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

The impact of long-term care interventions on healthcare utilisation among older persons: a scoping review of reviews

BACKGROUND

As the ageing population grows, the demand for long-term care (LTC) services will rise, concurrently amplifying healthcare utilisation. This review aims to examine and consolidate information on LTC interventions that influence healthcare utilisation among older persons.

METHODS

A scoping review was performed through a systematic search in PubMed, EBSCO CINAHL, EBM Reviews - Cochrane Database of Systematic Reviews, Embase, APA PsycInfo, EBM Reviews - Health Technology Assessment, and EBM Reviews - NHS Economic Evaluation Database. Systematic reviews with meta-analyses published between 1 January 2010 and 2 June 2022 among older persons aged 60 and above were included. The characteristics of LTC interventions were mapped to the World Health Organization (WHO) Healthy Ageing Framework. The effect sizes of healthcare utilisations for LTC interventions were recalculated using a random-effects model. The methodological quality was assessed with the AMSTAR-2 checklist, while the quality of evidence for each association was evaluated using GRADE.

RESULTS

Thirty-seven meta-analyses were included. The most prominent domain of the healthy ageing framework was managing chronic conditions. One hundred twelve associations between various LTC interventions and healthcare utilisations were identified, with 22 associations impacting healthcare utilisation. Four interventions were supported by suggestive or convincing evidence. Preventive home visits were found to reduce hospital admission (OR: 0.73, 95% CI: 0.59, 0.91, p = 0.005), caregiver integration during discharge planning (OR: 0.68, 95% CI: 0.57, 0.81, p < 0.001), and continuity of care (OR: 0.76, 95% CI: 0.61, 0.95, p = 0.018) reduced hospital readmission, and perioperative geriatric interventions reduced the length of hospital stay (MD: -1.50, 95% CI: -2.24, -0.76, p < 0.001). None of the associations impacted emergency department visits, medication use, and primary care utilisations with convincing evidence. Most reviews received low methodological quality.

CONCLUSION

The findings suggest that LTC interventions could benefit from transitioning to a community-based setting involving a multidisciplinary team, including carers. The spectrum of services should incorporate a comprehensive assessment to ensure continuous care.

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

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

An ethnography of mealtime care for people living with dementia in care homes

Many people living with dementia have difficulties at mealtimes, which can result in serious complications for physical and mental health, leading to hospital admissions and even death. However, current training in mealtime care for staff working with this population has been found to be poorly reported, with variable effectiveness. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to explore current practice in mealtime care for this population, identify good practice, and understand the factors influencing mealtime care. Approximately 28 h of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care staff and residents living with dementia. Twenty-five semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. A constant comparative approach was taken, to probe emergent findings and explore topics in greater depth. Key thematic categories were identified, including: tensions in mealtime care; the symbolic nature of mealtime care; navigating tensions via a person-centred approach; contextual constraints on mealtime care; and teamwork in mealtime care. The findings indicated that a person-centred approach helps carers to find the right balance between apparently competing priorities, and teamwork is instrumental in overcoming contextual constraints. This evidence has contributed to development of a training intervention for care home staff. Future research should investigate the feasibility of mealtime care training in care homes.

Nutritional Status of the Elderly Residing in a 24-Hour Medical Care Facility After Nutritional Intervention

Malnutrition is a significant issue among elderly individuals in 24-hour care facilities, leading to increased morbidity. The aim of the study was to compare the nutritional status before and after nutritional intervention based on selected indicators of nutritional status among residents of a 24-hour care institution. The study included a group of 104 people aged 65 to 97 years. Nutritional status was assessed before and after the nutritional intervention based on indicators: levels of prealbumin, albumin, transferrin, total lymphocyte count, BMI, and MNA scale. The nutritional intervention consisted of administering oral nutritional supplements (ONS) to patients, regardless of nutritional status. The method of retrospective analysis of patients' medical records was used. Statistical analysis was performed using IBM SPSS Statistics 24 for Windows. Improvements in nutritional status occurred among patients with malnutrition based on MNA and prealbumin indices, and in groups of patients with moderate or mild malnutrition as determined by transferrin, prealbumin and albumin. The mean levels of nutritional indices significantly increased: MNA (p = .001), BMI (p = .001), prealbumin (p = .001), and albumin (p < .001). The use of ONS resulted in better nutritional status parameters based on MNA, albumin and prealbumin. These indices may be predictors of reducing the risk of various disorders among the elderly.

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study

Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.

Exploring Whether Weight-Related Cues Affect Food Intake in Older Adults with Dementia

Purpose

Past research has shown that exposure to the image of a slim person reduces food consumption among young adults. However, it remains unknown whether this paradigm could be adapted and applied to increase food intake among older adults with dementia by exposing them to the image of a higher-weight person to mitigate weight loss and malnutrition. The present study explored whether weight-related visual cues affect the amount of food consumed by older adults with dementia.

Participants and Methods

In the experiment, twenty-one elderly people with dementia living in a nursing home were visually exposed to one of four conditions (a cartoon image of a normal-weight chef, a higher-weight chef, a flower or no image) during real-life daily lunch situations over the course of four weeks, during which each condition was presented for one week.

Results

Results demonstrate that participants finished their meals more frequently when they were exposed to the image of the higher-weight chef than when they were not exposed to any images.

Conclusion

These results suggest that exposure to a cartoon chef character representing a stereotyped social group related to body weight activates the stereotype and increases stereotype-consistent behavior in older adults with dementia. The present findings will contribute to understanding the effect of visual information on eating behavior and to designing eating environments which facilitate sufficient nutrition intake among older adults with dementia.

