The moderating effect of nutritional status on depressive symptoms in veteran elders with dementia: a spaced retrieval combined with Montessori-based activities

Co-designing a mealtime intervention integrating Spaced Retrieval and montessori-based activities for people with dementia living in nursing homes

IntroductionEating difficulties significantly impact the nutrition, health, and well-being of people with dementia worldwide. Training strategies, such as Spaced Retrieval and Montessori-based activities, have the potential to enhance the self-eating ability of people with dementia but have not been widely tested. This paper reports the co-design and preliminary testing of the SPREMON (Spaced Retrieval and Montessori-based activities) intervention to enhance mealtime independence and experiences for people with dementia living in nursing homes.MethodsInformed by experience-based co-design methodology, this study used a three-phase approach to intervention development. Three initial sessions were conducted with aged care professionals to develop and refine the intervention. Four pilot sessions were conducted with people with dementia to assess the feasibility and suitability of intervention elements. A final consultation session explored the data and identified barriers and facilitators to successful implementation. While field notes were kept in early sessions, the final session was audio-recorded and transcribed for analysis. Thematic analysis was undertaken with all qualitative data, while observational data are reported using descriptive statistics.FindingsSix aged-care professionals, 3 researchers, and 9 people with dementia participated in the intervention development. The intervention approach was positively appraised for its potential to enhance self-feeding abilities in people with dementia while saving staff time. Participants suggested improvements to the Spaced Retrieval approach by incorporating visual and verbal cues to make it less confrontational. However, challenges regarding the lack of detail and guidance for implementing Montessori-based activities made them difficult to apply without clarification. Additional barriers included staff shortages, engagement difficulties, and scheduling conflicts. Pilot activities highlighted practical considerations for intervention implementation and patient engagement.Discussion and ImplicationsThis study demonstrates that the SPREMON intervention holds significant potential to enhance the self-eating ability of people with dementia living in nursing homes. However, the paper also highlights potential challenges in the implementation.

Promoting Mealtime Independence and Mealtime Experience for Individuals With Dementia: A Study Protocol

BACKGROUND

Difficulties in eating can profoundly influence the well-being of those living with dementia. Previous research has shown that Spaced Retrieval and Montessori-based interventions can enhance eating independence during meals and optimise nutritional health in people living with dementia in nursing homes. However, few studies examine the effects of these interventions on those living with dementia who follow western-style eating etiquette.

AIM

This pilot study aims to evaluate the effectiveness of the SPREMON (Spaced Retrieval and Montessori-based activities) mealtime intervention on mealtime independence, mealtime engagement and affect (mood), and nutritional status among people living with dementia in a nursing home.

METHOD

This quasi-experimental study will involve people with dementia living in nursing homes. The intervention consists of Spaced Retrieval and Montessori-based activities designed to enhance eating procedural memory and eating motor skills over 7 weeks. Data will be collected pre-intervention and post-intervention and at 3-month follow-up. Depending on the distribution of the data, an ANOVA or Friedman test will be used to examine the differences in the means for mealtime independence, engagement and affect, and nutritional status over time.

DISCUSSION

There is limited evidence of the impact of Spaced Retrieval and Montessori-based activities in people living with dementia using western dining etiquette. This study bridges this knowledge gap and provides new knowledge about the effectiveness of such interventions to enhance mealtime independence and engagement and affect for people with dementia living in nursing homes.

TRIAL REGISTRATION

ANZCTR identifier: ACTRN12623001031651p.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

The impact of montessori-based programmes on individuals with dementia living in residential aged care: A systematic review

OBJECTIVES

This systematic review examined the effectiveness of Montessori-based programmes for individuals with dementia living in residential aged care.

METHODS

Nine databases were searched between January 2010 to October 2021, including Scopus, CINAHL, MEDLINE, Web of Science, SocINDEX with Full Text, PubMed, PsycINFO, Cochrane library and Cochrane Registry. Publications were included if they used Montessori-based programmes as interventions for individuals with dementia living in residential aged care and were qualitative, quantitative, mixed-method, or pilot studies. The quality of eligible studies was assessed using Joanna Briggs Institute critical appraisal instruments and the Mixed Method Critical Appraisal Tool. The findings were tabulated and narratively synthesised.

RESULTS

Fifteen studies were included in this review. The quality scores of the 15 studies ranged from 62 to 100 out of 100. Four key categories of outcomes were observed: (1) significantly improved engagement; (2) significantly improved mental health outcomes, including affect, depression, agitation, excessive eating and psychotropic medication prescriptions; (3) significantly improved feeding difficulty but mixed results regarding nutritional status; and (4) no significant changes in the activities of daily living and quality of life of individuals with dementia.

CONCLUSION

Cognitive capacity, personal preferences, individual care needs and the design of Montessori-based activities are pivotal to tailoring personalised Montessori-based activities for individuals with dementia in residential aged care and to maximise intervention outcomes. The synergistic effect of integrating Spaced Retrieval with Montessori-based activities in improving the eating ability and nutritional status of individuals with dementia was also noticed. The study summarised evidence about the effectiveness of Montessori-based programmes for individuals with dementia and informed healthcare professionals about how to implement individualised Montessori-based programmes.

Evaluating a brief intervention for mealtime difficulty on older adults with dementia

AIMS AND OBJECTIVE

To test a spaced retrieval intervention using spaced retrieval to alleviate mealtime difficulties in older people with dementia.

