Self-feeding performance in nursing home residents

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.

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.

Self-Feeding Ability as a Predictor of Mortality Japanese Nursing Home Residents: A Two-Year Longitudinal Study

OBJECTIVES

To examine the ability of different elements of the Self-Feeding Assessment Tool for Elderly with Dementia (SFED) to predict mortality risk in nursing home residents.

DESIGN AND SETTING

Data from 387 residents in five nursing homes for the elderly in Japan were obtained using a baseline survey. This measure's ability to predict mortality risk was examined over a two-year observation period. Participants and Measurement: Demographic information (sex, age, height, weight, medical history) on 387 initial participants was gathered. A total of 10 individuals were excluded from the analysis because of the inability to eat by mouth at baseline, while 36 were excluded owing to missing mortality data during the observation period. The resulting 341 residents were divided into a death group or survival group according to whether they were still alive after two-year observation period. In addition to basic information and the SFED, the baseline survey included the Barthel Index (BI), Clinical Dementia Rating (CDR), and Mini Nutritional Assessment-Short Form (MNA®-SF). The ability of SFED to predict time-to-event mortality was examined using Cox proportional hazards regression analysis, including other measures associated with mortality as confounding variables.

RESULTS

In total, 129 participants (37.8%) died during the observation period, and their mean SFED score was significantly lower than that of surviving ones (11.1 ± 6.7 vs. 15.0 ± 5.6, P<0.001). SFED score was significantly associated with two-year mortality in the Cox proportional hazards regression analysis after adjusting for sex, age, medical history, BI, CDR, and MNA®-SF (hazard ratio = 0.941, 95% confidence interval = 0.898-0.985, P = 0.010). Additionally, three SFED categories were significantly associated with mortality risk: movement ("able to eat without dropping food"), concentration ("able to maintain attention to meal"), and safety ("able to swallow without choking, with no change in vocal quality after eating").

CONCLUSIONS

Self-feeding ability as measured by SFED score was associated with long-term mortality in elderly living in nursing homes. Accordingly, adjusting feeding assistance based on regular SFED-based assessments may help maintain self-feeding ability and enhance quality of life in this population, as well as providing evidence for end-of-life care options and greatly improving care quality.

Feasibility of LifeFul, a relationship and reablement-focused culture change program in residential aged care

Background

The protective, custodial, task-oriented care provided in residential aged care facilitates decreases health and wellbeing of residents. The aim of the study was to conduct a feasibility study of LifeFul – a 12 month reablement program in residential aged care.

Methods

LifeFul was developed based on systematic reviews of reablement and staff behaviour change in residential aged care, and in consultation with aged care providers, consumers and clinicians. LifeFul includes: engaging and supporting facility leaders to facilitate organisational change, procedural changes including dedicated rostering, assigning each resident a ‘focus’ carer and focusing on the psychosocial care of residents part of handovers and staff training. The study was conducted in three Australian residential aged care facilities. A pre-post mixed methods design was used to evaluate recruitment and retention, fidelity and adherence, acceptability, enablers and barriers and suitability of outcome measures for the program.

Results

Eighty of 146 residents agreed to participate at baseline and 69 of these were followed up at 12 months. One hundred and four of 157 staff participated at baseline and 85 of 123 who were still working at the facilities participated at 12 months. Staff perceived the program to be acceptable, barriers included having insufficient time, having insufficient staff, negative attitudes, misunderstanding new procedures, and lack of sufficient leadership support. Quantitative data were promising in regards to residents’ depression symptoms, functioning and social care related quality of life.

Conclusion

It is feasible to deliver and evaluate LifeFul. The program could be improved through increased leadership training and support, and by focusing efforts on residents having a ‘best week’ rather than on completing a document each handover.

Trial registration

Registered prospectively on 22nd January 2016 on ANZCTR369802.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0822-3) contains supplementary material, which is available to authorized users.

The Alzheimer functional status instrument: An instrument to assess rehabilitation strategies for Alzheimer patients

The Alzheimer Functional St atus Inventory (AFSI) was developed to assess a kinesiotherapy program for 22 randomized pairs ofpatients with Senile Dementia of the Alzheimer Type (SDAT) residing in the Dementia Study Unit of the Edith Nourse Rogers Memorial VA Medical Center; Bedford, Massachusetts. The AFSI was developed by an interdisciplinary team to overcome some of the limitations of standard geriatric instruments to detect changes in functional status in SDAT patients following a rehabilitation program. The AFSI, which is performance-based, includes items adapted from Granger's PULSES Profile and activity disturbances itemsfrom the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), items on mood andbehaviorduring assessment, as well as, one on communication status. The AFSI thus includes items which evaluate physical, psychosocial, and cognitive dimensions offunctional status. These dimensions are:

• Sensory function; • Range of motion skills including lower limb and upper limbfunction; • Mood state; • Behavioral status; and • Time to complete tasks.

