Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis

Eating performance in relation to intake of solid and liquid food in nursing home residents with dementia: A secondary behavioral analysis of mealtime videos

BACKGROUND

Persons with dementia commonly experience low food intake leading to negative nutritional and functional outcomes. While multilevel personal and environmental factors that influence intake are implicated, evidence is lacking on the role of characteristics of dynamic eating performance cycles. An eating performance cycle is defined as the process of getting food from the plate or container, transporting it into the mouth, and chewing and swallowing it.

OBJECTIVE

This study aimed to examine the association between intake and characteristics of eating performance cycles among nursing home residents with dementia.

METHODS

A secondary analysis of 111 mealtime video clips from a nursing home communication training study was conducted. The 111 videos involved 25 residents and 29 staff (N = 42 unique staff-resident dyads) in 9 nursing homes. The Cue Utilization and Engagement in Dementia Mealtime video-coding scheme was used to code the characteristics of eating performance cycles, including eating technique (resident-completed, staff-facilitated), type of food (solid, liquid), duration of each eating performance cycle, and intake outcome (intake, no intake). The Generalized Linear Mixed Model was used to examine the interaction effects of eating technique by type of food, eating technique by duration, and type of food by duration on intake outcome.

RESULTS

Totally 1122 eating performance cycles were coded from 111 video clips. The majority of the cycles (85.7%) resulted in intake. There were significant interactions for eating technique by duration, and type of food by duration. As the duration of the eating performance cycle increased, staff-facilitated cycles resulted in greater odds of intake than resident-completed cycles (OR = 17.80 vs. 2.73); and cycles involving liquid food resulted in greater odds of intake than cycles involving solid food (OR = 15.42 vs. 3.15). Though the interaction between eating technique and type of food was not significant, the odds of intake were greater for resident-completed cycles than for staff-facilitated cycles regardless of the type of food being involved in the cycle (OR = 3.60 for liquid food, OR = 10.69 for solid food).

CONCLUSIONS

The findings pointed out the importance of supporting resident independence in eating performance, providing liquid food when residents struggle with solid food, and provision of longer and continuous facilitation at mealtimes to improve intake. The findings inform the development and implementation of innovative mealtime assistance and staff training to promote eating performance and intake.

Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions

Malnutrition is widespread in older people and represents a major geriatric syndrome with multifactorial etiology and severe consequences for health outcomes and quality of life. The aim of the present paper is to describe current approaches and evidence regarding malnutrition treatment and to highlight relevant knowledge gaps that need to be addressed. Recently published guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) provide a summary of the available evidence and highlight the wide range of different measures that can be taken-from the identification and elimination of potential causes to enteral and parenteral nutrition-depending on the patient's abilities and needs. However, more than half of the recommendations therein are based on expert consensus because of a lack of evidence, and only three are concern patient-centred outcomes. Future research should further clarify the etiology of malnutrition and identify the most relevant causes in order to prevent malnutrition. Based on limited and partly conflicting evidence and the limitations of existing studies, it remains unclear which interventions are most effective in which patient groups, and if specific situations, diseases or etiologies of malnutrition require specific approaches. Patient-relevant outcomes such as functionality and quality of life need more attention, and research methodology should be harmonised to allow for the comparability of studies.

Effective elements of home-delivered meal services to improve energy and protein intake: A systematic review

Home-delivered meal services are an example of a nutritional intervention in the home setting developed to enhance dietary intake and contribute to the independence of especially older adults. There is a lack of evidence about the contribution of specific elements of any home-delivered meal service on the improved outcomes. Therefore, a systematic review was performed to evaluate which elements of home-delivered meal services are effective to improve energy and protein intake, nutritional status, functional outcomes and satisfaction in adults. Pubmed, Embase and Web of Science databases were searched for studies assessing energy and protein intake, nutritional or functional status, or satisfaction of these services. The quality of the studies was assessed using the Quality Criteria Checklist for Primary Research. Of 138 studies meeting the search criteria, 19 were included, none of which met the criteria to be rated as high quality. These studies show that various elements of home-delivered meal services such as Meals on Wheels providing protein-enriched bread or snacks in addition to meals or providing meals and snacks for whole days can improve outcomes such as energy and protein intake and satisfaction. A distinction can be made between services focusing on supporting homebound, essentially healthy, older adults and services aiming at the optimal, nutritional, transmural care for patients at risk for malnutrition. This review shows that various elements of these meal services can improve key outcomes. Following the rising interest and importance of these interventions, there is an urgent need to optimize such services to improve nutritional care at home regarding the increasingly limited time frame of admission in hospitals.

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.

The Challenge of Managing Undernutrition in Older People with Frailty

Many older people with frailty are at risk of malnutrition and poor health, yet there is evidence that improving nutrition and weight loss can reduce frailty. This will become more important as the number of older people with frailty increases worldwide in future. Identifying those at risk is challenging due to the difficulty of reaching and screening those older people most at risk, the large number of nutritional assessment tools used, and the lack of consensus on the criteria to make a diagnosis of malnutrition. The management of older people with or at risk of malnutrition should be multi-modal and multi-disciplinary, and all care staff have an important role in delivering appropriate nutritional advice and support. This paper will highlight a number of practical approaches that clinicians can take to manage malnutrition in older people with frailty in community and acute settings, including environmental changes to enhance mealtime experience, food fortification and supplementation.

