Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: a pilot study

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.

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.

Orange napkins increase food intake and satisfaction with hospital food service: A randomized intervention

OBJECTIVES

Increased malnutrition risk has been identified in >30% of hospitalized adults in Israel. Because orange has been identified as an appetite stimulant, orange napkins were considered a low-cost enhancement of the meal context. The aim of this study was to assess the effect of an orange napkin on the meal tray on food intake and satisfaction with food service among adults hospitalized in an internal medicine department.

METHODS

One hundred and thirty-one patients hospitalized in Internal Medicine Department E, Edith Wolfson Medical Center, Holon, Israel, participated in the study. Patients were randomized to lunch trays with an orange (experimental) or white (control) napkin. Digital imaging was used with the modified Comstock Scale to quantify dietary intake. A validated questionnaire was used to score satisfaction with the hospital's food service. Medical history, anthropometric measures, reason for hospitalization, and meal modifications were extracted from the medical record.

RESULTS

Patients in the orange napkin group (n = 66) consumed 17.6% more hospital-provided food than those in the white napkin (control) group (n = 65), driven by the significantly greater proportion of the carbohydrate side dishes and the vegetable dishes consumed. Patients in the orange napkin group also reported significantly greater satisfaction with the hospital's food service.

CONCLUSION

The addition of an orange napkin to the meal tray of patients hospitalized in internal medicine departments can increase dietary intake and improve satisfaction with hospital food services. At about 5 cents per piece, the orange napkin is a low-cost, easily implemented strategy to address malnutrition risk in hospitalized adults.

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.

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.

Taste, choice and timing: Investigating resident and carer preferences for meals in aged care homes

There has been little empirical investigation of the preferences of people living in aged care homes for food services. The aim of the present study was to elicit consumer preferences and their willingness to pay for food service in aged care homes. Current residents or their family members were invited to take part in the discrete choice experiment questionnaire administered via interview. Of the 109 eligible residents and 175 eligible family members approached for consent 121 (43%) participated, including 43 residents. Participant preferences were influenced by food taste, choice in relation to serving size, timing of meal selection, visual appeal, and additional cost. Participants indicated they would be willing to pay an additional $24 (US$18.42) per week for food which tasted excellent and $8 (US$6.14) per week to have choice in serving sizes. The study found that respondents were willing to pay a premium to receive food that met their expectations of taste, and for a high level of control over serving sizes, which has implications for the funding and provision of food and dining in long-term care in the future.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The Influence of Cognitive Status on Elder Food Choice and Meal Service Satisfaction

BACKGROUND

This article describes the testing of a new nursing home food delivery system that empowers elders to choose the foods they want to eat and gives them an active voice in menu development.

METHODS

Using a 2-group, repeated measures design, 61 elderly residents from 2 eastern Washington nursing homes were recruited to participate in a 6-month study. Outcome measures included food and meal service satisfaction, body weight, serum prealbumin, and food intake.

RESULTS

Serum prealbumin levels and body weight increased post intervention for treatment group residents. Mini-Mental Status Examination (MMSE) scores were not associated with the changes in serum prealbumin, body weight, or food intake.

DISCUSSION

The MMSE scores did not influence the resident's ability to actively participate in the rate the food process or choose the foods they liked and preferred to eat. Cognitive impaired older adults experienced weight gain similarly to higher functioning elderly individuals.

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

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

The effect of interventions to prevent and treat malnutrition in patients admitted for rehabilitation: a systematic review with meta-analysis

BACKGROUND

Malnutrition occurs frequently among patients in rehabilitation, leading to poorer outcomes. Evidence of the effects of interventions to prevent or treat malnutrition is required to guide clinical practice in this setting. This systematic review aimed to determine the effect of oral nutrition interventions implemented in rehabilitation on nutritional and functional outcomes.