A Framework for Developing Nursing Knowledge About the Effects of Dementia on Older Persons' Abilities

A dearth of nursing knowledge exists about the specific effects of the cognitive and other changes of dementia on older persons' abilities. Consequently, limited direction is available to guide nursing research and practice in this context. Thus, the authors designed a framework that directs the development of such knowledge. In this article, the assumptions and elements of the framework are detailed. An extensive illustration of the application of the framework is provided concerning ideational apraxia in dementia and self-care abilities related to feeding. It is shown how nurses can draw information from the scholarship of other disciplines and incorporate it into an understanding of the effects of dementia on abilities. The framework can be used to systematically focus research and practice concerning the care of people suffering fromdementia.

Eating tools in hand activate the brain systems for eating action: a transcranial magnetic stimulation study

There is increasing neuroimaging evidence suggesting that visually presented tools automatically activate the human sensorimotor system coding learned motor actions relevant to the visual stimuli. Such crossmodal activation may reflect a general functional property of the human motor memory and thus can be operating in other, non-limb effector organs, such as the orofacial system involved in eating. In the present study, we predicted that somatosensory signals produced by eating tools in hand covertly activate the neuromuscular systems involved in eating action. In Experiments 1 and 2, we measured motor evoked response (MEP) of the masseter muscle in normal humans to examine the possible impact of tools in hand (chopsticks and scissors) on the neuromuscular systems during the observation of food stimuli. We found that eating tools (chopsticks) enhanced the masseter MEPs more greatly than other tools (scissors) during the visual recognition of food, although this covert change in motor excitability was not detectable at the behavioral level. In Experiment 3, we further observed that chopsticks overall increased MEPs more greatly than scissors and this tool-driven increase of MEPs was greater when participants viewed food stimuli than when they viewed non-food stimuli. A joint analysis of the three experiments confirmed a significant impact of eating tools on the masseter MEPs during food recognition. Taken together, these results suggest that eating tools in hand exert a category-specific impact on the neuromuscular system for eating.

Results of a field test and follow-up study of a restorative care training program

BACKGROUND

To implement restorative care in assisted living facilities, staff and administrators need to understand the philosophy and learn methods to help residents maintain optimal function.

OBJECTIVE

In this study, researchers investigated the use of a Web-based training program to improve the restorative care knowledge, attitudes, and practices of assisted living administrators and staff.

DESIGN

The study design was one group repeated measure to consider the impact of the training program on participant's knowledge of restorative care and restorative care techniques, attitudes toward restorative care, and self-reported practices.

PARTICIPANTS

Participants included 266 administrators and 203 direct care staff from assisted living facilities in eight states.

METHODS

Measurements were done at baseline (pretest), following the instruction (posttest), and one month later (follow-up).

RESULTS

Researchers found that participants (n=469) significantly improved their scores from pre- to posttest. In a follow-up study (n=244), over half of participants reported making changes at their facility as a result of the restorative care training. Most of the changes are related to care practices, such as an emphasis on encouraging, motivating, and offering positive feedback to residents.

CONCLUSIONS

Researchers concluded that there is a need for restorative care training for both administrators and staff of assisted living facilities. The study also demonstrates that a brief training session (2h or less) can bring about significant change in the learner's knowledge of facts, attitudes, and practices. It demonstrates that much of that change continues for at least 1 month after the training. It also demonstrates the loss of knowledge and points out the need for training to be followed up with continuing education and administrator encouragement. Furthermore, this study demonstrates that the Web is a feasible method of delivering restorative care training to assisted living facility administrators and staff.