Selection bias on intellectual ability in autism research: a cross-sectional review and meta-analysis

Background

Current global estimates suggest the proportion of the population with autism spectrum disorder (ASD) who have intellectual disability (ID) is approximately 50%. Our objective was to ascertain the existence of selection bias due to under-inclusion of populations with ID across all fields of autism research. A sub-goal was to evaluate inconsistencies in reporting of findings.

Methods

This review covers all original research published in 2016 in autism-specific journals with an impact factor greater than 3. Across 301 included studies, 100,245 participants had ASD. A random effects meta-analysis was used to estimate the proportion of participants without ID. Selection bias was defined as where more than 75% of participants did not have ID.

Results

Meta-analysis estimated 94% of all participants identified as being on the autism spectrum in the studies reviewed did not have ID (95% CI 0.91–0.97). Eight out of ten studies demonstrated selection bias against participants with ID. The reporting of participant characteristics was generally poor: information about participants’ intellectual ability was absent in 38% of studies (n = 114). Where there was selection bias on ID, only 31% of studies mentioned lack of generalisability as a limitation.

Conclusions

We found selection bias against ID throughout all fields of autism research. We recommend transparent reporting about ID and strategies for inclusion for this much marginalised group.

Electronic supplementary material

The online version of this article (10.1186/s13229-019-0260-x) contains supplementary material, which is available to authorized users.

Effectiveness of nutritional interventions addressed to elderly persons: umbrella systematic review with meta-analysis

Background

The number of Europeans aged over 65 will double between 2010 and 2060, reaching 30% of the European population. Nutrition is emerging as a key element of healthy life since both obesity and malnutrition are established risk factors for morbidity and disability. The aim of this umbrella review (UR) is to summarize the findings of all current systematic reviews (SRs) and meta-analyzes (MAs) on the effectiveness of nutritional intervention designed to promote healthy aging in older individuals.

Methods

Eligible articles published in English or Italian between January 2000 and May 2016 were identified in six databases. Only studies that analyzed nutritional interventions in the population of 65 years and over, or papers specifically targeting older adults were deemed eligible.

Results

Twenty-eight papers, out of which twenty-five SRs and three MAs, met the inclusion criteria and were included in this umbrella SR. Supplementation with vitamin D and other kind of products was highly effective in preventing falls and fractures. Furthermore, several interventions, ranging from the prescription of supplements to environmental and organizational programs, resulted in an improvement in energy and protein intake, as well as positive weight outcomes. Positive findings were also found for the elderly at risk of malnutrition and for older patients with dementia.

Conclusions

The findings of this UR indicate that the use of a wide range of supplements and environmental and organizational intervention improve a number of anthropometric, nutritional and functional indices in the elderly.

Health promotion interventions for older people living alone: a systematic review

AIMS

The aim of this systematic literature review was to identify health promotion interventions for older people living alone and to describe the effectiveness of these interventions.

METHODS

A literature search was conducted using five databases, including CINAHL, Ovid MEDLINE, PubMed, Cochrane, Scopus, and Web of Science, and this comprehensive literature search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Potentially relevant studies were evaluated and selected by two authors. Studies were assessed based on inclusion criteria. The Standardised Critical Appraisal Tool from Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used to appraise the methodological quality of these studies.

RESULTS

Of the 2852 unique studies identified in the systematic search, the full texts of three studies meeting the inclusion criteria were reviewed. The results showed that the level of physical activity and self-efficacy for physical activity, activities of daily living, food enjoyment, and energy intake increased and leisure engagement decreased with health promotion interventions.

CONCLUSION

The findings of this review indicate that interventions to improve health promotion positively affect the health of older people living alone and enhance their quality of life. There is a need for further research involving multidimensional interventions for older people living alone.

Efficacy of non-pharmacological interventions to treat malnutrition in older persons: A systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL knowledge hub project

INTRODUCTION

We aimed to perform a review of SRs of non-pharmacological interventions in older patients with well-defined malnutrition using relevant outcomes agreed by a broad panel of experts.

METHODS

PubMed, Cochrane, EMBASE, and CINHAL databases were searched for SRs. Primary studies from those SRs were included. Quality assessment was undertaken using Cochrane and GRADE criteria.

RESULTS

Eighteen primary studies from seventeen SRs were included. Eleven RCTs compared oral nutritional supplementation (ONS) with usual care. No beneficial effects of ONS treatment, after performing two meta-analysis in body weight changes (six studies), mean difference: 0.59 (95%CI -0.08, 1.96) kg, and in body mass index changes (two studies), mean difference: 0.31 (95%CI -0.17, 0.79) kg/m2 were found. Neither in MNA scores, muscle strength, activities of daily living, timed Up&Go, quality of life and mortality. Results of other intervention studies (dietary counselling and ONS, ONS combined with exercise, nutrition delivery systems) were inconsistent. The overall quality of the evidence was very low due to risk of bias and small sample size.