METHODS

Five databases were searched to identify relevant publications; intervention trials of oral nutrition interventions (such as oral nutrition supplements, foodservice interventions, clinical care processes, enhanced eating environments) conducted with patients admitted for rehabilitation, reporting dietary intake, anthropometric, biochemical or functional outcomes. The reviewers determined study eligibility and assessed the included studies for risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS

From 1765 publications, 10 studies trialling oral nutrition supplements, foodservice interventions and clinical care processes (of neutral or positive quality) were identified. Compared to meals alone, oral nutritional supplements significantly improved energy and protein intake, with some evidence for improvements in anthropometry and length of stay. There was little evidence that speciality supplements were beneficial compared to standard versions. Meta-analyses demonstrated significantly greater energy [weighted mean difference (WMD) = 324 kcal, 212-436 kcal 95% confidence interval (CI)] and protein (WMD = 9.1 g, 0.2-17.9 g 95% CI) intake with energy dense meals. Opposing results were reported in studies investigating enhanced clinical care processes.

CONCLUSIONS

The provision of oral nutrition supplements and energy dense meals improved energy and protein intake and therefore may comprise effective strategies for addressing malnutrition in rehabilitation. The effect of these strategies on other nutritional and functional outcomes should be explored further.

Interventions for improving mealtime experiences in long-term care

Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

The need to improve the nutrition of the elderly living in long term care has long been recognised, but how this can best be achieved, and whether (and which) intervention is successful in reducing morbidity is less well understood. The aim of this systematic review was to determine the effectiveness of mealtime interventions for the elderly living in residential care. Mealtime interventions were considered as those that aimed to change/improve the mealtime routine, practice, experience or environment. Following comprehensive searches, review and appraisal, 37 articles were included. Inadequate reporting in over half of the articles limited data quality appraisal. Mealtime interventions were categorised into five types: changes to food service, food improvement, dining environment alteration, staff training and feeding assistance. Meta-analysis found inconsistent evidence of effects on body weight of changes to food service (0.5 kg; 95% CI: -1.1 to 2.2; p=0.51), food improvement interventions (0.4 kg; 95% CI: -0.8 to 1.7; p=0.50) or alterations to dining environment (1.5 kg; 95% CI: -0.7 to 2.8; p=0.23). Findings from observational studies within these intervention types were mixed, but generally positive. Observational studies also found positive effects on food/caloric intake across all intervention types, though meta-analyses of randomised studies showed little evidence of any effects on food/caloric intake in food improvement studies (-5 kcal; 95% CI: -36 to 26; p=0.74). There was some evidence of an effect on daily energy intakes within dining environment studies (181 kcal/day, 95% CI: -5 to 367, p=0.06). The need to improve the nutrition of the elderly living in residential long term care is well recognised. This review found some evidence that simple intervention around various aspects of mealtime practices and the mealtime environment can result in favourable nutritional outcomes. Further large scale pragmatic trials, however, are still required to establish full efficacy of such interventions.

The influence of nutritional supplement drinks on providing adequate calorie and protein intake in older adults with dementia

OBJECTIVES

Investigate the impact of the provision of ONS on protein and energy intake from food and ability to meet protein and calorie requirements in people with dementia.

DESIGN

After consent by proxy was obtained, participants took part in a cross over study comparing oral intake on an intervention day to an adjacent control day.

SETTING

The study occurred in Nursing homes and hospitalised settings.

PARTICIPANTS

Older adults with dementia over the age of 65 were recruited. 26 participants (aged 83.9+/-8.4years, MMSE 13.08+/-8.13) took part. Intervention (if any): On the intervention day nutritional supplement drinks were provided three times. Each drink provided 283.3+/-41.8 Kcal of energy and 13.8+/-4.7g of protein. Supplements were removed approximately 1 hour before meals were served and weighed waste (g) was obtained.

MEASUREMENTS

Intake of food consumed was determined on intervention and control days using the quartile method (none, quarter, half, three quarters, all) for each meal component.

RESULTS

More people achieved their energy and protein requirements with the supplement drink intervention with no sufficient impact on habitual food consumption.