The effectiveness of an exercise programme for elders with dementia in a Taiwanese day-care centre

The purpose was to examine the effectiveness of an exercise programme for elders with dementia in Taiwan aimed to maintain their activities of daily living such as feeding, dressing, grooming, washing and toileting. This was a single study group, repeated measure research design. Twenty-six dementia elders were recruited from a day-care centre located in southern Taiwan. Caregivers of the day-care centre provided all subjects an exercise programme. The exercise programme consisted of stretching and walking five times per week, and leg-weight bearing at least three times per week for 20-30 min each. The data were obtained three times (baseline, 2 months post intervention and 4 months post intervention). Results showed slight changes in the scores of one-leg-standing, 30 s chair rise, functional reach and get up and go test but were not statistically significant. Results also indicated that scores in the performance of activities of daily living were significantly higher than at baseline and at 4 months post intervention. In conclusion, this study provides information for dementia day-care centres in Taiwan about how elders with dementia can maintain physical fitness and perform activities of daily living.

Direct observation of behavior: a review of current measures for use with older adults with dementia

This review article reports on methods of direct observation of behaviors for use in long-term care settings, particularly with older adults who have dementia. This article provides information on the theoretical roots, administration methods, and psychometric properties of measures of direct observation of individual behavior. It is hoped that this review will help gerontological nurses make informed choices about the direct observation measures that suit their specific needs, highlight the role of direct observation in quality improvement for dementia care, and facilitate a balance between identifying a gold standard and allowing flexibility to assess project-specific behaviors.

Feeding difficulty in older adults with dementia

AIMS AND OBJECTIVES

To use concept analysis to identify characteristics of feeding difficulty and its antecedents and consequences that provide direction for assessment and management.

BACKGROUND

Feeding difficulty is often recognised as a common problem for older adults and is associated with weight loss, poor nutrition and risk for aspiration pneumonia. The cognitive impairment found in persons with dementia impairs the ability of these adults to complete motor and perceptual tasks required for eating and often prevent the older adult from accepting help with feeding from caregivers.

DESIGN

Systematic review.

METHODS

In 2006, literature searches using keywords (feeding, eating, nutrition, malnutrition, feeding assessment, dementia, ageing and concept analysis, dementia and feeding and excluding enteral feeding, tube feedings, PEG and enteral nutrition) were done in Medline, CINHAL, AGELINE and Social Science Full Text. Seventy relevant articles in English were found. After a review of the relevant articles, concept analysis was used to develop a definition of feeding difficulty, its defining characteristics and to delineate feeding difficulty from its antecedents and consequences.

RESULTS

Feeding difficulties arise at the interface between the caregiver strategies to assist the older adult with getting food into the mouth and chewing and swallowing food. A model of feeding difficulty delineates the antecedents and consequences of feeding difficulties.

CONCLUSIONS

The conceptual model of feeding difficulties provides a strong and clear organising structure for research that can be used to developed evidence based guidelines for practice.

RELEVANCE TO CLINICAL PRACTICE

The conceptual model provides directions for assessment of feeding difficulties and their antecedents. The model can be used to identify interventions that address antecedents of feeding difficulty (risk factors) and different types of feeding difficulties.

Mealtimes as Active Processesin Long-term Care Facilities

Mealtimes are central to the nutritional care of residents in long-term care facilities. There has been little Canadian research to guide interdisciplinary practice around mealtimes. This study included a grounded theory approach to explore mealtime experiences of 20 people with dementia living in two long-term care facilities, and the meal-related care they received from registered nurses, health care aides, and dietitians. Theoretical sampling directed the collection and analysis of data from mealtime observations in special care units and key informant interviews with care providers. The constant comparison method was used to analyze and conceptualize the data. A substantive theory emerged with three key themes:

Each mealtime is a unique process embedded within a long-term care facility's environment. Residents are central to the process through their actions (i.e., arriving, eating, waiting, socializing, leaving, and miscellaneous distracted activities). Internal (i.e., residents’ characteristics) and external (i.e., co-resident, direct caregiving, indirect caregiving, administrative, and government activities) influences affect residents’ actions at mealtimes.

The theory suggests that optimal mealtime experiences for residents require individualized care that reflects interdisciplinary, multi-level interventions.

The Minimum Data Set Weight-Loss Quality Indicator: Does It Reflect Differences in Care Processes Related to Weight Loss?

OBJECTIVES

To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss.

DESIGN

Cross-sectional.

SETTING

Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator.

PARTICIPANTS

Four hundred long-term residents.

MEASUREMENTS

Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols.

RESULTS

The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss.

CONCLUSION

The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.

Medical nutrition therapy for the prevention and treatment of unintentional weight loss in residential healthcare facilities

OBJECTIVES

To identify the rate of unintentional weight loss (UWL) in adults following their admission into residential healthcare facilities, assess the effectiveness of a new medical nutrition therapy (MNT) protocol for the prevention and treatment of UWL, and describe nutrition assessment and intervention activities of dietitians.