CONCLUSIONS

This review has highlighted the lack of high quality evidence to indicate which interventions are effective in treating malnutrition in older people. High quality research studies are urgently needed in this area.

How Widely are Supportive and Flexible Food Service Systems and Mealtime Interventions Used for People in Residential Care Facilities? A Comparison of Dementia-Specific and Nonspecific Facilities

While improved mealtime practices can reduce agitation, improve quality of life, and increase food intake for people in aged care, the degree of implementation of these strategies is unknown. This study describes food service practices in residential aged care facilities, focusing on units caring for people with dementia. An online survey was distributed to residential aged care facilities for completion by the food service manager (n = 2057). Of the 204 responses to the survey, 63 (31%) contained a dementia-specific unit. Most facilities used adaptive equipment (90.2%) and commercial oral nutritional supplements (87.3%). A higher proportion of facilities with a dementia-specific service used high-contrast plates (39.7%) than those without (18.4%). The majority of facilities had residents make their choice for the meal more than 24 h prior to the meal (30.9%). Use of high contrast plates (n = 51, 25%) and molds to reform texture-modified meals (n = 41, 20.1%) were used by one-quarter or less of surveyed facilities. There is a relatively low use of environmental and social strategies to promote food intake and wellbeing in residents, with a focus instead on clinical interventions. Research should focus on strategies to support implementation of interventions to improve the mealtime experience for residents.

Interventions maintaining eating Independence in nursing home residents: a multicentre qualitative study

Background

Despite 32 years of research and 13 reviews published in the field, no intervention can be considered a gold standard for maintaining eating performance among residents with dementia. The study aim was to highlight the interventions derived from tacit knowledge and offered daily in assisting eating by healthcare professionals (HCPs) in nursing homes (NHs).

Method

A multicentre descriptive qualitative study was performed in 2017. Thirteen NHs admitting residents with moderate/severe functional dependence in eating mainly due to dementia, were approached. A purposeful sample of 54 HCPs involved on a daily basis in assisting residents during mealtime were interviewed in 13 focus groups. Data analysis was conducted via qualitative content analysis.

Results

The promotion and maintenance of eating performance for as long as possible is ensured by a set of interventions targeting three levels: (a) environmental, by ‘Ritualising the mealtime experience by creating a controlled stimulated environment’; (b) social, by ‘Structuring effective mealtime social interactions’; and (c) individual, by ‘Individualising eating care’ for each resident.

Conclusions

In NHs, the eating decline is juxtaposed with complex interventions regulated on a daily basis and targeting the environment, the social interactions, and the residents’ needs. Several interventions that emerged as effective, according to the experience of participants, have never been documented before; while others are in contrast to the evidence documented. This suggests the need for further studies in the field; as no conclusions regarding the best interventions have been established to date.

Facilitators and barriers to optimizing eating performance among cognitively impaired older adults: A qualitative study of nursing assistants’ perspectives

Background and Objectives

Cognitively impaired individuals are at increased risk for functional and behavioral difficulties at mealtimes, leading to compromised eating performance, low food and fluid intake, and negative functional and nutritional outcomes. Nursing assistants are the most critical front-line care staff and best positioned to manage the personal and environmental factors that influence resident eating performance. Identifying nursing assistants’ perceptions of barriers and facilitators to engaging residents in eating will provide important experientially based foundation for developing and testing evidence-driven interventions to promote mealtime care.

Methods

A qualitative descriptive study was conducted in three sites: two nursing homes and one hospital gero-psychiatric inpatient unit. Six focus groups were conducted with a purposive sample of 23 nursing assistants who regularly provided mealtime care to residents with cognitive impairment. Interview questions addressed barriers and facilitators at resident, caregiver, environmental (facility), and policy levels in optimizing mealtime care. Audio recordings of focus groups were transcribed and analyzed using qualitative descriptive content analysis. Both barriers and facilitators were organized into a hierarchical taxonomy based on similarities and differences framed by the Social Ecological Model.

Results

The majority of barriers and facilitators were at the caregiver level. Caregiver-level barriers included lack of preparation and training, competing work demands, time pressure, and frustration. Caregiver-level facilitators included caregiver preparation and motivational, technical, informational, and instrumental assistance. Environmental-level barriers and facilitators related to the physical, social, and cultural environment and facility practices. Only barriers to optimizing mealtime care were identified at resident and policy levels.

Conclusions

Nursing assistants identified multilevel barriers as well as a wide range of caregiver and environmental facilitators to optimizing dementia mealtime care. Findings can inform the development and implementation of multifaceted innovative mealtime assistance and staff training programs to promote resident eating performance while fostering person-centered individualized mealtime care practice.

Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care

Background

Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required.

Methods

A mixed methods study conducted between April–November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made.

Results

Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff’s creative mealtime initiatives.