Prospective, observational study of the impact of finger food on the quality of nutrition evaluated by the simple evaluation of food intake (SEFI) in nursing home residents

INTRODUCTION

Finger food is a type of meal that can be eaten without cutlery, and may, therefore, be easier to consume for patients with cognitive disorders. The objective of this study was to assess whether finger food increased the quantity of food ingested among older nursing home residents. The secondary objectives were to evaluate satisfaction after meals and costs associated with the meals.

METHODS

This was a single-center prospective study conducted on paired observations, comparing food intake observed during three finger food meals vs. three "control" meals (standard meals), for the same residents, in a public nursing home, from 21 April to 18 June 2021.

RESULTS

A total of 266 meals were evaluated for 50 residents. The mean intake (simple evaluation of food intake) score was 40.7 ± 1.7 out of 50 with finger food, and 39.0 ± 1.5 for standard meals. Finger food was associated with a higher probability of an intake score ≥ 40 (odds ratio [OR] 1.91 (95% CI 1.15-3.18; p = 0.01). The difference in satisfaction scores following the meals did not reach statistical significance: 3.86 (SD 1.19) vs. 3.69 (SD 1.11) for the finger food and standard meals, respectively; p = 0.2. Finger foods had an excess cost of 49% compared to a standard meal.

CONCLUSION

The occasional or seasonal (rather than systematic) use of these meals seems to be a valid option to reintroduce novelty and pleasure into the residents' diet. However, potential adopters should be aware that the finger food meals were 49% more expensive than standard meals.

Too low protein and energy intake in nursing homes residents

OBJECTIVES

An optimal diet contributes to reducing malnutrition prevalence in the nursing home population. For this population, recommended daily intakes are ≥1.0 g protein/kg body weight and ≥27 energy kcal/kg body weight. The aim of this study was to identify the protein and energy intake of nursing home residents and to assess groups at increased risk for low intake.

METHODS

Cross-sectional data regarding food intake was collected by three-day observations in 189 residents (aged ≥65 y, mean age 85.0 y) of five different nursing homes. Linear mixed models were used to examine associations of protein and energy intake as dependent variables with demographic and disease-related problems as determinants. Results were adjusted for age, sex, and mobility levels and stratified by a protein/energy-enriched diet (P/E+).

RESULTS

The daily protein intake of the residents was 0.80 (SD 0.22) g/kg body weight, with 84.7% having an intake below the recommended daily 1 g/kg body weight. Mean daily energy intake was 20.7 (SD 6.1) kcal/kg body weight, with 85.2% having an intake below recommendation. Protein/energy intake was higher in the P/E+ group compared with standard diet: 0.92 (SD 0.23) versus 0.74 (SD 0.19) g/kg body weight, and 23.9 (SD 6.1) versus 19.1 (SD 5.4) kcal/kg body weight, respectively. The oldest age groups (>85 y), chair-bound residents, women, and residents having difficulties with chewing, dysphagia, a reported decreased food intake, or a decreased appetite were at a higher risk for a low protein/energy intake.

CONCLUSION

Nearly all nursing home residents were at increased risk for not meeting the minimum protein/energy requirements. Intakes should, on average, be increased with ≥15 g protein and ≥520 kcal to reach the minimum intake targets. Although using a P/E+ diet was associated with higher intakes, even these residents had intakes below the requirements.

COVID-19 as an Independent Risk Factor for Weight Loss in Older Adults Living in Nursing Homes

INTRODUCTION

In nursing homes, where residents are at elevated risk for malnutrition, the specific additive effect of the coronavirus disease 2019 (COVID-19) on weight loss has not yet been adequately evaluated. This study aimed to determine the factors independently associated with weight loss in nursing home residents who survived the first wave of the COVID-19 pandemic, whether they have contracted COVID-19 or not.

METHODS

This research was a retrospective study conducted in three nursing homes. Residents who survived the first French COVID-19 lockdown (March to May 2020) were included, provided their weight records were available. Baseline data included the body mass index (BMI), capacity to self-feed, need for texture-modified food, disability, and legal guardianship status. The diagnosis of COVID-19 was based on the results of a positive reverse transcriptase-polymerase chain reaction test. Univariate and multivariate logistic regression analyses were used to investigate associations between resident characteristics, COVID-19 status, and at least 5% weight loss.

RESULTS

Of the 316 included residents (72% female, mean age of 88 years, 48% severely disabled, and 38% under legal guardianship), 111 (35%) contracted COVID-19 and 102 (32%) lost at least 5% of their body weight. No difference was observed between the baseline characteristics of residents subsequently affected or unaffected by COVID-19. In the univariate analysis, old age, severe disability, texture-modified food, the need for close mealtime supervision, and COVID-19 were significantly associated with at least 5% weight loss. In the multivariate logistic regression analysis, COVID-19 (p = 0.02) and the need for close mealtime supervision (p = 0.02) were associated with weight loss in a model that also included age, BMI, texture-modified food, disability, and nursing home.

CONCLUSION

For nursing home residents, COVID-19 was an independent risk factor for weight loss. Weight loss was most common in residents needing close mealtime supervision, suggesting that organizational issues may have affected the quality of the nutritional care provided during the lockdown.