DESIGN

Prospective intervention study in which volunteer dietitians were randomly assigned to usual nutrition care (UC) or MNT protocol care (MNT-PC) groups. Dietitians recruited newly admitted residents and tracked their weights for up to 6 months using standardized weighing procedures. Data on weight outcomes and nutrition care activities were abstracted from medical records and compared between study groups. Subjects/settings Thirty-one dietitians from 29 facilities completed the field test (16 MNT-PC, 13 UC). Medical record data were available for 394 residents (223 MNT-PC, 171 UC), and complete weight trend data were available for 364 residents (200 MNT-PC, 164 UC).

INTERVENTION

The new MNT protocol for UWL in residential facilities emphasized assessment; intervention (including weighing frequency); communication with staff, medical doctor, family, and resident; and reassessment. Main outcome measures Rate of UWL and weight status 90 days after admission and weight status 90 days after identification of UWL. Statistical analyses Chi;(2), Independent t test, analysis of variance, and multiple regression using the general linear model.

RESULTS

Fourteen of 364 residents (4%) were admitted with significant preexisting weight loss, which was successfully treated in eight residents during the first 90 days. Substantial unintentional weight loss (>or=5% in any 30 days) developed in 78 residents (21%). MNT-PC dietitians were more likely to identify UWL. When UWL was identified, and, after providing nutrition care to these residents for an additional 90 days, 32 of 61 residents (52%) maintained or gained weight. Dietitians in UC and MNT-PC groups were equally successful in treating preexisting or postadmission unintentional weight loss when it was identified. Differences were found in nutrition care activities. MNT-PC dietitians reported more nutrition assessment activities, whereas UC dietitians reported more intervention activities. Conclusions/applications Nutrition care protocols with standardized weighing procedures can increase the identification of UWL in the residential healthcare environment. Improved identification supports the additional assessment activities used by MNT-PC dietitians. Similar outcomes for UC and MNT-PC groups when UWL was identified indicate that usual nutrition care was already a high standard of care for intervention.

Using family-style meals to increase participation and communication in persons with dementia

Although researchers stress the importance of encouraging independent behavior in persons with dementia, institutional practices often foster dependence. This study took place in a six-resident locked dementia care unit that followed the common institutional practice of serving meals on prepared plates. The purpose of this study was to examine if changing the mode of meal delivery to "family-style," where residents were presented with serving bowls and empty plates, would increase resident communication and participation in mealtime tasks. An ABAB' reversal design revealed very low rates of appropriate communication (5% of intervals) and mealtime participation (10% of tasks) during baseline, when residents received prepared plates (A). Communication and participation doubled when family-style meal delivery was introduced (B) and dropped back to baseline levels when it was withdrawn (A). Because the levels of communication and participation during family-style meals were still low, the nursing assistant was provided with instruction on prompting and praising appropriate mealtime behaviors (B'). After instruction was provided and family-style meals were reintroduced, resident participation rose to 65% of tasks and appropriate communication increased to 18% of observations. This study suggests family-style meals may result in modest increases in mealtime participation and communication of residents with dementia, but staff training in prompting and praising may be necessary to see large changes in these behaviors.

Problem behaviour, caregiver reactions, and impact among caregivers of persons with Alzheimer's disease

BACKGROUND

Problem behaviours that occur during Alzheimer's disease (AD) can have major impact on caregivers. How caregivers react to these behaviours may determine the total impact experienced from caregiving.

PURPOSE

This study examined the relationships between problematic behaviours and caregiving impact in 30 primary caregivers of persons with AD. The first question explored the relationship between frequency of problem behaviour and impact; the second explored the relationship between caregiver reactions to problem behaviours and impact from caregiving.

METHODS

The frequency of problem behaviour and the caregiver reaction was measured using The Revised Memory and Behaviour Problem Checklist (Teri et al. 1992). The impact from caregiving was operationalized using the Cost of Care Index developed by Kosberg and Cairl (1986).

RESULTS

Significant associations were found for 11 of the 20 subscales that measured the association between the frequency of problem behaviour in the client and the impact from caregiving experienced by the caregiver. In comparison, the association between caregiver's reaction to problem behaviours and impact from caregiving was even more significant in value with 15 subscales of 20 being significant. Female caregivers experienced a greater reaction to disruptive and depressive behaviour when compared with male caregivers even though both genders reported similar frequencies of problem behaviours. In regard to findings about the impact from caregiving, four of the six indicators were higher for women than for men.

