The mealtime experience of a cognitively impaired elder: ineffective and effective strategies

How are the mealtime experiences of people in residential aged care facilities informed by policy and best practice guidelines? A scoping review

BACKGROUND

Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impact their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Giddens' (The constitution of society: outline of the theory of structuration, 1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents' mealtime experiences.

METHODS

Using Arksey and O'Malley's (Int J Soc Res Methodol 8:19-32, 2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.

RESULTS

Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.

CONCLUSIONS

Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

How do we provide good mealtime care for people with dementia living in care homes? A systematic review of carer-resident interactions

People with dementia who live in care homes often depend on care home staff for help with eating and drinking. It is essential that care home staff have the skills and support they need to provide good care at mealtimes. Good mealtime care may improve quality of life for residents, and reduce hospital admissions. The aim of this systematic review was to identify good practice in mealtime care for people with dementia living in care homes, by focusing on carer-resident interactions at mealtimes. Robust systematic review methods were followed. Seven databases were searched: AgeLine, BNI, CENTRAL, CINAHL, MEDLINE, PsycINFO and Web of Science. Titles, abstracts, and full texts were screened independently by two reviewers, and study quality was assessed with Joanna Briggs Institute tools. Narrative synthesis was used to analyse quantitative and qualitative evidence in parallel. Data were interrogated to identify thematic categories of carer-resident interaction. The synthesis process was undertaken by one reviewer, and discussed throughout with other reviewers for cross-checking. After title/abstract and full-text screening, 18 studies were included. Some studies assessed mealtime care interventions, others investigated factors contributing to oral intake, whilst others explored the mealtime experience. The synthesis identified four categories of carer-resident interaction important to mealtime care: Social connection, Tailored care, Empowering the resident, and Responding to food refusal. Each of the categories has echoes in related literature, and provides promising directions for future research. They merit further consideration, as new interventions are developed to improve mealtime care for this population.

Development and reliability of the Korean version of the Feeding Abilities Assessment

OBJECTIVE

The purpose of this study is to introduce a standardised assessment tool by verifying the reliability of the translated Korean version of the Feeding Abilities Assessment (K-FAA), which was developed to suit Korean culture.

METHODS

The research subjects were 65 patients with dementia living in nursing homes. The K-FAA was completed by verifying the suitability of translation and reverse translation. The validity of the K-FAA was established through content validity, while its reliability was analysed based on internal consistency reliability for the items, test-retest reliability and inter-rater reliability.

RESULTS

The content validity index determined, based on the assessment of professors, occupational therapists, and nurses, was more than .70. Cronbach's α was more than .929, showing good internal consistency. A test-retest reliability of .884 was derived using Pearson's correlation coefficient (p < .01), and an inter-rater reliability of .800 was derived using the kappa coefficients; intraclass correlation coefficient was .897, which also indicated good reliability.

CONCLUSION

The K-FAA was modified to fit the Korean domestic situation, and this assessment had high reliability. Therefore, K-FAA can evaluate the feeding ability of patients with dementia. Future studies should focus on providing evidence-based data to maintain or supplement the feeding ability of patients with dementia in Korea.

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.

Best intentions or best practice? A case study of the nutritional needs and outcomes of a person with dementia living in a residential aged care home

AIMS

To evaluate the nutritional status and needs of a person with dementia living in an aged care home, including identification of barriers to, and effective strategies for, the provision of person-centred care.

BACKGROUND

Nutrition and hydration care are integral to quality of life for adults with dementia, but there is little research on whether staff knowledge around effective care strategies for residents is translated into optimal care.

DESIGN

Focused ethnographic single-case design.

METHODS

The perspectives of the resident, her prime family member, and six care staff were triangulated through interviews, observation, document audit, and medical file review to investigate the resident's nutrition and hydration status and needs (October 2014-April 2015).

RESULTS

During 3 years in care, this resident had lost weight steadily. Staff appeared attentive but did not maintain a systematic record of body mass index. At meals, staff encouraged eating but used ineffective strategies. Food was not served in ways that facilitated active participation. Eating and drinking were structured as tasks to be completed rather than activities to be enjoyed.

CONCLUSION

This instrumental case study identified a task-oriented, rather than person-centred, approach to nutrition and hydration care, adversely affecting the resident's nutritional health and capability to participate actively.

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.

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

OBJECTIVES

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

DESIGN

A cross-sectional design was used.

SETTING

Five nursing homes in Taiwan.

PARTICIPANTS

Ninety-three residents with dementia were enrolled.

