULTS

Nutritional interventions should be an integral component of dementia treatment. They should be based on a routine screening for malnutrition, followed by assessment when appropriate, and periodic body weight control in order to recognize problems early. In all stages of dementia, adequate oral nutrition can be supported by attractive, high-quality food according to individual needs served in a pleasant ambience, by adequate nursing support and treatment of underlying causes of malnutrition. If nutritional requirements are not met by usual or enriched food, oral nutritional supplements are recommended in order to improve nutritional status. Beneficial effects of energy and/or nutrient supplementation on cognitive abilities are however not proven. Artificial nutrition is only rarely indicated, namely after careful weighing of individual benefits and risks considering the patients (presumed) will. In patients with advanced dementia and in the terminal phase of life artificial nutrition is not recommended.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Do interventions with staff in long-term residential facilities improve quality of care or quality for life people with dementia? A systematic review of the evidence

BACKGROUND

Common sense suggests and research indicates relationships between staff factors in residential dementia care and quality of life (QOL) for residents, with poor care increasing suffering. However, we do not have a coherent picture of which staff interventions have an impact on quality of care (QOC) or resident QOL.

METHODS

A comprehensive search of 20 years' peer-reviewed literature using Medline, PsycINFO, Embase, PubMed, CINAHL, and the Cochrane, Campbell Collaboration identified 4,760 studies meriting full text review. Forty-six met the inclusion criteria, namely interventions in long-term facilities helping staff develop their capacity to provide better care and/or QOL for residents with dementia. Thirty-five other papers comprised an associated predictor review.

RESULTS

Conclusions from these limited data are further compromised because nine studies failed to measure effects on residents and only half assessed effects after the project team withdrew. Of these, excellent studies produced change over the medium (3-4 months) or longer term, including reduction in challenging behavior and restraint use but this applied only to a minority. A number of studies failed to measure effects on QOC, limiting conclusions about mechanisms underlying change.

CONCLUSION

In general, level of intervention required depended on the target. For outcomes like restraint use, structured education sessions with some support appear adequate. Programs to reduce pain require more support. For complicated issues like challenging behavior and increasing co-operation in showering, detailed, supportive, on-site interventions are required. Improvements in restraint and staff/resident interactions were the most promising findings. (Review registration number: PROSPERO 2014:CRD42014015224).

RelAte: pilot study of the effects of a mealtime intervention on social cognitive factors and energy intake among older adults living alone

Mealtime interventions typically focus on institutionalised older adults, but we wanted to investigate whether they may also be effective among those living independently. Using a randomised controlled trial design, we assessed the effects of a novel mealtime intervention on self-efficacy, food enjoyment and energy intake. A total of 100 adults living alone aged over 60 years were randomised to the treatment or control conditions: all received a guidebook on nutrition and culinary skills. Treatment group participants received a weekly visit from a trained volunteer who prepared and shared a meal with them. Participants in the treatment group showed improvements relative to those in the control group at borderline significance (P=0·054) for self-efficacy and at significance for food enjoyment. Significant improvements were observed in female participants in the treatment but not in the control group in energy intake (although following corrections for multiple comparisons, only the effect on food enjoyment remained significant). These findings will inform the design of future complex interventions. For this type of intervention to be successful, more focus has to be placed on making interventions more personalised, potentially according to sex. Findings are important for nutritional sciences as they indicate that, in order to improve energy intake and food enjoyment among older adults, multimodal nutritional interventions including social components may be successful.

Validation of the Spanish version of the Edinburgh feeding evaluation in dementia scale applied to institutionalized older persons with dementia: a study protocol

Aim

The aim of this study was to obtain a Spanish version of the Edinburgh Feeding Evaluation in Dementia Scale version, to assess its reliability for use by medical staff and caregivers at residential care homes, to evaluate by confirmatory methods its construct validity. A further aim was to determine the criterion validity with respect to biochemical markers of malnutrition such as serum albumin, transferrin, cholesterol and lymphocytes, the body mass index and the mini nutritional assessment.

Design

Clinimetric cross‐validation study.

Methods

Institutionalized subjects with dementia will be observed while consuming meals and evaluated with the instrument independently by nurses and caregivers.

ESPEN guidelines on nutrition in dementia

BACKGROUND

Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified.

OBJECTIVE

It is the purpose of these guidelines to cover these issues with evidence-based recommendations.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members.

RESULTS

26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life.

CONCLUSION

Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

Optimizing Eating Performance for Long-Term Care Residents With Dementia: Testing the Impact of Function-Focused Care for Cognitively Impaired

OBJECTIVES

The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.

DESIGN

A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.

PARTICIPANTS AND SETTING

Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.

MEASUREMENTS

Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care "feeding" item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single "chair sit-sitting balance" item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).

RESULTS

At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).

CONCLUSION

Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.

Environmental Considerations for Improving Nutritional Status in Older Adults with Dementia: A Narrative Review

As the number of older adults in the United States continues to grow, the American health care system will face the unique challenge of providing care for these individuals, including many who will be diagnosed with some form of dementia. As dementia progresses, patients require increasing amounts of care and nutrient intake usually declines. This tends to result in weight loss, malnutrition, and increased morbidity and mortality. Various interventions have been developed with the goal of improving meal intake and reducing unintentional weight loss in patients with dementia. Several studies have shown that meal intake improves with the provision of adequate assistance, either from staff members or from volunteer feeding assistants. Some studies have focused on the method of meal service and its influence on meal intake and nutrition status. Both buffet-style and family-style dining have shown promising results in terms of improving meal intake and quality of life among older adults in long-term-care settings. Other environment-related interventions include improving lighting and visual contrast, altering the dining room to more closely resemble a home-style setting, using the aroma of food to stimulate appetite, using routine seating arrangements, and using relaxing or familiar music in the dining room to provide a calmer environment. The purpose of this review is to evaluate the research on environment-based interventions to improve nutritional status among older adults with dementia, to describe potential for practical applications, and to identify gaps in the existing literature whereon further research is warranted.