CONCLUSIONS

Caregiver reaction to problem behaviours was more highly associated with impact from caregiving than the actual frequency of the behaviours. These findings have great implications for intervention programs. Caregivers, especially females, need to receive individualized, specific education/training on how to understand and manage disruptive and depressive behaviour in persons with AD.

A conceptual framework for achieving high-quality care in nursing homes

Nursing home care accounts for 12% of healthcare expenditures in the United States, yet serious concerns remain about the quality of care provided in these settings. This article describes a comprehensive systems model that views organizational environments as consisting of four interacting dimensions: organizing arrangements, social factors, technology, and physical setting. This model is then used as a conceptual framework (vis-à-vis an extensive literature review) to identify factors that contribute to poor-quality care in nursing homes and to highlight previous research efforts. The literature review also provides a useful framework to guide nursing home administrators and healthcare quality professionals in their implementation of quality improvement processes and serves to help direct future research in this very important arena.

Improving morning care routines of nursing home residents with dementia

OBJECTIVES

This study examined the effectiveness of a behavioral rehabilitation intervention for improving the performance of morning care activities of daily living (ADL) of nursing home residents with dementia.

DESIGN

Participants and their caregivers were observed for 5 days each under conditions of Usual Care (naturalistic) and Skill Elicitation (intervention), and for 15 days under Habit Training (intervention follow-up). Observations involved the ADL categories of DRESSING, OTHER ADL, and NO ADL. A 3 x 3 design (condition x ADL category) was used.

SETTING

Observations occurred in five proprietary nursing homes in Pittsburgh, Pennsylvania.

PARTICIPANTS

The participants were 58 women and 26 men, mean age 82 years (range = 64-97, SD = 6.3), with Probable Alzheimer 's disease (AD) (n = 19) and Possible AD (n = 65), with a mean MMSE score of 6.07.

INTERVENTION

Condition 1, Usual Care, was the naturalistic caregiving condition. Condition 2, Skill Elicitation, consisted of an individualized behavioral rehabilitation intervention designed to identify and elicit retained ADL skills. Under Condition 3, Habit Training, the behavioral rehabilitation intervention was continued to reinforce and solidify retained skills and to facilitate further functional gains.

MEASUREMENTS

A computer-assisted data collection system was used to document in real-time the assists used by caregivers, the participants' ADL performance, and the participants' responses to caregiving, including disruptive behavior.

RESULTS

Compared with Usual Care, during Skill Elicitation participants increased the proportion of time engaged in nonassisted and assisted dressing significantly and increased their overall participation in ADL, with a concomitant significant decrease in disruptive behavior. These functional gains were demonstrated within 5 days of initiating the behavioral rehabilitation intervention and were maintained for 3 weeks during Habit Training. Physical assists were provided for significantly smaller proportions of a morning care session during Skill Elicitation and Habit Training compared with Usual Care.

CONCLUSIONS

Even very severely cognitively impaired and functionally disabled nursing home residents can respond to a systematically implemented behavioral rehabilitation intervention. Their rapid response to this intervention suggests that it is alleviating excess disabilities brought on by care patterns rather than retraining ADL task performance. Residents with dementia benefit from behavioral rehabilitation by becoming more appropriately involved in their care and being less disruptive. However, behavioral rehabilitative care takes considerably more time than usual care.

Feeding difficulty in elderly patients with dementia: confirmatory factor analysis

The latent structure of feeding difficulty in elderly patients with dementia was investigated using multivariate statistical techniques including exploratory and confirmatory factor analysis. A survey design of 345 elderly patients with the diagnosis of dementia using a questionnaire completed by key workers and primary nurses, was used in local psychogeriatric and continuing care of the elderly facilities. Feeding difficulty and nursing intervention were estimated followed by fitting of latent variable models of feeding difficulty to the data using structural equation modelling. Three models of feeding difficulty in elderly patients with dementia, with 2, 3 and 4 factor structures respectively were compared. All three models showed a good fit to the data as assessed by several standard criteria. The 3 and 4 factor models, however, showed significantly better fit than the 2 factor model. The 4 factor model introduced a latent variable of "oral difficulty" with feeding which merits further investigation. This study demonstrates the possibility of developing reliable and validated scales for the assessment of feeding difficulty in elderly patients with dementia.