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Cultural perspectives in feeding difficulty in Taiwanese elderly with dementia

OBJECTIVE

To investigate factors related to feeding difficulty that is shown in the interaction between nursing assistants and elderly residents with dementia.

METHODS

Forty-eight residents and 31 nursing assistants were observed during meal times in a congregate dining room of a Taiwanese nursing home specializing in dementia care. Residents' eating behaviors, the dining environment, interactions between the nursing assistant and the residents, and feeding strategies used by nursing assistants were observed. Nutritional data for residents were collected from medical charts. The EdFED Scale #2 and interviews of nursing assistants provided information about feeding difficulty. Interviews also provided data on strategies used to address feeding difficulties.

FINDINGS

The most frequent feeding difficulty was refusal to eat (37.5%). The strategies used by nursing assistants were limited. Nursing assistants stated they needed more training to address feeding difficulty in residents with dementia.

CONCLUSIONS

Future research should be focused on the interface between the residents and nursing assistants who must identify various feeding difficulties and select appropriate interventions.

CLINICAL RELEVANCE

Results might provide information that can be used to develop effective interventions and promote high-quality mealtime care in patients with dementia.

Nutritional issues in long-term care

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.

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.

The Development and Testing of a Questionnaire to Measure Complexity of Nursing Work Performed in Nursing Homes: NCCQ-NH

The quality of care in nursing homes has improved over the last 2 decades; however serious problems persist. Although staffing levels are a primary concern, studies show that ineffective management structures may be a contributing factor to poor quality care. Evidence suggests that the complexity of work performed within the organization is an important consideration in developing effective management structures. The purpose of this article is to describe the development and initial testing of an instrument to measure the complexity of nursing work in nursing homes. A sample of 168 nursing personnel (RNs, LPNs, CNAs) from 7 nursing homes participated in the study. The results of measures to determine the reliability and validity were generally acceptable for a new scale. A modified version of the original scale can be used to provide scientific evidence on which to base the design of management structures in nursing homes.

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

AIMS AND OBJECTIVES

The purposes of this study were to develop a comprehensive feeding skills training programme for nursing assistants and to test the effects of this training programme on their knowledge, attitude and behaviour and the outcome of dementia patients including total eating time, food intake and feeding difficulty.

BACKGROUND

Dementia patients have a high probability of feeding problems that result in a substantial risk of malnutrition. Assisting residents with eating is a major task for nursing assistants and they require better training to provide adequate quality of nutritional care.

DESIGN METHODS

A quasi-experimental study was conducted. Two convenience-chosen dementia-specialized long-term care facilities in North Taiwan were randomly assigned into either a control or a treatment group. Sixty-seven nursing assistants were enrolled (treatment: 31; control: 36). Twenty nursing assistants and the same number of dementia patients were observed during mealtime. The treatment group participated in a feeding skills training programme including three hours of in-service classes and one hour of hands-on training, whereas the control group did not receive any training.

RESULTS

The treatment group had significantly more knowledge (F = 47.7, P < 0.001), more positive attitude (F = 15.75, P = 0.001) and better behaviours (t = 6.0, P < 0.001) than the control group after the intervention. Dementia patients in the treatment group had significantly longer total eating time (t = 2.7, P < 0.05) and higher Edinburgh Feeding Evaluation in Dementia scores (more feeding difficulty) (t = 2.1, P < 0.05) than the control group. There was no significant difference on food intake between the two groups (t = 0.8, P = 0.49).

CONCLUSION

This feeding skills training programme has been found to change nursing assistants' knowledge, attitude, and behaviour as well as increasing the eating time for the dementia patients.

RELEVANCE TO CLINICAL PRACTICE

This study raises attention regarding on-the-job training for nursing assistants. Furthermore, the feeding problems among dementia patients should be further explored as well as the nutritional care.