CONCLUSION

Findings from these 26 participants with dementia indicate that supplement drinks may be beneficial in reducing the prevalence of malnutrition within the group as more people meet their nutritional requirements. As the provision of supplement drinks is also demonstrated to have an additive effect to consumption of habitual foods these can be used alongside other measures to also improve oral intake.

Determinants of foodservice satisfaction for patients in geriatrics/rehabilitation and residents in residential aged care

BACKGROUND

Poor satisfaction with institutional food is a significant moderator of food intake in geriatrics/rehabilitation and residential aged care.

PURPOSE

To quantify the relationship between foodservice satisfaction, foodservice characteristics, demographic and contextual variables in geriatrics/rehabilitation and residential aged care.

METHODS

The Resident Foodservice Satisfaction Questionnaire was administered to 103 patients of 2 geriatrics/rehabilitation units and 210 residents of nine residential aged care facilities in Brisbane, Australia. Ordered probit regression analysis measured the association of age, gender, ethnicity and appetite, timing and amount of meal choice, menu selectivity, menu cycle, production system, meal delivery system and therapeutic diets with foodservice satisfaction.

RESULTS

Patient and resident appetite (P < 0.01), the amount and timing of meal choice (P < 0.01), self-rated health (P < 0.01), accommodation style (P < 0.05) and age (P < 0.10) significantly moderated foodservice satisfaction. High protein/high energy therapeutic diets (P < 0.01), foodservice production (P < 0.01) and delivery systems (P > 0.01) were significant moderators for those with 'fair' self-rated health.

CONCLUSIONS

Patient and resident characteristics and structural and systems-related foodservice variables were more important for influencing foodservice satisfaction than characteristics of food quality. The results suggest modifications to current menu planning and foodservice delivery methods: reducing the time-lapse between meal choice and consumption, augmenting the number of meals at which choice is offered, and revising food production and delivery systems.It is important that residents in poorer health who are a high risk of under-nutrition are provided with sufficient high protein/high energy therapeutic diets. Diets that restrict macro- and micro-nutrients should be minimized for all patients and residents.

Memories, identity and homeliness: the social construction of mealtimes in residential care homes in South Wales

Mealtimes in residential care homes are fundamentally social occasions, providing temporal structure to the day and opportunities for conversation and companionship. Food and drink are imbued with social meanings and used to express and create relationships between people. There is a dearth of research exploring care home residents' mealtime experiences in the United Kingdom. This paper reports on particular findings from a qualitative study which investigated factors influencing nutritional care provided to residents in two different types of residential care settings in South Wales, UK. Data were generated through focus group interviews with relevant staff members (N = 15), individual interviews with managers (N = 4) and residents (N = 16) of the care homes and their informal carers (N = 10), observation of food preparation and mealtimes throughout the day, and analysis of appropriate documents. Data were analysed using thematic analysis. This paper's focus is on the ways in which care home residents' experiences and understandings of mealtimes were influenced by various environmental factors, such as the home's geographical location, physical lay-out and ambience. Moreover, the shared meaning of mealtimes for residents, informal carers and staff was constructed from each group's socio-cultural background, family experiences and memories, and was integral to residents' sense of normality, community and identity.

Construct validation and test-retest reliability of a mealtime satisfaction questionnaire for retirement home residents

Mealtime satisfaction is an important component of quality of life (QOL) in residential care, yet there currently is no self-administered tool described in the literature. The purpose of this study is to investigate internal and test-retest reliability, and construct validity of a mealtime satisfaction questionnaire (MSQ) designed for residential care, more specifically retirement homes. A 15-item MSQ was developed and eligible participants from four retirement homes (n = 749) were invited to participate. The participation rate was 24% and the median age was 88 years for respondents. The internal consistency of the MSQ was high (Cronbach Alpha = 0.83) and the test-retest reliability was also high (Intraclass coefficient = 0.91, P < 0.01). The MSQ was associated with a valid and reliable QOL instrument for older adults (Mann Whitney Test = 1595.5, P < 0.01). The MSQ is reliable and is content and construct valid. QOL can be enriched by improving mealtime satisfaction in retirement homes.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes

BACKGROUND

A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging.