Improving dressing behavior in cognitively impaired nursing home residents

This study tested the extent to which a behavioral intervention, Strategies to Promote Independence in Dressing (SPID), improved dressing independence among 90 cognitively impaired nursing home residents (average score on Mini Mental Status Exam = 7.35 +/- .69). The effect of SPID on caregiving efficiency, the time required for nursing assistants to use the strategies, was also examined. The results showed improved independence (decrease in assistance) from 6.08 +/- .12 at baseline to 4.93 +/- .19 following 6 intervention weeks. This significant improvement in dressing independence occurred without a clinically relevant increase in caregiver time (less than 1 min). Seventy-five percent of the subjects improved one or more levels of dressing independence, and more than 20% achieved their maximum intervention effect during the first week of treatment.

Cognitive developmental approach to dementia

Systematic observations of people suffering from dementia of the Alzheimer's type (DAT) reveal they regress in behavior and become childlike. These observations have been used to structure clinical research and therapeutic interventions for dementia patients. However, no concise framework explains successful caregiving. Models for care exist but they lack an adequate framework for the long-term care of a person with DAT. This state of the science review describes what is known about cognitive functioning in people with DAT. It examines studies based on cognitive functioning. It also then relates this information to an emerging theory tentatively identified as a "cognitive developmental approach" which may be useful for understanding people with dementia and for predicting caregiver requirements.

The Mokken scaling procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia

Feeding difficulty increases as the condition of dementia progresses. Compensating for this difficulty in feeding is time consuming for lay and professional carers and is the cause of many practical and ethical problems. The current work reports on an analysis by means of Mokken scaling, of the pattern of accumulation of feeding difficulty--described as obstinacy or passivity--in a sample of 182 elderly people with dementia in a psychogeriatric setting. The existence of a cumulative, unidimensional scale was demonstrated which may have some clinical value. Further lines of investigation to validate the scale are suggested.

Feeder position and food and fluid consumed by nursing home residents

In many cultures, eating has both nutritional and social functions. To the elderly it can be a symbolic experience embedded in lifelong patterns and cultural preferences (Kolodny & Malek, 1991). The environment during the mealtime goes beyond the physical into the social arena. A properly balanced diet promotes health, contributes to the prevention of disease and disability, and aids in recovery from illness and accident. Appropriate nutrition throughout the life span is one of the best means of diminishing degenerative changes, thereby increasing longevity (Melkus, 1994; Steffl, 1984). More than 50% of elderly patients admitted to hospitals and nursing facilities suffer from, or are threatened by, malnutrition, either preceding their admission or subsequent to it. Inadequate nutrition extols a high price and may result in impaired immune response, aggravated infection, organ system failure, delayed healing, reduced energy, and impaired mobility (Mikulencak, 1992). In view of the importance of adequate nutrition, the manner of feeding has special significance. The purpose of this study was to explore whether the position of the feeder (standing vs. sitting) has any bearing on the food intake of the elderly who need to be fed.

"I can do it!" Dressing: promoting independence through individualized strategies

Caregivers contribute to loss of functional performance and dependency in cognitively impaired persons when they "do for," that is, dress the person instead of supporting independence in dressing. Persons with dementia have functional reserves that can be activated when caregivers use levels of assistance, standard, and problem-oriented strategies to support the person's cognitive and physical deficits. Use of these strategies requires less than one minute of additional caregiver time and leads to positive outcomes for the person and the caregiver.

The effect of skill training on functional abilities of nursing home residents with dementia

The purpose of this experimental study was to compare the effects of skill training, a traditional stimulation approach, and regular care (control group) on the ability to perform the basic activities of daily living of nursing home residents with dementia. Sixty-three subjects were randomly selected and randomly assigned to the three groups. Ability to perform the basic activities of daily living (ADLs) and progress toward meeting individually set ADL-related goals were measured. Significant differences were found in two of the three measures used. In general, the greatest improvement was found in the skill training group, modest improvement in the simulation group, and decline in the control group.

Development of the refined ADL Assessment Scale for patients with Alzheimer's and related disorders

1. Most activities of daily living (ADL) scales currently available for assessment of the older person's functional level were developed for the physically (not cognitively) impaired individual. 2. The Refined ADL Assessment Scale (RADL) measures three dimensions of functional ability: the components of a given task in sequential order, degree of assistance needed to carry out the task, and the amount of time needed to complete the task. 3. Each of the 14 tasks on the RADL is broken down into its simpler component parts, a process called task analysis. 4. The RADL may be used as a guide to providing assistance with the basic ADLs and to evaluate an individual's improvement with treatment.