Ethical aspects of caregivers' experience with persons with dementia at mealtimes

BACKGROUND

Persons with dementia are at risk of malnutrition and thus in need of assistance during mealtimes. Research suggest interventions for caregivers to learn how to facilitate mealtimes and eating, while other suggest a working environment enabling the encounter needed to provide high-quality care. However, the phenomenon of caring for this unique population needs to be elucidated from several perspectives before suggesting suitable implications that ensure their optimal health.

OBJECTIVES

To illustrate the meanings within caregivers' experiences of caring for persons with dementia during mealtime situations. We also measured weight and food intake among individuals with dementia to explain better the phenomenon of caring for them during mealtimes.

METHODS

Mixed method including focus group interviews with seven caregivers analyzed using phenomenological hermeneutics. In addition, for nine persons with dementia, weight and food intake were collected and descriptive statistics were calculated.

ETHICAL CONSIDERATIONS

Ethical review was obtained from an ethics committee, and all caregivers signed a consent form after being informed on the issue of research ethics. Relatives for persons with dementia were informed and signed the consent. In addition, throughout the study, the persons' expressions were observed aiming to respect their vulnerability, integrity, and dignity.

FINDINGS

One theme emerged from interviews (struggling between having the knowledge and not the opportunity), which was built upon three subthemes (being engaged and trying; feeling abandoned and insufficient; being concerned and feeling guilty). Seven of nine persons with dementia lost a minimum of 1.3 kg of weight and ate a maximum of 49.7% of the food served.

CONCLUSION

Caregivers struggle because they have knowledge about how to provide high-quality care but are unable to provide this care due to organizational structures. The weight loss and insufficient eating among the persons with dementia may support this conclusion. Sufficient time for adequate care should be provided.

A shared mealtime approach to improving social and nutritional functioning among older adults living alone: study protocol for a randomized controlled trial

BACKGROUND

Older adults living alone are at increased risk of malnutrition as well as social isolation. Previous research has evaluated psychosocial interventions aimed at improving social support for older adults living alone. One meta-analysis in particular has suggested that multimodal psychosocial interventions are more effective than unimodal interventions. As such, it may be more effective to deliver an intervention which combines nutritional and social support together. Consequently, we designed the RelAte intervention, which focuses on shared mealtimes as a source of combined social and nutritional support for older adults living alone who are at risk of social isolation.

OBJECTIVE

The objective of the RelAte trial was to evaluate the impact of such an intervention on energy intake, anthropometric measurements, and nutritional social cognitive variables among older adults living alone in the community.

METHODS

There are 100 participants that will be recruited and randomized to either the treatment (n=50) or the control group. The treatment group will receive a visit from a trained peer volunteer once weekly for a period of 8 weeks. Outcomes of interest include: energy intake, social cognitive factors related to diet, abdominal circumference, body mass index, psychosocial well-being, frailty, nutritional status, and health utilities. Outcomes will be obtained at baseline, immediately postintervention (8 weeks after baseline), 12-week follow-up, and 26-week follow-up by assessors blinded to participants' randomized assignment.

RESULTS

The Relate trial is currently active. We are currently at data analysis stage. The study started in June 2013 and will run until June 2015.

CONCLUSIONS

Results from this study will primarily describe the effectiveness of a shared mealtime intervention for older adults living alone in terms of their dietary well-being, physical health, and psychosocial well-being.

TRIAL REGISTRATION

TRIAL REGISTRATION

Clinicaltrials.gov NCT02007551; http://clinicaltrials.gov/ct2/show/NCT00102401 (Archived by WebCite at http://www.webcitation/6WptuVTtz).

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.

Factors influencing the degree of eating ability among people with dementia

AIMS AND OBJECTIVES

To explore the degree of eating ability in people with dementia and identify what factors affect their eating ability.

BACKGROUND

Appropriate food consumption is important to human life. Although eating difficulties are common among people with dementia, little is known about what factors might influence their eating ability.

DESIGN

Descriptive, cross-sectional study.

METHODS

A total of 149 people with dementia residing in nursing facilities in Seoul or the Gyeonggi area of Korea were evaluated using the Korean Mini-Mental State Examination, Korean Activities of Daily Living Scale and Eating Behaviour Scale. Data were analysed using descriptive statistics, one-way analysis of variance, Pearson correlation coefficient and multiple regression analysis.

RESULTS

The participants showed a moderate level of dependency with respect to eating ability and were most dependent on the use of utensils. There were significant differences in eating ability according to general characteristics such as duration of residence, duration of illness, degree of visual impairment, eating place, and diet type. The eating ability of the participants was significantly correlated with cognitive function and physical function. Cognitive function, physical function, duration of illness, eating place (living room or dining room), and diet type (soft or liquid) significantly predicted eating ability in people with dementia.

CONCLUSIONS

The findings of this study suggest that it is necessary to thoroughly assess the eating ability of people with dementia and to develop appropriate training programs to maintain or improve their remaining eating ability. The creation of a pleasurable physical and social environment for eating might also be helpful.

RELEVANCE TO CLINICAL PRACTICE

These findings would be able to serve a useful basis in the development of materials for nursing intervention programs for people with dementia during mealtimes by improving the techniques and care qualities of nursing caregivers.