HOMEFOOD randomized trial-beneficial effects of 6-month nutrition therapy on body weight and physical function in older adults at risk for malnutrition after hospital discharge

BACKGROUND/OBJECTIVES

Malnutrition is common among older adults. Dietary intervention studies in older adults aiming to improve anthropometrics measures and physical function have been inconsistent. We aimed to investigate the effects of nutrition therapy in combination with home delivered meals and oral nutritional supplements (ONS) in community-dwelling older adults discharged from hospital.

METHODS

A total of 106 participants (>65 years) were randomized into the intervention group (n = 53) and into the control group (n = 53). The intervention group received individual nutrition therapy (five in person visits and three phone calls) and freely delivered energy- and protein- rich foods, while the control group received standard care. Dietary intake, anthropometrics, and short physical performance battery (SPPB) were assessed at baseline and at endpoint.

RESULTS

Energy intake at baseline was similar in both groups (~1500 kcal at the hospital) but there was a significant increase in energy intake and body weight in the intervention group (+919 kcal/day and 1.7 kg, P < 0.001 in both cases) during the study period, compared to a significant decrease in both measures among controls (-815 kcal/day and -3.5 kg, P < 0.001 in both cases). SPPB score increased significantly in the intervention group while no changes were observed among controls.

CONCLUSIONS

Most Icelandic older adults experience substantial weight loss after hospital discharge when receiving current standard care. However, a 6-month multi-component nutrition therapy, provided by a clinical nutritionist in combination with freely delivered supplemental energy- and protein-dense foods has beneficial effects on body weight, physical function, and nutritional status.

STUDY REGISTRATION

This study was registered at ClinicalTrials.gov ( NCT03995303 ).

'After mealtime is before mealtime' - an ethnographic exploration of nursing home residents' practices of dealing with meal requirements

BACKGROUND

In nursing homes, food is part of the care provided to residents, causing it to be strictly organised within the institutional framework. Moreover, once food has been integrated into the institutional logic, structural and economic aspects regarding organisation of food and eating may dictate individual and social needs, as a theoretical perspective informed by Goffman's notion of the 'total social institution' suggests. This paper describes nursing home residents' practices of dealing with meal requirements in two Austrian nursing homes, to understand how food integrates into the daily routine and how the institutional setting influences the social and material arrangement of food.

METHODS

An ethnographic design was chosen to gain an in-depth understanding. Two urban nursing homes were studied over 21 months (approx. 800 h of participant observation and ethnographic interviews collected). Data analysis took place iteratively, following Grounded Theory strategies.

RESULTS

As the thick descriptions resulting from this procedure show, observing everyday practices of eating in nursing homes reveals complex dimensions of residents being subject to institutional logics, and also demonstrates that residents develop elaborate strategies to deal with the institutional circumstances.

CONCLUSION

A better understanding of the resulting tensions between the restrictions of living in a formal organisation and the agencies of residents described, may contribute to better understanding the effects of structural constraints and to designing more flexible processes.

Chinese expert consensus on prevention and intervention for the elderly with malnutrition (2022)

Malnutrition is a state of altered body composition and body cell mass due to inadequate intake or utilization of energy or nutrients, leading to physical and mental dysfunction and impaired clinical outcomes. As one of the most common geriatric syndromes, malnutrition in the elderly is a significant risk factor for poor clinical outcomes, causing a massive burden on medical resources and society. The risk factors for malnutrition in the elderly are diverse and include demographics, chronic diseases, and psychosocial factors. Presently, recommendations for the prevention and intervention of malnutrition in the elderly are not clear or consistent in China. This consensus is based on the latest global evidence and multiregional clinical experience in China, which aims to standardize the prevention and intervention of malnutrition in the elderly in China and improve the efficacy of clinical practice and the prognosis of elderly patients.

Nutritional Management in Adult Patients With Dysphagia: Position Paper From Japanese Working Group on Integrated Nutrition for Dysphagic People

This position paper prepared by the Japanese Working Group on Integrated Nutrition for Dysphagic People (JWIND) aims to summarize the need for nutritional management in adult patients with dysphagia, the issues that nutrition professionals should address, and the promising approaches as well as to propose a vision for the future of nutritional care for adult patients with dysphagia. JWIND is a joint certification system recognized by the Japan Dietetic Association and the Japanese Society of Dysphagia Rehabilitation; its members are mostly experts known as "Certified Specialist of Registered Dietitian for Dysphagia Rehabilitation." Malnutrition and dysphagia are associated with each other. Therefore, malnutrition detection and intervention are essential for patients with dysphagia. However, evidence on the usefulness nutritional assessment and intervention to ensure appropriate nutritional care remains insufficient. Here, we present current knowledge of the relationship between primary diseases causing dysphagia and malnutrition, the indicators used for nutritional assessment, and nutritional interventions such as texture-modified diet (TMD) quality improvement, oral nutritional supplementation, and comprehensive intervention. We also discuss the current status and issues in nutritional care for adult patients with dysphagia. Furthermore, we have proposed measures that nutrition professionals should consider based on 3 perspectives: nutritional assessment, TMD, and nutritional intervention. Individualized and specialized nutritional management by registered dietitians (RDs) through appropriate assessment of the nutritional status of adult patients with dysphagia is needed. To maintain and improve swallowing function and nutritional status, RDs should intervene from the state of risk or early dysphagia onset, providing individualized care per their expertise as part of a multidisciplinary team. However, systematic clinical practice and research regarding the association of nutrition with dysphagia are currently insufficient. Therefore, further clinical practice and evidence building, including the verification of the efficacy on nutritional support through intervention research, are needed.