Conclusions

This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0964-3) contains supplementary material, which is available to authorized users.

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.

A contextual identification of home-living older adults' positive mealtime practices: A honeycomb model as a framework for joyful aging and the importance of social factors

In this study, we outlined contextual identifications within positive mealtime practices among home-living older adults in Denmark. We aimed to understand and facilitate optimal dietary intake and to promote well-being for older adults who live at home. We used data from 22 participants, who wrote diary entries and took photos of their meal experiences over a 6-day period. We followed this with in-depth interviews, using the photos as mediators within a photo-elicitation framework. The results revealed that social factors play a major role in positive mealtime practices and that the types of commensal eating vary based on the contextual setting. Furthermore, we found that, in the new generation of older adults, some men have extremely good cooking skills and are interested in contextual food matters. Meeting older adults' needs for adequate nutrition requires in-depth knowledge, including a complex understanding of individual preferences and contextual everyday practices.

Engaging food service providers to change food service practices in aged care facilities

AIM

The present study describes the impact of a novel education program for food service staff from Australian aged care facilities (ACF) to facilitate improvements in food service practices. The purpose was to explore; (i) the impact of the intervention (ii) barriers and facilitators of the program from food service providers' perspectives and (iii) make program planning and practice recommendations.

METHODS

Participants completed pre- and post-program questionnaires, attended two focus groups on program process and impact and 4 months later reported through individual interviews on changes they had implemented. Results were triangulated between the questionnaires, focus groups and interviews and impacts and outcomes identified through directed content analysis.

RESULTS

Thirty senior-level chefs and a cook participated from 27 ACF from Victoria, Australia. Participation impacted on the menu, dining experiences and food service practices. All of the participants were enacting changes in their workplace 4 months later as change agents. A focus on skilling the participants as 'change agents', brokering ongoing peer-support and the celebrity and/or expert status of the facilitators were attributed to the success of the intervention.

CONCLUSIONS

This novel intervention empowered Victorian food service providers to make positive changes in ACF. Further research is required to measure if these self-reported changes are sustainable and relevant to other facilities and to establish the effect on food experience, satisfaction and well-being of residents.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Optimizing nutrition in older people

Older adults are at increased risk of malnutrition, for a variety of physiological and psychological reasons. This has implications for health, quality of life, independence and economic circumstances. Improvements in nutrition are known to bring tangible benefits to older people and many age-related diseases and conditions can be prevented, modulated or ameliorated by good nutrition. However, practical and realistic approaches are required to optimize diet and food intake in older adults. One area where improvements can be made relates to appetite. Encouraging older adults to prepare meals can increase appetite and food intake, and providing opportunities for older adults to eat a wide variety of foods, in company, is a simple strategy to increase food intake. The protein requirement of older adults is subject to controversy and although considered the most satiating macronutrient, it appears that protein does not elicit as great a satiating effect in older adults as it does in younger individuals. This indicates that there is potential to increase protein intake without impacting on overall energy intake. Other areas where simple practical improvements can be made include both packaging of foods that are easy to prepare and the education of older adults on the safe storage and preparation of food. Research into improving the diets and nutritional status of older adults has indicated that many of the strategies can be easily and cost-effectively undertaken.

Prevalence of inadequate micronutrient intakes of Canadian long-term care residents

This study determines the prevalence of inadequate micronutrient intakes consumed by long-term care (LTC) residents. This cross-sectional study was completed in thirty-two LTC homes in four Canadian provinces. Weighed and estimated food and beverage intake were collected over 3 non-consecutive days from 632 randomly selected residents. Nutrient intakes were adjusted for intra-individual variation and compared with the Dietary Reference Intakes. Proportion of participants, stratified by sex and use of modified (MTF) or regular texture foods, with intakes below the Estimated Average Requirement (EAR) or Adequate Intake (AI), were identified. Numbers of participants that met these adequacy values with use of micronutrient supplements was determined. Mean age of males (n 197) was 85·2 (sd 7·6) years and females (n 435) was 87·4 (sd 7·8) years. In all, 33 % consumed MTF; 78·2 % (males) and 76·1 % (females) took at least one micronutrient pill. Participants on a MTF had lower intake for some nutrients (males=4; females=8), but also consumed a few nutrients in larger amounts than regular texture consumers (males=4; females =1). More than 50 % of participants in both sexes and texture groups consumed inadequate amounts of folate, vitamins B6, Ca, Mg and Zn (males only), with >90 % consuming amounts below the EAR/AI for vitamin D, E, K, Mg (males only) and K. Vitamin D supplements resolved inadequate intakes for 50-70 % of participants. High proportions of LTC residents have intakes for nine of twenty nutrients examined below the EAR or AI. Strategies to improve intake specific to these nutrients are needed.