OBJECTIVES

To identify which staffing models are associated with the best patient and staff outcomes.

SEARCH STRATEGY

We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles.

SELECTION CRITERIA

This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC.

MAIN RESULTS

We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited.

AUTHORS' CONCLUSIONS

Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

Mealtimes in nursing homes: striving for person-centered care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.

Oral feeding options for people with dementia: a systematic review

To review the benefits of oral feeding options in people with dementia.

DESIGN

Systematic literature search with review of potentially eligible studies by two independent investigators.

SETTING

PubMed/MEDLINE, EMBASE, the Cochrane Library, CINAHL, and PsychINFO literature indices between January 1990 and October 2009.

PARTICIPANTS

Clinical trials with random or nonrandom control groups were included if they reported on clinical outcomes of oral feeding interventions for people with dementia.

MEASUREMENTS

Investigators abstracted data from included studies using a structured instrument. Studies were graded on quality and potential bias, and overall strength of evidence was summarized.

RESULTS

Thirteen controlled trials provided data on use of supplements for people with dementia, and 12 controlled trials tested assisted feeding or other interventions. Studies provide moderate-strength evidence for high-calorie supplements, and low-strength evidence for appetite stimulants, assisted feeding, and modified foods to promote weight gain in people with dementia. The few studies measuring function or survival showed no difference.

CONCLUSION

High-calorie supplements and other oral feeding options can help people with dementia with feeding problems to gain weight; they are unlikely to improve other outcomes. These treatments can be offered alone or in combination as an alternative to tube feeding.

Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision

Background

Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision.

Methods

We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes.

Results

Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data.

This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication.

There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06).

Conclusions

Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful.

Trial registration

Trial registration: ISRCTN86057119.

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost

BACKGROUND

The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.

METHODS

A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.

RESULTS

Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.

CONCLUSIONS

This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Dining experience, foodservices and staffing are associated with quality of life in elderly nursing home residents

PURPOSE

Few studies have quantitatively investigated potential relationships between quality of life (QOL) in long term care (LTC) and foodservices.

OBJECTIVE

To investigate if dining experiences, and food and nutritional services affect elderly nursing home residents' QOL.

DESIGN AND PARTICIPANTS

A total of 395 residents in 38 nursing homes participated in this cross-sectional study.

MEASUREMENTS

Information on dining experiences and QOL was gathered by face-to-face interviews with cognitively intact residents; primary institutional caregivers completed a questionnaire for cognitively impaired residents. Additional data were also obtained from participants' medical charts and from administrators and foodservice managers. Multivariate ordinary least squares (OLS) regression was used to determine which institutional characteristics were related to QOL.

RESULTS

Number of dining companions, autonomy in relation to food, tray meal delivery service, and ratio of residents per resident assistant were significantly related to QOL in both cognitively intact and cognitively impaired residents. For cognitively intact residents, number of medical conditions, therapeutic menus, and use of china dishes were also related to QOL. For cognitively impaired residents, independence with eating and frequency of menu revision were also related to QOL.

CONCLUSION

Modifying certain aspects of food and nutritional services, as well as residents' dining experience, may improve QOL of elderly LTC residents.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Malnutrition and mealtime ambiance in nursing homes

Inadequate nutritional intake is the predominant cause of malnutrition in older persons. It is one of the most common and devastating conditions in nursing home residents. It is multifactorial and treatment or nutrition care plans should try to address the main causes. Such plans often include means to stimulate appetite to prevent or treat anorexia. One important stimulus, which can be modulated easily, is the meal ambiance. This article deals with the theory or mechanism behind this meal ambiance stimulus, discusses some study results, and makes practical recommendations.

Eating behavior and obesity at Chinese buffets

The aim of this study was to investigate whether the eating behaviors of people at all-you-can-eat Chinese buffets differs depending upon their body mass. The resulting findings could confirm or disconfirm previous laboratory research that has been criticized for being artificial.