Mealtime interventions and their outcomes in care homes for older people considering the five aspects meal model: An integrative review

Mealtimes are important events in care homes for physical and social well-being. However, residents usually have little input concerning meal timings, what food is offered, and how it is served. This integrative review explored mealtime interventions and their outcomes in care homes related to the Five Aspects Meal Model (FAMM). Research articles published 2010-2021 were searched for in ASSIA, CINAHL, PsycINFO, PubMed, and SveMed+ and resulted in 13 articles focusing on interventions. The analysis was based on the aspects of FAMM: room, meeting, product, management control system, and atmosphere. The result shows that even though interventions specifically focused on one aspect, they often evaluated outcomes related to several aspects. Different aspects can work together to foster effective mealtimes. FAMM eased to visualise the usefulness of mealtime interventions from a broad perspective and can be a useful tool for assessing and improving mealtime situations in clinical practice.

Exploring Meal Provision and Mealtime Challenges for Aged Care Residents Consuming Texture-Modified Diets: A Mixed Methods Study

Dysphagia has become more prevalent with age. Thus, the demand for texture-modified diets (TMDs) has increased. While the nutritional perspectives have been studied, the provision of TMDs and mealtime practice has received less attention. This study aimed to explore the TMD provision and mealtime challenges of residents requiring TMDs in aged care facilities. The study was conducted across five aged care facilities using a mixed methods design involving 14 TMD menu audits by a foodservice dietitian, 15 mealtime observations, and semi-structured interviews with residents and staff (n = 18). TMD menus failed to meet all nutrition requirements and foodservice and clinical standards based on the dietitian NZ foodservice and nutrition audit tool. A content analysis offered three main themes: (1) Foodservice production. Inconsistent quality and meal portions were observed. The variety, choice, and portion size of TMDs required improvement based on the residents’ preferences; (2) Serving procedures. There was a lack of standardisation of meal distribution and feeding assistance; and (3) Dining environment. The dining room set-up varied across facilities, and residents expressed different preferences towards the dining environment. There is a need to improve staff awareness of mealtime consistency and optimise feeding assistance. The dining environment should be individualised to accommodate residents’ psychosocial needs. Standardised policies and continuous training can facilitate quality mealtime implementation.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

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.

Visual Modeling: A Socialization-Based Intervention to Improve Nutritional Intake Among Nursing Home Residents

Purpose Malnutrition is a widespread, dangerous, and costly condition among institutionalized older adults and can be both a contributor to and consequence of dysphagia for individuals with cognitive impairment. However, interventions to maximize intake in individuals with dementia are limited and frequently problematic, with negative implications for independence and quality of life. The goal of this study was to examine a novel, socialization-grounded intervention based on visual modeling, utilizing the theoretical underpinnings of motor resonance and mimicry. Method To examine the impact of environment on intake, data were collected from four nursing home residents (M _age = 83.5 years, SD = 4.2; three women) with dementia. Weight of food and liquid intake was measured across 15 meals and three different mealtime conditions: the "baseline condition" in which the individual ate alone, the "watch condition" in which the individual ate in the company of a "mealtime buddy," and the "eat" condition in which the individual consumed a meal while the "mealtime buddy" did the same. Results Data visualization supported a weak functional relation between eating environment and amount of intake consumed across participants. Log response ratio estimates suggested a trend for increased weight of food consumed during the eat condition as compared to baseline and the eat condition as compared to the watch condition for some participants. Conclusions These results preliminarily support the benefit of a visual model for increased consumption in some individuals with dementia. The presence and magnitude of the effect across conditions varied based on individual-level factors, such as cognitive status, which has implications for implementation. Overall, this study provides initial proof of concept regarding the use of visual modeling as an intervention approach, laying the foundation for larger scale future studies.

Effects of a Multifaceted Intervention Program on the Eating Ability of Nursing Home Residents

Oropharyngeal dysphagia is a common problem for nursing home residents that leads to aspiration pneumonia and malnutrition. Musculature surrounding head and neck and tongue strength are crucial for safe and efficient oropharyngeal swallowing. Oral hygiene facilitates the smooth swallowing. The aim of this study was thus to investigate the effects of a multifaceted intervention program which combines the interactive oral activities, tongue strength training and oral cleaning procedure on the eating ability of nursing home residents. A sequential, multiple time series, single-group quasi-experimental research design was used, and 41 residents were recruited to participate in this study. The study was divided into three phases, each lasting two months. In phase 1, the participants were conducting their usual activities, except that the outcome variables were measured on five occasions to obtain baseline data. Phase 2 was a two-month washout period, and phase 3 was the intervention period. Thirty-six residents completed phase 1, and 34 residents completed the phase 3 intervention period. The eight-week phase 3 intervention program comprised three sessions per day, conducted seven days a week, with each session lasting 15–20 min. Outcome variables were measured at weeks 0, 2, 4, 6, and 8 in phases 1 and 3 to evaluate the feasibility of the program. Following the intervention program, controlling for baseline differences, the patients’ tongue strength, food consumption, mealtime duration, oral health, and dysphagia severity were significantly improved in phase 3 relative to phase 1. These improvements lasted through to at least 2 months posttest. The study illustrates that this multifaceted intervention program may be an effective approach for improving the eating ability of nursing home residents.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A systematic review of qualitative research.