A Systematic Review of Behavioural Interventions Promoting Healthy Eating among Older People

Because eating habits are inseparably linked with people's physical health, effective behaviour interventions are highly demanded to promote healthy eating among older people. The aim of this systematic review was to identify effective diet interventions for older people and provide useful evidence and direction for further research. Three electronic bibliographic databases-PubMed, Scopus and Web of Science Core Collection were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria. English language peer-reviewed journal articles published between 2011 and 2016 were selected for data extraction and quality assessment. Finally, a total of 16 studies were identified. The studies' duration ranged from three weeks to seven years. The majority of studies were carried out in European countries. Seven studies had a moderate quality while the remaining studies were at a less than moderate level. Three dietary educational interventions and all meal service related interventions reported improvements in older people's dietary variety, nutrition status, or other health-related eating behaviours. Multicomponent dietary interventions mainly contributed to the reduction of risk of chronic disease. The results supported that older people could achieve a better dietary quality if they make diet-related changes by receiving either dietary education or healthier meal service. Further high-quality studies are required to promote healthy eating among older people by taking regional diet patterns, advanced information technology, and nudging strategies into account.

The Role of Food Antioxidants, Benefits of Functional Foods, and Influence of Feeding Habits on the Health of the Older Person: An Overview

This overview was directed towards understanding the relationship of brain functions with dietary choices mainly by older humans. This included food color, flavor, and aroma, as they relate to dietary sufficiency or the association of antioxidants with neurodegenerative diseases such as dementia and Alzheimer’s disease. Impairment of olfactory and gustatory function in relation to these diseases was also explored. The role of functional foods was considered as a potential treatment of dementia and Alzheimer’s disease through inhibition of acetylcholinesterase as well as similar treatments based on herbs, spices and antioxidants therein. The importance of antioxidants for maintaining the physiological functions of liver, kidney, digestive system, and prevention of cardiovascular diseases and cancer has also been highlighted. Detailed discussion was focused on health promotion of the older person through the frequency and patterns of dietary intake, and a human ecology framework to estimate adverse risk factors for health. Finally, the role of the food industry, mass media, and apps were explored for today’s new older person generation.

Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

Background

Care homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.

Objectives

To understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.

Methods

Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.

Findings

Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.

Limitations

Findings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.

Conclusions

NHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.

Funding

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

The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial

RATIONALE

Suboptimal nutritional practices in elderly care settings may be resolved by an efficient introduction of nutritional guidelines.

AIMS

To compare two different implementation strategies, external facilitation (EF) and educational outreach visits (EOVs), when introducing nutritional guidelines in nursing homes (NHs), and study the impact on staff performance.

METHODOLOGICAL DESIGN

A quasi-experimental study with baseline and follow-up measurements.

OUTCOME MEASURES

The primary outcome was staff performance as a function of mealtime ambience and food service routines.

INTERVENTIONS/RESEARCH METHODS

The EF strategy was a 1-year, multifaceted intervention that included support, guidance, practice audit and feedback in two NH units. The EOV strategy comprised one-three-hour lecture about nutritional guidelines in two other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Mealtime ambience was evaluated by 47 observations using a structured mealtime instrument. Food service routines were evaluated by 109 food records performed by the staff.

RESULTS

Mealtime ambience was more strongly improved in the EF group than in the EOV group after the implementation. Factors improved were laying a table (p = 0.03), offering a choice of beverage (p = 0.02), the serving of the meal (p = 0.02), interactions between staff and residents (p = 0.02) and less noise from the kitchen (p = 0.01). Food service routines remained unchanged in both groups.

CONCLUSIONS

An EF strategy that included guidance, audit and feedback improved mealtime ambience when nutritional guidelines were introduced in a nursing home setting, whereas food service routines were unchanged by the EF strategy.

Exploring residents' experiences of mealtimes in care homes: A qualitative interview study

Background

Many interventions aim to alleviate well-documented problems of malnutrition in residential care homes and improve residents’ health and wellbeing. Despite some positive findings, little is known about how and why mealtime interventions might be effective, and in particular, what effects residents’ experiences of mealtimes have on health outcomes. The aim of this study was to gain an insight into these experiences and explore some of the issues that may impact on residents’ enjoyment of meals, and resulting health and wellbeing.

Methods

Semi-structured interviews were conducted with eleven residents from four care homes in the South West UK. Thematic analysis was used to derive content and meaning from transcribed interviews. Interviews were supplemented by researcher observations of mealtimes.

Results

The dining experience was a focal point for participants’ broader experiences of residing in a care home. Three themes pertaining to residents’ experiences were identified: (1) Emotional and psychological connections with other residents; (2) managing competing interests with limited resources; and (3) familiarity and routine.

Conclusion

Mealtimes are a mainstay of life in a care home through which residents’ experiences are characterised, exemplified and magnified. Understanding how residents interact with one another, accommodating their preferences and encouraging autonomy may enhance their mealtime experiences. It may also help to ease the transition from independent-living to life in care, which can be particularly stressful for some residents, and improve health and wellbeing over the long-term.

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 use of fortified foods to treat malnutrition among older adults: a systematic review

Purpose

Food fortification with common kitchen ingredients has been suggested to improve nutritional intake. The purpose of this paper was to systematically review the efficacy of food fortification on calorie and protein intake among older adults.