METHODS AND PROCEDURES

Trained observers recorded the height, weight, sex, age, and behavior of 213 patrons at Chinese all-you-can-eat restaurants. Various seating, serving, and eating behaviors were then compared across BMI levels.

RESULTS

Patrons with higher levels of BMI were more likely to be associated with using larger plates vs. smaller plates (OR 1.16, P < 0.01) and facing the buffet vs. side or back (OR 1.10, P < 0.001). Patrons with higher levels of BMI were less likely to be associated with using chopsticks vs. forks (OR 0.90,P < 0.05), browsing the buffet before eating vs. serving themselves immediately (OR 0.92, P < 0.001), and having a napkin on their lap vs. not having a napkin on their lap (OR 0.92, P < 0.01). Patrons with lower BMIs left more food on their plates (10.6% vs. 6.0%, P < 0.05) and chewed more per bite of food (14.8 vs. 11.9, P < 0.001).

DISCUSSION

These observational findings of real-world behavior provide support for laboratory studies that have otherwise been dismissed as artificial.

A Preliminary Evaluation of the Paid Feeding Assistant Regulation: Impact on Feeding Assistance Care Process Quality in Nursing Homes

PURPOSE

The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality.

DESIGN AND METHODS

Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality.

RESULTS

Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents.

IMPLICATIONS

Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.

Effect of Family-Style Meals on Energy Intake and Risk of Malnutrition in Dutch Nursing Home Residents: A Randomized Controlled Trial

BACKGROUND

Social facilitation and meal ambiance have beneficial effects on food intake in healthy adults. Extrapolation to the nursing home setting may lead to less malnutrition among the residents. Therefore, we investigate the effect of family-style meals on energy intake and the risk of malnutrition in Dutch nursing home residents.

METHODS

In 2002 and 2003, a randomized controlled trial was conducted among 178 residents (mean age 77 years) in five Dutch nursing homes. Within each home, two wards were randomized into an intervention (n = 94) and a control group (n = 84). For 6 months, the intervention group received their meals family style, and the control group received the usual individual preplating services. Outcome measures were intakes of energy (kJ), carbohydrates (g), fat (g), and protein (g) and Mini Nutritional Assessment (MNA) score (0-30).

RESULTS

The change in daily energy intake between the control and intervention group differed significantly (991 kJ; 95% confidence interval [CI], 504-1479). The difference in intake of macronutrients was 29.2 g (95% CI, 13.5-44.9) for carbohydrate, 9.1 g (95% CI, 2.9-15.2) for fat, and 8.6 g (95% CI, 3.4-13.6) for protein. The percentage of residents in the intervention group classified by the MNA as malnourished decreased from 17% to 4%, whereas this percentage increased from 11% to 23% in the control group.

CONCLUSIONS

Family-style meals stimulate daily energy intake and protect nursing home residents against malnourishment. Therefore, replacement of the preplating meal services with family-style meals in nursing homes is recommended.

Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial

OBJECTIVE

To assess the effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents without dementia.

DESIGN

Cluster randomised trial.

SETTING

Five Dutch nursing homes.

PARTICIPANTS

178 residents (mean age 77 years). Two wards in each home were randomised to intervention (95 participants) or control groups (83).

INTERVENTION

During six months the intervention group took their meals family style and the control group received the usual individual pre-plated service.

MAIN OUTCOME MEASURES

Quality of life (perceived safety; autonomy; and sensory, physical, and psychosocial functioning), gross and fine motor function, and body weight.

RESULTS

The difference in change between the groups was significant for overall quality of life (6.1 units, 95% confidence interval 2.1 to 10.3), fine motor function (1.8 units, 0.6 to 3.0), and body weight (1.5 kg, 0.6 to 2.4).

CONCLUSION

Family style mealtimes maintain quality of life, physical performance, and body weight of nursing home residents without dementia.

TRIAL REGISTRATION

Clinical trials NCT00114582.