DATA SOURCES

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

REVIEW METHODS

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

FINDINGS

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

CONCLUSIONS

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

Interventions to optimise nutrition in older people in hospitals and long-term care: Umbrella review

Background

Inpatients have a high need for protein‐energy intake because of increased physical stress metabolism due to illnesses. Protein‐energy undernutrition in older patients increases the risk of complications such as falls, pressure ulcers and even death. An overview of effective interventions addressing this complex issue of malnutrition in older people is missing.

Aims

To give an overview of effective interventions to optimise nutrition in older people in hospitals and long‐term care.

Design

An umbrella review, according to the Joanna Briggs Institute and PRISMA statement, was conducted in April 2020.

Methods

A systematic search of publications from 2010 until 2020 was conducted in CINAHL, PubMed and Cochrane Database. Included were studies reporting nutrition interventions that involved nurses or the interprofessional team in optimising older hospitalised people's nutrition. Excluded were studies investigating the effects of parenteral nutrition, certain food supplements or tube feeding and research from intensive, community or palliative care. Components of interventions were classified according to the intervention Nutrition management: Patients’ assistance, patients’ instruction, foodservice, environment for meals and nutrient‐dense snacks.

Findings

Included were 13 reviews from 19 countries of the continents Asia, Australia, Europe and North America from hospitals and long‐term care settings. An interprofessional food promoting culture, including staff training as part of a multi‐component measure, has shown to be a successful element in implementing activities of Nutrition Management.

Conclusion

Several studies synthesised that optimising nutrition in older people in hospitals and long‐term care is achievable. Interventions were effective if—on a meta‐level—staff training was addressed as part of a multi‐component measure to reach an interprofessional food promoting culture.

Implications for practice

Interventions to optimise older people's nutrition have to consider an interprofessional food promoting culture, including staff training about the importance of nutrition, patients’ assistance and an appropriate environment for meals.

An appealing meal: Creating conditions for older persons' mealtimes - a focus group study with healthcare professionals

BACKGROUND

Healthcare professionals' knowledge and attitudes may have an impact on older persons' nutritional status. Therefore, it is important to explore different healthcare professionals' perspectives on older persons' meals.

AIM

The aim of this study was to describe healthcare professionals' understanding of and views on the mealtime experience of older persons in municipal care.

METHODS

Seven focus group discussions with various healthcare professionals (nurse assistants, registered nurses and occupational therapists) (n = 52) working in nursing homes and/or home care for older persons were conducted and analysed using interpretive description. The COREQ checklist was used for reporting the findings.

RESULTS

The results revealed a striving to create conditions for an appealing meal, regardless of profession. This overall theme, 'An appealing meal - creating conditions for older persons' mealtimes', consisted of four sub-themes: 'Food is crucial', 'The mealtime as a social interaction', 'Identifying the individual older person's needs' and 'Integrating different perspectives of meal-related situations among the team'.

CONCLUSION

The findings show that the different professionals strive to prioritise meals in the everyday care of older persons, but at same time there is a lack of a common view on how to prioritise meal-related issues. This indicates that the care may be fragmented, being based on each professional's duties and interpretation of responsibility for older persons' meals, rather than constituting comprehensive integrated person-centred care provided by a multidisciplinary team.

RELEVANCE TO CLINICAL PRACTICE

To enhance older persons' mealtimes, we need to map how mealtimes are valued and implemented in clinical practice and approached in healthcare professionals' education. Education on older person's nutritional needs should be team-based, and not focus on the perspective of a single profession.

Sharing meals: promising nutritional interventions for primary health care including nursing students and elderly people

Background

The risk of malnutrition among elderly people is high and living alone increases the risk. As the number of older persons living alone is expected to increase due to the demographic development of an increasing older population, more knowledge about low-cost, sustainable nutritional interventions is needed. The purpose of this study was to investigate how nursing students can be a resource in the nutritional care of older persons living alone by sharing weekly meals.

Methods

Twenty-three nursing students and 23 elderly people who lived alone and received home nursing care participated in the project period of 9 weeks and shared 1–2 weekly meals. Shortly after the study period, 13 students and 4 elderly persons were interviewed in individual, face-to-face, semi-structured interviews. The questions included their experiences, the perceived impact of sharing meals, and facilitators and barriers of such meal interventions. The interview material was transcribed and analyzed using qualitative content analysis as described by Graneheim and Lundman.

Results

Our study found that both nursing students and older persons expressed positive experiences from sharing meals. Nursing students with some nutritional knowledge can provide a useful, sustainable supplement to the home-care nursing staff’s limited resources and time. Improvements were found, including preparation of ready meals and the meal environment, different facilitators and barriers of the meal experience, and the possible positive impact on the elderly persons’ nutritional status, which affects meal enjoyment, appetite, food intake and weight.

Conclusion

During their practical placement in the community, nursing students can provide a useful contribution to the nutritional care of elderly persons who are at nutritional risk living alone at home by the intervention of sharing a meal together. This is a low-cost supplement to other primary health-care measures that can affect both nutritional status and adjust the appropriate care for patients. This study demonstrates a small contribution to the complex nutritional care literature based on the growing elderly population in home care and the nursing student as a valuable resource for the multidisciplinary team approach necessary to meet this challenge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-021-00412-8.