Design/methodology/approach

A systematic search was conducted using Boolean search logic and seven research databases to identify interventions using fortified foods to increase calorie and protein intake among older adults. Ten studies published in English since 1996 were eligible for inclusion. Study quality was evaluated using an adapted Modified Jadad Questionnaire.

Findings

Food fortification was associated with increased calorie intake in eight studies, increased protein intake in five studies, and increased body weight in three studies. However, studies were limited by lack of rigor in methodology and small sample sizes.

Originality/value

Food fortification may improve calorie and protein intake, but results are limited by study weaknesses. Additionally, it is unclear whether improved intake results in improved clinical outcomes.

Goal-Directed Drinking Behaviors Can Be Modified Through Behavioral Mimicry

PURPOSE

This study tested whether behavioral mimicry can alter drinking behavior. It was hypothesized that participants would increase drinking behaviors given increased confederate drinking but not cup touching.

METHODS

Nineteen healthy adults (Mage = 20.32 years) completed 2 picture description tasks; during 1 task, a confederate frequently sipped water (complete drinking gesture), and during the other, the confederate touched her cup but did not drink (partial gesture). Outcome measures included number of drinks per minute, number of cup touches per minute, percentage of time spent drinking, and percentage of time spent touching the cup.

RESULTS

Participants spent more time drinking and had an increased drinking rate during the drinking condition versus the cup-touching condition. For a majority of participants, drinking rate increased during the drinking condition versus baseline. Drinking, but not cup touching, rate also increased given increased confederate cup touching for many.

CONCLUSIONS

Mimicry likely contributes to social modeling of drinking behaviors. This effect appears more robust given a complete target gesture (full drink); however, a partial goal-directed drinking gesture may also yield a mimicked response. Beyond the theoretical implications, these results provide directions for research investigating more naturalistic mechanisms for increasing dietary intake in various patient populations (e.g., individuals with dysphagia).

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia

BACKGROUND

Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake.

OBJECTIVES

To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH).

DESIGN

A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences.

SETTING AND PARTICIPANTS

30 residents living with advanced dementia in 11 U.S. NHs.

MEASUREMENTS

Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale.

INTERVENTION

Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days.

RESULTS

Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8).

CONCLUSION

All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

Quality Indicators of Nutritional Care Practice in Elderly Care

OBJECTIVES

The aim is to explore the effects of antecedent, structural and process quality indicators of nutritional care practice on meal satisfaction and screened nutritional status among older adults in residential care homes.

DESIGN

Data for this Swedish cross-sectional study regarding older adults living in residential care homes were collected by i) a national questionnaire, ii) records from the quality registry Senior Alert, iii) data from an Open Comparison survey of elderly care in 2013/2014. The data represented 1154 individuals in 117 of 290 Swedish municipalities.

MEASUREMENTS

Meal satisfaction (%) and adequate nutritional status, screened by the Mini Nutritional Assessment Short Form (MNA-SF), were the two outcome variables assessed through their association with population density of municipalities and residents' age, together with 12 quality indicators pertaining to structure and process domains in the Donabedian model of care.

RESULTS

Meal satisfaction was associated with rural and urban municipalities, with the structure quality indicators: local food policies, private meal providers, on-site cooking, availability of clinical/community dietitians, food service dietitians, and with the process quality indicators: meal choice, satisfaction surveys, and 'meal councils'. Adequate nutritional status was positively associated with availability of clinical/community dietitians, and energy and nutrient calculated menus, and negatively associated with chilled food production systems.

CONCLUSION

Municipality characteristics and structure quality indicators had the strongest associations with meal satisfaction, and quality indicators with local characteristics emerge as important for meal satisfaction. Nutritional competence appears vital for residents to be well-nourished.

Training Nonnursing Staff to Assist with Nutritional Care Delivery in Nursing Homes: A Cost-Effectiveness Analysis

OBJECTIVES

To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents.

DESIGN

Randomized, controlled trial.

SETTING

Five community NHs.

PARTICIPANTS

Long-stay NH residents with an order for caloric supplementation (N = 122).

INTERVENTION

Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care.

MEASUREMENTS

Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake.

RESULTS

Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance.

CONCLUSION

It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.

Nutrition Recommendations in Elderly and Aging

Maintaining optimal health and well-being in the older adult requires understanding of how physiologic changes influence nutritional status, familiarity with the available validated tools to assess status, identification of factors predisposing older adults to malnutrition, and evidence-based practice regarding the nutritional needs of this age group. Evidence-based guidance on these core practice components is provided to the clinician in this article.

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.

The Effect of Dining Room Physical Environmental Renovations on Person-Centered Care Practice and Residents’ Dining Experiences in Long-Term Care Facilities

This qualitative study evaluated the effect of dining room physical environmental changes on staff practices and residents’ mealtime experiences in two units of a long-term care facility in Edmonton, Canada. Focus groups with staff ( n = 12) and individual interviews with unit managers ( n = 2) were conducted. We also developed and used the Dining Environment Assessment Protocol (DEAP) to conduct a systematic physical environmental evaluation of the dining rooms. Four themes emerged on the key influences of the renovations: (a) supporting independence and autonomy, (b) creating familiarity and enjoyment, (c) providing a place for social experience, and (d) challenges in supporting change. Feedback from the staff and managers provided evidence on the importance of physical environmental features, as well as the integral nature of the role of the physical environment and organizational support to provide person-centered care for residents.