Feeding and hydration issues for older adults with dementia

All cultures dictate the need to feed the hungry and create rituals for almost every life passage around the consumption of food and beverage. Yet, in old age and among those who cannot advocate for themselves, mealtime is medicalized and demoted to an insignificant event without dignity or regard for individualized needs. Attention must be paid to not only what people eat, but how they eat, and how they are supported in that process. Kayser-Jones summarized the extensive findings of several ethnographic studies in nursing homes by noting the multi-factorial issues involved in delivering excellent care to all residents, especially those lacking an advocate. Her findings exposed how lack of staff education, inadequate staffing and supervision, disregard for personal and cultural preferences, lack of assessment for comorbid health problems, intake of food and fluids, dysphagia, and oral health problems all contributed to malnutrition and dehydration among the residents studied. This seminal set of studies, along with Dr. Kayser-Jones' testimony in US Congressional hearings directly affected the design of federal regulatory protocols to address malnutrition and dehydration. In an attempt to increase the number of staff available to assist at meals, the Centers for Medicare and Medicaid issued a change in regulations on Sept. 26, 2003, allowing reimbursement for staff trained for a total of 8 hours to act as feeding assistants. This change is intended to, "provide more residents with help in eating and drinking and reduce the incidence of unplanned weight loss and dehydration". Although seen as answering some of the staffing ratio issues at meal times,this rule change has been criticized for not addressing the complexities of resident needs at meal times. Although offering food and fluid is time-consuming and requires special knowledge of physiological changes and empathy for persons whose behavior might be objectionable at times, it may be one of the few times during the day that the individual with dementia receives normalized social interaction. Thus, as in the care of all vulnerable persons with dementia, whether at home or in an institution, perhaps the greatest challenge and need is for nurses and other caregivers to provide a social environment that promotes individual dignity and comfort.

Getting the Basics Right: Care Delivery in Nursing Homes

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

From nursing home to hospital and back again: an educational program to improve care for hospitalized nursing home patients

Hospital nurses have little knowledge of the geriatric syndromes and the processes of caregiving in nursing homes. This lack of knowledge is a barrier to continuity of care for patients admitted to hospitals from nursing homes. An educational program, including both classroom and clinical components, was designed to help bridge this gap. A plan for dissemination to other hospital staff was developed by the 15 nurses who participated.

Quality measurement in nursing: an update of where we are now

This article summarizes the findings of the third review of nursing quality measurement literature commissioned by the American Nurses' Association, discusses implications of the current state of the art of nursing measurement, and suggests directions based upon lessons learned from all 3 reviews. Using both computer and hand searching methods, 326 articles describing measurement of nursing care quality were abstracted. Recommendations based on the analysis of Literature include incorporating the Nursing Minimum Data Set into databases; documenting nursing hours and nursing educational preparation; determining appropriate patient outcomes within different settings; continued research identifying nurse-sensitive outcomes; and continued nursing leadership in quality improvement efforts for health care.

The Memorial Meal Mates: a program to improve nutrition in hospitalized older adults

A common problem among older hospitalized patients is inadequate nutritional intake. The Memorial Meal Mates project was developed to address this problem. College-aged volunteers were provided a 3-hour in-service taught by an interdisciplinary team. During a 2-month period, the Memorial Meal Mates fed 34 patients, who were compared with 34 other patients fed by nursing staff. The mean intake of the Meal Mates group was 58.88%, compared with the mean intake of the control group of 32.45%. Patients fed by the volunteers nearly doubled their intake over those fed by nursing staff.

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.

A case study of the death of an older woman in a nursing home: are nursing care practices in compliance with ethical guidelines?

This article presents a case study describing and analyzing ethical issues in the care during the last 11 weeks of life of a 101-year-old nursing home resident. The case presented here is part of a larger ongoing ethnographic study of death and dying in nursing homes. Two nursing care issues with ethical implications are discussed. First, the resident could not eat or drink independently, but she received no assistance with her meals. Second, she remained in a wheelchair for many hours and developed three pressure ulcers on her buttocks. Furthermore, she became tired when sitting in the wheelchair for long periods of time, fell out of the wheelchair, and subsequently was restrained "for her safety." Using selected principles from the International Council of Nurses and the American Nurses Association code for nurses, the resident's care is discussed and recommendations for improving the care of nursing home residents are presented.

Dysphagia among nursing home residents: an assessment and management protocol

The literature suggests that 40% to 60% of nursing home residents have some degree of dysphagia, i.e., difficulty in swallowing. Poorly managed, this can lead to aspiration pneumonia; choking; chronic malnutrition; decreased quality of life; and frustration for residents, family, and staff. This article reviews the nursing literature on dysphagia management and then describes a comprehensive protocol to assess and manage patients with swallowing problems in long term care.

Factors influencing the proportion of food consumed by nursing home residents with dementia

BACKGROUND

Assessment of and interventions for promoting eating in persons with late-stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late-stage dementia.

METHODS

Fifty-three dyads composed of nursing home residents with late-stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure-Modified (IBM-M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO-B).

RESULTS

Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 = .41; F(3,49) = 12.54; P < .001). The quality of the resident-CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not.

CONCLUSIONS

Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late-stage dementia fails to ingest adequate nutrients.