High Frequency Protein-Rich Meal Service to Promote Protein Distribution to Stimulate Muscle Function in Preoperative Patients

Apart from meeting daily protein requirements, an even distribution of protein consumption is proposed instrumental to optimizing protein muscle synthesis and preserving muscle mass. We assessed whether a high frequency protein-rich meal service for three weeks contributes to an even daily protein distribution and a higher muscle function in pre-operative patients. This study was a post-hoc analysis of a randomized controlled trial (RCT) in 102 patients. The intervention comprised six protein-rich dishes per day. Daily protein distribution was evaluated by a three-day food diary and muscle function by handgrip strength before and after the intervention. Protein intake was significantly higher in the intervention group at the in-between meals in the morning (7 ± 2 grams (g) vs. 2 ± 3 g, p < 0.05) and afternoon (8 ± 3 g vs. 2 ± 3 g, p < 0.05). Participants who consumed 20 g protein for at least two meals had a significantly higher handgrip strength compared to participants who did not. A high frequency protein-rich meal service is an effective strategy to optimize an even protein distribution across meals throughout the day. Home-delivered meal services can be optimized by offering more protein-rich options such as dairy or protein supplementation at breakfast, lunch and prior to sleep for a better protein distribution.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

DATA EXTRACTION

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

DATA ANALYSIS

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

RESULTS

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

CONCLUSION

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

Effect of communal dining and dining room enhancement interventions on nutritional, clinical and functional outcomes of patients in acute and sub-acute hospital, rehabilitation and aged-care settings: A systematic review

AIMS

This review aimed to synthesise evidence on the impact of communal dining and/or dining room enhancement interventions on nutritional, clinical and functional outcomes of patients in hospital (acute or subacute), rehabilitation and residential aged-care facility settings.

METHODS

Five electronic databases were searched in March 2020. Included studies considered the impact of communal dining and/or dining room enhancements on outcomes related to malnutrition in hospital (acute or subacute), rehabilitation and residential aged care facility settings. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality checklist. Overall quality was assessed using GRADEpro software. Outcome data were combined narratively for communal dining and dining room enhancements respectively.

RESULTS

Eighteen articles from 17 unique studies were identified. Of these studies, one was a randomised control trial (moderate quality) and 16 were observational studies (all low quality). Communal dining interventions (four studies, n = 490) were associated with greater energy and protein intake and higher measures of quality of life than non-communal mealtime settings. Dining room enhancement interventions (14 studies, n = 912), overall, contributed to increased intake of food, energy, protein and fluid.

CONCLUSIONS

Results indicate that communal dining and/or dining room enhancement has a positive impact on several outcomes of interest, however, most available evidence is of low quality. Therefore, there is a need for further large-scale, well-designed experimental studies to assess the potential impacts of these interventions.

Interventions to Support Older People's Involvement in Activities Related to Meals. A Systematic Review

The objective of this systematic review is to assess whether old people should be actively involved in activities related to meals to support quality of life, nutritional status and functional abilities related to meals. Two electronic databases Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness were searched, supported by PubMed citation, snowball searches. Eleven primary studies were included. The quality was low. No studies assessed the effect on health-related quality of life. Three types of interventions to support activities related to meals were identified: Meal-related activities to facilitate improved autonomy seemed to overall improve nutritional intake, physical and social function related to meals, plus mealtime coping. Interventions of encouragement and reinforcement by staff to facilitate independence in eating seemed to have beneficial effect on nutritional intake and physical function related to meals. Interventions using food preparation and cooking to support participation seemed to have beneficial effects on social function related to meals and mealtime coping. There is an urgent need for good quality, adequately powered studies in this area and among old people in all health care settings.

Fidelity challenges while implementing an intervention aimed at increasing eating performance among nursing home residents with cognitive decline: A multicentre, qualitative descriptive study design

AIMS AND OBJECTIVES

To increase the knowledge on fidelity challenges in intervention studies promoting eating independence in residents with cognitive decline living in nursing homes (NHs).

BACKGROUND

A few studies have documented to date factors affecting fidelity in intervention studies performed in NH settings. Moreover, fidelity issues in intervention studies aimed at promoting eating independence among NH residents with cognitive decline have not been studied to date.

DESIGN

A hybrid study design was performed in 2018 and reported here according to the COnsolidated criteria for REporting Qualitative research.

METHODS

In a clustered multicentre before/after intervention study design, a nested, multicentre qualitative descriptive design was performed. Four researchers with a nursing background, who received appropriate training, implemented the designed intervention. This consisted in intentional rounds in the dining rooms during lunchtime and was based on supportive, prescriptive and informative prompts delivered to residents with cognitive decline aimed at stimulating eating independence. A momentary assessment method was used, based on daily diary filled in by participant researchers after every session of intervention delivery on the following five dimensions of fidelity: (a) adherence, (b) dose (or exposure), (c) intervention quality, (d) participant responsiveness and (e) programme differentiation. A direct content analysis of the narratives reported on the diaries was performed.

RESULTS

Factors increasing or hindering intervention fidelity during its implementation emerged at the NH, staff, family caregivers, resident, researchers and at the intervention itself levels.

CONCLUSIONS

Several factors emerged and all reported potentially both positive and negative influences on fidelity while implementing an intervention aimed at promoting eating independence among NH residents. Fidelity challenges should be considered as dynamic in NH intervention studies, where continuous adjustments of the intervention delivered are required.

RELEVANCE TO CLINICAL PRACTICE

A calm environment, with staff members showing a caring behaviour, and researchers having achieved good familiarity with the NH setting, the residents, their family carers and the staff members, can all increase intervention fidelity.

Overview of systematic reviews: Effectiveness of non-pharmacological interventions for eating difficulties in people with dementia

AIM

To evaluate the effectiveness of non-pharmacological interventions for eating difficulties in people with dementia (PWD).