DESIGN

A single-case study design.

SETTING

Nursing Homes in North Central England, United Kingdom.

PARTICIPANTS

Older people with Alzheimer's disease.

METHODS

A single-case study using an ABA design was used. Data were collected using the Edinburgh Feeding Evaluation in Dementia scale, Mini Nutritional Assessment, and Body Mass Index before intervention, postintervention and following 3 months of postintervention. Realist evaluation was used to identify for which participants the intervention was effective, and an economic evaluation was also carried out.

FINDING

Of 15 participants who entered the study, eight completed all phases of the study. A mean 104.4 h were needed to deliver the intervention. The number of sessions required ranged from 90-222. The length of time each participant retained information (for all sessions) ranged from 13-28 min. Participants had most difficulty with: "putting food into mouth and chewing it"; "realizing it was mealtime"; and "eating a whole meal continuously." A reduction in the difficulty with mealtimes occurred between phase A1-A2 for most participants. Six participants maintained this in phase A3. Similar patterns were evident for nutritional scores. For most participants, the effect size of the intervention was moderate or large.

CONCLUSIONS

Spaced retrieval is useful in reducing mealtime difficulties in older participants with dementia. While the results of this study are promising, further large and multicentre trials are needed to explore the effectiveness of the intervention in diverse populations.

In Quest of Tablet Apps for Elders With Alzheimer's Disease: A Descriptive Review

Caregivers search for mobile device apps that offer meaningful and enjoyable activities to simultaneously enhance the preserved cognitive and functional abilities of those in their care. The purpose of this review article was to describe the current state of tablet apps with which elders with Alzheimer's disease and related forms of dementia may engage as users. Using the keywords "app," "Alzheimer's," and "dementia," a sample of 83 apps was selected from the iTunes Store, Google, and discussion boards of Apple Support Communities. A descriptive content analysis was conducted using a coding scheme on the characteristics of tablet app activity and the requirements for functional abilities of the users. This review found that the activities of the selected apps included games, simple watching and viewing, music and sounds, memory training, learning and information, and social interaction starters. A high-level cognitive and physical ability such as eye-hand coordination is often required to play the majority of the game apps. A few apps are designed specifically for the population. Individuals' variability in cognitive and functional abilities necessitates a person-centered approach in designing and selecting games and activities for apps in order to increase engagement and promote positive experiences in older adults.

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.

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.

Prednosti metode Montessori pri obravnavi oseb z demenco

Uvod: Demenca je kronično obolenje s tendenco upadanja kognitivnih sposobnosti obolelega. Uporaba metod za obvladovanje in trening osnovnih življenjskih aktivnosti, ki omogočajo daljše obdobje samostojnega življenja pacienta z demenco, je v tujini uveljavljena z različnimi novejšimi koomplementarnimi pristopi. Ena izmed uveljavljenih metod je pristop Marie Montessori, prilagojen odraslim pacientom z demenco. V članku je predstavljena metoda montessori pri obravnavi pacienta z demenco in njeni učinki na kakovost življenja pacienta z demenco. Metode: Uporabljena je bila deskriptivna raziskovalna metodologija s pregledom domače in tuje literature. Za prikaz pregleda petih preko spleta dostopnih podatkovnih baz in odločanja o uporabnosti pregledanih virov je bila uporabljena metoda PRISMA. V končni pregled literature je bilo ključenih 19 člankov, objavljenih do maja 2016. Za obdelavo podatkov je bil uporabljen model analize konceptov. Večina zajetih raziskav je bila izvedena v Združenih državah Amerike. Rezultati: Po pregledu raziskav so bila identificirana tri tematska področja: (1) vpliv metode montessori na sodelovanje in prizadevanje, (2) vpliv metode montessori na vedenje, povezano s hranjenjem, in (3) vpliv metode montessori na širšo skupino kognitivnih sposobnosti. Diskusija in zaključek: Kljub majhnemu številu člankov, ki opisujejo uporabo metode montessori pri obravnavi pacientov z demenco, metodo lahko predstavimo kot učinkovito. Avtorji raziskav ugotavljajo, da pristop ne le omogoča ohranjanje kognitivnih sposobnosti, temveč le-te celo izboljšuje.

Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well IN dementiA (EDWINA) systematic review

Background

Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service or dining environment modification, education, exercise or behavioural interventions in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia).

Methods

We comprehensively searched Medline and twelve further databases, plus bibliographies, for intervention studies with ≥3 cognitively impaired adult participants (any type/stage). The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data. Meta-analysis (statistical pooling) was not appropriate so data were tabulated and synthesised narratively.

Results

We included 56 interventions (reported in 51 studies). Studies were small and there were no clearly effective, or clearly ineffective, interventions. Promising interventions included: eating meals with care-givers, family style meals, soothing mealtime music, constantly accessible snacks and longer mealtimes, education and support for formal and informal care-givers, spaced retrieval and Montessori activities, facilitated breakfast clubs, multisensory exercise and multicomponent interventions.

Conclusions

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. A variety of promising indirect interventions need to be tested in large, high-quality RCTs, and may be approaches that people with dementia and their formal or informal care-givers would wish to try.

Trial registration

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007611).

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0256-8) contains supplementary material, which is available to authorized users.