Pilot Testing of the Restorative Care Intervention: Impact on Residents

The purpose of this pilot study was to test the feasibility and effectiveness of a two-tiered motivational intervention, the Res-Care Intervention, on nursing home residents. Twenty-one residents consented to participate in the study. The residents were 88.3 (+/- 4.9) years of age, had lived in the facility 1.6 (+/- 3.4) years, were women (93%), White (93%), and unmarried (85%). Although there were some positiv trends, there was not a statistically significant difference in any of the resident outcomes following implementation of the Res-Care Intervention. The findings have been used to revise the Res-Care Intervention to include additional education needs for the nursing assistants, revisions in the motivational intervention for the nursing assistants and nurses, clarification of documentation and motivational techniques to improve documentation, and implementation of a more comprehensive treatment fidelity plan.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

The Meaning of Mealtimes: Connection to the Social World of the Nursing Home

Food that reflects our family backgrounds is a source of comfort that can play an important part in recovery from illness or adaptation to the nursing home, especially for older individuals. However, no studies could be found that explored residents' perspectives on how their food and food service preferences are, or are not, met in nursing homes. This exploratory qualitative study examined dietary preferences acquired during the course of a lifetime, and the meaning of mealtimes to 20 nursing home residents, and attempted to connect that meaning with their social world. Exploring the meaning of food and food service to nursing home residents could furnish insights for improving nutritional status, adaptation to the nursing home, and quality of life through promotion of individualized nutritional care.

Resident coping strategies in the nursing home: an indicator of the need for dietary services change

Inadequate food intake leading to malnutrition impacts up to 85% of nursing home residents. Malnutrition can result in compromised quality of life and lead to chronic disability, functional decline, increased health care utilization and costs, and death. This article examines organizational structure (Perrow, 1979) and person-environment fit (Lawton, 1982) as factors in nutritional care of nursing home residents. The strategies used by residents to cope with organizational food and food service issues, competence, and environmental press in the nursing home can alert nurses to the need for changes in dietary services to increase food intake and quality of life.

Pros and cons of using paid feeding assistants in nursing homes

Recently the Centers for Medicare and Medicaid Services (CMS), citing increasing resident acuity, staffing shortages, and high turnover rates that make it difficult for nursing homes to provide adequate feeding assistance to residents who need minimal help at mealtimes, began allowing nursing facilities to use single-task workers to provide assistance during mealtimes. This article describes the use of single-task workers to provide feeding assistance to nutritionally at-risk residents during a 6-month clinical study designed to evaluate the effectiveness and feasibility of implementing a buffet-dining program in an academic long-term care facility.

Measuring Nursing Home Resident Satisfaction With Food and Food Service: Initial Testing of the FoodEx-LTC

BACKGROUND

Malnutrition impacts the quality of life and general health of many older persons living in our nation's 20,000 nursing homes (1). Despite the urgency of this issue, no instrument that measures resident satisfaction with food and food service was found in an extensive literature search. The purpose of this article is to describe the development and initial testing of a resident satisfaction with food and food service questionnaire (FoodEx-LTC) in the context of the Quality Nutrition Outcomes-Long-Term Care Model.

METHODS

This pilot study was conducted in two phases. During phase one the instrument was developed, peer-reviewed, and pretested. Phase two further tested the instrument using a correlational design, measuring both intermediate and long-term outcomes found on the Quality Nutrition Outcomes-Long-Term Care Model.

RESULTS

Hypothesis testing was used to measure construct validity. 4 of 5 FoodEx-LTC domains were significantly correlated with depression, 2 of 5 with serum albumin. The FoodEx-LTC demonstrates acceptable reliability for a new instrument. The coefficient alpha scores ranged from.69-.87 and test-retest correlations ranged from.55-.89, dependent upon domain.

CONCLUSIONS

FoodEx-LTC appears to be a valid and reliable measure of resident food and food service satisfaction in nursing homes. This line of inquiry is of great importance because perceived quality of food and food service are strongly related to quality of life for residents in nursing homes, and adequate food intake is integral to maintaining weight and preventing protein-calorie malnutrition among elderly residents.