BACKGROUND

Eat difficulties are common problems in PWD. Prolonged eating difficulties may lead to inadequate/excessive food and drink intake and other adverse outcomes.

DESIGN

Overview of systematic reviews.

DATA SOURCES

Cochrane Library, JBI Library, PubMed, Embase, CINAHL, PsycINFO, and Psychology and Behavioral Sciences Collection, CNKI, WANFANG, from inception up until 23 September 2019.

REVIEW METHODS

This overview was conducted in accordance with methodological recommendations of Cochrane. Two researchers independently selected studies based on inclusion criteria, extracted data, assessed eligible studies using AMSTAR 2 and GRADE system, and summarized the conclusions.

RESULTS

Eighteen systematic reviews were included. Some evidence showed that environmental modifications, education/training, and Oral nutrition supplements (ONS) were beneficial to improving eating difficulties. But the current evidence failed to support the effectiveness of other interventions.

CONCLUSION

The overall confidence of systematic reviews is relatively low. High-quality studies are needed to further validate the effectiveness of non-pharmacological interventions for eating difficulties in PWD.

IMPACT

This overview provides evidence on the effectiveness of non-pharmacological interventions for eating difficulties in PWD. It will guide caregivers to choose more effective interventions to cope with eating difficulties and reduce the risk of adverse outcomes.

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

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

Optimizing sensory quality and variety: An effective strategy for increasing meal enjoyment and food intake in older nursing home residents

A decline in appetite and consequently in food intake is often observed with ageing, particularly in older adults living in nursing homes. Several strategies have been tested in nursing homes to counter this phenomenon. However, the approaches have rarely focused on food improvement, and most studies have assessed the impact of flavor enhancement on eating behavior. The present experiment aimed to assess the impact of improving sensory quality versus increasing sensory variety on food intake and meal enjoyment in elderly individuals living in a nursing home. Four conditions were compared: control condition, a Quality+ condition (recipes were improved according to sensory preference of the target population), a Variety+ condition (participants were offered a variety of main dishes and several condiments throughout the meal) and a Quality&Variety+ condition combining the two previous conditions. Eighty-two residents (age range: 71-101 years) participated in eight lunchtime sessions (2 replicates × 4 conditions). Compared to control condition, our results showed that improving the sensory quality of the dishes and/or providing variety led to increased meal enjoyment and food intake (energy intake: +5% for Quality+; +7% for Variety+). No additional effect was observed when the two factors were combined (+7% for Quality&Variety+). These results suggest that meal improvement strategies can be used to increase food intake in order to prevent and treat malnutrition in dependent older adults.

"Tailoring homely meals": Family members' motivations underlying nursing home visits during residents' meals

AIM

Elderly nursing home residents are often malnourished or at risk of malnutrition. Family members often visit residents during mealtimes, which might be an ideal opportunity for interventions targeted at improving the nutritional status of older residents. Therefore, this study aimed to explore motivations behind family member visits with nursing home residents during mealtime in Taiwan.

METHODS

This phenomenological study was conducted with family members of residents from four nursing homes in Taiwan. Participants were purposively sampled. Data were collected with individual face-to-face interviews from 18 family members. Data from transcribed audio-recorded interviews were analyzed using the approach of van Manen.

RESULTS

Analysis of the interview data identified the essence of motivations underlying family members' visits to nursing home residents during mealtimes, which we termed "tailoring homely meals." This referred to providing food tailored to residents' needs, providing a comforting family atmosphere, assisting residents during mealtime, and monitoring food consumption.

CONCLUSIONS

The motivations of family members to visit during mealtime could guide healthcare professionals working with East Asian populations in developing interventions to reduce the possibility of malnutrition, while also improving their quality of life. We recommend providing the following for nursing home residents: a nutritious and balanced diet, supporting their independence and ability to feed themselves, and encouraging involvement of family members during mealtimes.

Enhancing independent eating among older adults with dementia: a scoping review of the state of the conceptual and research literature

Background

Addressing eating difficulties among older individuals with dementia living in nursing homes requires evidence-based interventions. However, to date, there is limited evidence of effective interventions designed to maintain and/or increase independent eating. In a field in which evidence is still lacking, a critical analysis of the state of research describing its main features can help identify methodological gaps that future studies should address. Hence, the aim of this study was to map the state of the research designed to maintain and/or promote independent eating in older individuals with dementia living in nursing homes.

Methods

A scoping review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Reviews and conceptual analyses performed with different methodological approaches, published in indexed journals, and written in English were included. Keywords Were searched for in the MEDLINE, the Cumulative Index of Nursing and Allied Health, and in the Scopus databases to identify papers published up to 31 May 2018.

Results

17 reviews were included, assessing interventions’ effectiveness (n = 15) and providing conceptual frameworks for eating/mealtime difficulties (n = 2). Conceptual frameworks supporting interventions’ effectiveness have rarely been described in available studies. Moreover, interventions tested have been categorized according to non-homogeneous frameworks. Their effectiveness has been measured against (1) eating performance, (2) clinical outcomes, and (3) adverse event occurrence.

Conclusion

An increased use of conceptual frameworks in studies, as well as greater clarity in intervention categorization and outcomes, is necessary to enhance the reviews’ value in providing useful cumulative knowledge in this field. Interventions delivered should embody different components that integrate individual, social, cultural, and environmental factors, while when evaluating an intervention’s effectiveness, eating performance, clinical outcomes and adverse events should be considered. Together with more robust studies, involving clinicians could prove to be useful, as their knowledge of practice developed from direct experience can help develop innovative research questions.