Environmental Strategies to Promote Food Intake in Older Adults: A Narrative Review

Aging is often accompanied by lower intakes of food energy and consequent negative effects on health. To some extent this is due to declines in physiological ability, including the sensory responsiveness to regulate food intake. Fortunately, environmental factors may still influence food intake in older adults. Factors such as social facilitation, modeling, and nutrition knowledge and skills have been shown to stimulate their food intake. While environmental factors such as the eating location, portion size, food presentation, and labeling are known to influence eating behavior, their effectiveness in stimulating food intake in older persons is not well delineated. It is suggested that improving the environmental stimuli that promote food intake is a viable strategy to overcome age-related declines in nutrient intakes. This strategy is so promising that further research is warranted.

Increasing the qualitative understanding of optimal functionality in older adults: a focus group based study

Background

Decreased independence and loss of functional ability are issues regarded as inevitably connected to old age. This ageism may have negative influences on older adults’ beliefs about aging, making it difficult for them to focus on their current ability to maintain a good health. It is therefore important to change focus towards promoting Optimal Functionality (OF). OF is a concept putting the older adult’s perspective on health and function in focus, however, the concept is still under development. Hence, the aim was to extend the concept of optimal functionality in various groups of older adults.

Methods

A qualitative study was conducted based on focus group discussions (FGD). In total 6 FGDs were performed, including 37 older adults from three different groups: group 1) senior athletes, group 2) free living older adults, group 3) older adults living in senior living homes. All data was transcribed verbatim and analyzed following the process of deductive content analysis.

Results

The principal outcome of the analysis was “to function as optimally as you possibly can”, which was perceived as the core of the concept. Further, the concept of OF was described as multifactorial and several new factors could be added to the original model of OF. Additionally the findings of the study support that all three cornerstones comprising OF have to occur simultaneously in order for the older adult to function as optimal as possible.

Conclusions

OF is a multifaceted and subjective concept, which should be individually defined by the older adult. This study further makes evident that older adults as a group are heterogeneous in terms of their preferences and views on health and should thus be approached as such in the health care setting. Therefore it is important to promote an individualized approach as a base when caring for older adults.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0244-z) contains supplementary material, which is available to authorized users.

Improving food intake in persons living with dementia

Persons living with dementia have many health concerns, including poor nutritional states. This narrative review provides an overview of the literature on nutritional status in persons diagnosed with a dementing illness or condition. Poor food intake is a primary mechanism for malnutrition, and there are many reasons why poor food intake occurs, especially in the middle and later stages of the dementing illness. Research suggests a variety of interventions to improve food intake, and thus nutritional status and quality of life, in persons with dementia. For family care partners, education programs have been the focus, while a range of intervention activities have been the focus in residential care, from tableware changes to retraining of self-feeding. It is likely that complex interventions are required to more fully address the issue of poor food intake, and future research needs to focus on diverse components. Specifically, modifying the psychosocial aspects of mealtimes is proposed as a means of improving food intake and quality of life and, to date, is a neglected area of intervention development and research.

Staff views on how to improve mealtimes for elderly people with dementia living at home

Dementia commonly leads to difficulties in performing daily activities, which can also often affect the ability to prepare and eat meals. As a result, formal support to maintain good nutritional intake might be needed, but there is a lack of knowledge concerning how to support older persons with dementia living at home. The aim of this study was to explore and describe staff views on how to improve mealtimes for persons with dementia who are still living at home. A qualitative descriptive study was performed and data were collected during 2011–2012 through four focus group interviews with staff working in the homes of persons with dementia. Data were analyzed using inductive content analysis. The participants described several ways to improve mealtimes for persons with dementia and advocated adjustments facilitating the preservation of the persons’ independence. Finding suitable actions calls for knowledge about the person and his/her individual situation. Proposed actions were enabling meals at home, taking over, and moving meals outside of the home. In addition, it was found that, the types of meals served to these persons should be as familiar to the individual as possible. The results of this study indicate the importance of using a person-centered approach and meeting the individual needs when supporting people with dementia in regards to their meals when living at home. Individualized care in the home may be expensive, however, it is fair to say that people who become malnourished and admitted to hospitals is even more costly. Furthermore, sharing and reflecting experiences and knowledge can assist staff to identify ways to manage complex situations. Therefore, the use of refection should be a part of staff members’ everyday work.

Nutritional Care Needs in Elderly Residents of Long-Term Care Institutions: Potential Implications for Policies

OBJECTIVES

To collect information on actual nutritional intervention requirements in long-term care institutions and on the role of institutional factors in nutritional care.