Attending to difference: enacting individuals in food provision for residents with dementia

In the face of warnings about total institutions and growing concern about the quality of care, healthcare professionals in Western Europe and North America have increasingly been exhorted to tailor their services to individuals in their care. In this article, we invite our readers to become more interested in the kinds of differences care is being tailored to, and with what effects. Focusing on food provision for residents with dementia, we present three repertoires through which care workers attend to, and enact different sets of differences between individuals: providing choice allows residents to express fleeting preferences; knowing residents places emphasis on care providers' familiarity with a person; and catering to identities brings to the fore the tastes which make up part of who someone is. The analysis brings attending to difference to the fore as a practical process and suggests that tailoring care requires sensitivity to the different kinds of individuals enacted when attending to difference.

Addition Of Sauce Enhances Finger-Snack Intake Among Japanese Elderly People With Dementia

Purpose

The previous study demonstrated that the addition of a sauce is an effective means of influencing the consumption of finger foods among French elderly people with dementia. However, it is unclear the relative importance of low-level sensory factors such as flavor and a semi-solid nature and high-level cognitive factors such as memory stimulation and familiarity to the effect of the addition of sauce on food intake. The present study investigated whether the addition of sauce affects finger-snack intake among Japanese elderly people with dementia who were not familiar with sauce dipping.

Patients And Methods

A total of 21 patients with dementia who were recruited in a nursing home in Tokyo received a plate of cut baumkuchen (a very thinly layered German roll cake), which had pieces of baumkuchen both with and without sauce, at their afternoon snack time. The amount of food intake and the first choice between options were measured for each participant. We used chocolate (in Experiment 1, n = 21) and agave (Experiment 2, n =14) syrups as sauce samples.

Results

Results of both experiments demonstrate that snack consumption was greater for the with-sauce options than for the without-sauce options. A 90.5% of the participants in Experiment 1 and 64.3% of participants in Experiment 2 ate more snacks with sauce than without sauce.

Conclusion

These findings imply that low-level sensory factors such as flavor and a semi-solid nature contribute relatively more strongly to the enhancement of food consumption with the addition of sauce than do high-level cognitive factors such as memory stimulation and familiarity, because Japanese elderly people are not always familiar with the custom of wiping up the sauce with food.

Prevalence and Characteristics Associated with Modified Texture Food Use in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Purpose: To describe the prevalence and characteristics of modified-texture food (MTF) consumers when applying standard diet terminology.

Methods: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study including 32 long-term care (LTC) homes located in 4 Canadian provinces. Resident characteristics were collected from health records using a defined protocol and extraction form. Since homes used 67 different terms to describe MTFs, diets were recategorized using the International Dysphagia Diet Standardization Initiative Framework as a basis for classification.

Results: MTFs were prescribed to 47% (n = 298) of participants (n = 639) and prevalence significantly differed among provinces (P < 0.0001). Various resident characteristics were significantly associated with use of MTFs: dysphagia and malnutrition risk, dementia diagnosis, prescription of oral nutritional supplements; lower body weight and calf circumference; greater need for physical assistance with eating; poor oral health status; and dependence in all activities of daily living.

Conclusions: This is the first study that used a diverse sample of LTC residents to determine prevalence of MTF use and described consumers. The prevalence of prescribed MTFs was high and diverse across provinces in Canada. Residents prescribed MTFs were more vulnerable than residents on regular texture diets. These findings add value to our understanding of MTF consumers.

How do "robopets" impact the health and well-being of residents in care homes? A systematic review of qualitative and quantitative evidence

BACKGROUND

Robopets are small animal-like robots which have the appearance and behavioural characteristics of pets.

OBJECTIVE

To bring together the evidence of the experiences of staff, residents and family members of interacting with robopets and the effects of robopets on the health and well-being of older people living in care homes.

DESIGN

Systematic review of qualitative and quantitative research.

DATA SOURCES

We searched 13 electronic databases from inception to July 2018 and undertook forward and backward citation chasing.

METHODS

Eligible studies reported the views and experiences of robopets from residents, family members and staff (qualitative studies using recognised methods of qualitative data collection and analysis) and the effects of robopets on the health and well-being of care home residents (randomised controlled trials, randomised crossover trials and cluster randomised trials). Study selection was undertaken independently by two reviewers. We used the Wallace criteria and the Cochrane Risk of Bias tool to assess the quality of the evidence. We developed a logic model with stakeholders and used this as a framework to guide data extraction and synthesis. Where appropriate, we used meta-analysis to combine effect estimates from quantitative studies.

RESULTS

Nineteen studies (10 qualitative, 2 mixed methods and 7 randomised trials) met the inclusion criteria. Interactions with robopets were described as having a positive impact on aspects of well-being including loneliness, depression and quality of life by residents and staff, although there was no corresponding statistically significant evidence from meta-analysis for these outcomes. Meta-analysis showed evidence of a reduction in agitation with the robopet "Paro" compared to control (-0.32 [95% CI -0.61 to -0.04, p = 0.03]). Not everyone had a positive experience of robopets.

CONCLUSIONS

Engagement with robopets appears to have beneficial effects on the health and well-being of older adults living in care homes, but not all chose to engage. Whether the benefits can be sustained are yet to be investigated.

IMPLICATIONS FOR PRACTICE

Robopets have the potential to benefit people living in care homes, through increasing engagement and interaction. With the robopet acting as a catalyst, this engagement and interaction may afford comfort and help reduce agitation and loneliness.

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.