DESIGN

A cross-sectional analysis of baseline data (collected between September 2011 and September 2013) within the context of a multicenter prospective cohort study.

SETTING

Nineteen long-term care institutions.

PARTICIPANTS

Thirteen hundred and ninety-four resident elderly (age ≥60 years).

MEASUREMENTS

The prevalence of nutritional derangements (MNA-Short Form) and the need to introduce nutritional interventions on the residents.

RESULTS

Prevalence of malnutrition and risk of malnutrition were 35.2% [95%CI, 32.8-37.8] and 52.6% [95%CI, 50.0-55.2], respectively. Malnutrition was more frequent upon admission and in larger institutions (≥50 beds). Overall, 50% of the residents requiring an individualized nutritional care plan (any type) were not receiving it. Oral diet, the use of fluid thickeners and oral nutritional supplements had to be introduced in 306 (22.5%), 201 (15%) and 175 (13%) residents, respectively. The need to implement the oral diet was mainly due to inadequacy of texture according to chewing and swallowing capabilities. In gender and age-adjusted multivariable logistic regression models, nutritional interventions were associated with worse nutritional status (P<0.001 for all). Moreover, while the duration of stay was unrelated to the need for nutritional interventions, we observed that residents living in larger long-term care institutions (≥50 beds) were more likely to require improvement in nutrition care.

CONCLUSIONS

In long-term care elderly residents nutritional derangements are very common, underdiagnosed and undertreated. Nutritional screening should be part of routine care. However, also the systematic involvement of a nutritional care specialist appears to be an urgent need, particularly in larger institutions where the standards of care are likely to be lower.

Should we implement mealtime assistance in the hospital setting? A systematic literature review with meta-analyses

AIMS AND OBJECTIVES

This review aimed to determine the effect of mealtime assistance provided to hospitalised patients (≥65 years) by nurses, trained staff or volunteers on nutritional and anthropometric outcomes.

BACKGROUND

Malnutrition is a critical issue in hospitals with a reported prevalence of 20-50%. Nutritional supplementation has been associated with increased weight gain, improved function and decreased mortality; however, other system approaches including mealtime assistance may also contribute to improving nutritional intake.

DESIGN

A systematic literature review.

METHODS

Six electronic databases (CINAHL Plus, Cochrane Library, ProQuest Nursing and Allied Health Source, Scopus, PsycINFO and MEDLINE) were searched from their inception to August 2014. Inclusion criteria were hospitalised patients ≥65 years, provided mealtime assistance by nurses, volunteers or trained staff. Studies were examined for quality and risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS

From 5458 publications, five studies met the inclusion criteria. Studies were rated neutral and positive according to the Academy of Nutrition and Dietetics Quality Checklist. Adherence to study protocols was not always reported. Meta-analyses demonstrated significantly greater daily energy and protein intake where mealtime assistance was provided. Anthropometric outcomes generally did not differ significantly with mealtime assistance. Observation and sampling bias were noted in several studies.

CONCLUSIONS

There is evidence that mealtime assistance increases daily energy and protein intake in hospitalised patients (≥65 years). More robust research is needed to elucidate whether this strategy may be an effective means of addressing the high prevalence of malnutrition in hospitals.

RELEVANCE TO CLINICAL PRACTICE

The evidence identified suggests that mealtime assistance provided to hospitalised older patients (≥65 years) leads to a statistically significant increase in energy and protein intake. For many patients, this increase in both energy and protein intake will be clinically significant, reducing the gap between requirements and actual intake.

Reducing and managing faecal incontinence in people with advanced dementia who are resident in care homes: protocol for a realist synthesis

INTRODUCTION

Faecal incontinence (FI) is the involuntary loss of liquid or solid stool that is a social or hygienic problem. The prevalence of FI in residents of care homes is high, but it is not an inevitable consequence of old age or dementia. There is good evidence on risk factors, but few studies provide evidence about effective interventions. There is a need to understand how, why, and in what circumstances particular programmes to reduce and manage FI are effective (or not) for people with dementia. The purpose of this review is to identify which (elements of the) interventions could potentially be effective, and examine the barriers and facilitators to the acceptability, uptake and implementation of interventions designed to address FI in people with dementia who are resident in care homes.

METHODS AND ANALYSIS

A realist synthesis approach to review the evidence will be used which will include studies on continence, person-centred care, implementation research in care homes, workforce and research on care home culture. An iterative four-stage approach is planned. Phase 1: development of an initial programme theory or theories that will be 'tested' through a first scoping of the literature and consultation with five stakeholder groups (care home providers, user representatives, academics and practice educators, clinicians with a special interest in FI and continence specialists). Phase 2: a systematic search and analysis of published and unpublished evidence to test and develop the programme theories identified in phase 1. Phase 3: validation of programme theory/ies with a purposive sample of participants from phase 1.

ETHICS AND DISSEMINATION

The overall protocol does not require ethical review. The University research ethics committee will review interviews conducted as part of phase 1 and 3. The final fourth phase will synthesise and develop recommendations for practice and develop testable hypotheses for further research.