Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia

Optimizing mealtime care and outcomes for people with dementia and their caregivers: A systematic review and meta-analysis of intervention studies

Interventions addressing modifiable personal and environmental factors are critical to optimize dementia mealtime care, caregiving, and outcomes. This review synthesized the characteristics and effects of non-pharmacological interventions on mealtime care and outcomes in people with dementia and their caregivers. Five databases were searched from January 2012 to October 2024. Eligible studies were accessed for study quality and graded for level of evidence. Meta-analyses were performed for studies within the same intervention type that tested the impact on same outcomes. 33 studies were identified and categorized into five intervention types. Five studies were strong, 7 moderate, and 21 weak in quality. The levels of evidence varied from very low to moderate, with most being very low to low. Meta-analyses showed "resident training/therapy" decreased eating difficulties and increased food intake; "Nutritional supplement" improved cognition and depression; "environmental/food modification" increased food intake. Further research using rigorous designs is needed to increase evidence quality and determine effects of multi-component interventions. HIGHLIGHTS: Five intervention types were identified from the 33 included studies: nutritional supplements, resident training/therapy, caregiver training and/or mealtime assistance, environmental/food modification, and multiple component interventions. One-third of the included studies were strong to moderate, and two-thirds were weak in study quality. "Resident training/therapy" showed effects in reducing eating difficulties and increasing food intake. "Environmental/food modification" showed effects in increasing food intake. "Nutritional supplements" showed effects in improving cognitive function and depression.

Family caregivers use a Hand-Under-Hand online course to improve the nutritional status of patients with severe dementia: A quasi-experimental study

AIM

In Taiwan, over 90% of dementia patients received home care. Severe dementia-linked food refusal significantly affects nutrition, thereby straining caregivers. Family caregivers can reduce their burden by learning feeding and dementia nutrition online, thus preserving patient oral feeding. The study aim for family caregivers learn online Hand-Under-Hand (UH) techniques to ease feeding in severe dementia, enhancing nutrition and reducing their burden.

METHODS

In this quasi-experimental study, participants in the experimental group received 2-h UH courses online, while the control group received their usual care. The primary outcome indicators were abnormal eating behavior, nutritional status, and caregiver burden, with outcomes tracked at 0, 1, and 3 months. At the neurology outpatient clinic of a medical center in Taipei, 65 dyads-comprising patients with severe dementia and their caregivers-were randomly assigned to groups.

RESULTS

The study participants comprised 36 female and 29 male caregivers, with an average age of 58.09 years. The patient group included 43 females and 22 males, with a mean age of 83.32 years. Patients in the experimental group exhibited reduced abnormal eating behavior, and caregiver burden was reduced at 1 and 3 months, patients demonstrated improved nutritional status by month 3.

CONCLUSIONS

The accessibility and convenience of online courses enabled family caregivers to use UH feeding techniques to effectively improve the nutritional status and correct the abnormal eating behavior of patients with dementia, while also decreasing caregiver burden. Geriatr Gerontol Int 2024; 24: 867-873.

Assessing eating ability and mealtime behaviors of persons living with dementia: A systematic review of instruments

This systematic review aimed to describe the characteristics of instruments that assess eating ability and/or mealtime behaviors in persons living with dementia, and evaluate their psychometric properties. Five databases were searched for relevant records between 1/1/1980 and 5/25/2023. Records included instruments assessing eating ability and/or mealtime behaviors of people with dementia. The psychometric quality of the instruments was evaluated using the Psychometric Assessment for Self-report and Observational Tools (PAT). 45 eligible instruments were identified from 115 records. While 38 instruments were scored as having low psychometric quality, 7 had moderate quality. Edinburgh Feeding Evaluation in Dementia (EdFED), Mealtime Difficulty Scale for older adults with Dementia (MDSD), and Dementia Hyperphagic Behavior Scale (DHBS) were scored as having the highest quality (total PAT score = 9). Further refinement of existing instruments and additional psychometric testing in larger, diverse samples will improve pragmatic use in dementia mealtime care research and practice.

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.

Nutritional Care for Institutionalized Persons with Dementia: An Integrative Review

BACKGROUND

Older people are at risk of malnutrition, especially when they suffer from cognitive impairment. Guidelines that orient nursing care in this regard need to be updated. The aim of this review is to address the best available evidence on interventions that can benefit nutritional nursing care for institutionalized older adults with dementia.

METHODS

Integrative review using the Dimensions and Eureka search engines, and the PubMed, Embase, Scielo, CINAHL, and ScienceDirect databases. We searched from the year 2015 through to 2021. We employed the MMAT guidelines for mixed, qualitative, and quantitative studies, and the PRISMA, CASP, and JBI guidelines to value the reviews.

RESULTS

A total of 55 studies met the inclusion criteria. The best available evidence to support nutritional nursing care for institutionalized older adults with dementia highlights several aspects related to the assessment and caring interventions that are focused on people with dementia, their caregivers, and their context.

CONCLUSIONS

Both the assessment and nutritional care interventions for older people with dementia should consider the patient-caregiver dyad as the subject of care and understand the context as a fundamental part of it. The analysis of the context should look further than the immediate environment.

Longitudinal assessment of the eating pattern of people with dementia and its association with problems for feeding and malnutrition: a prospective follow-up study protocol

INTRODUCTION

Dementia conditions the patient's nutrition from the beginning and vice versa. Generating difficulties for feeding (FEDIF) will influence its evolution. There are currently few nutritional longitudinal studies in people with dementia. Most focus on problems already established. The Edinburgh Feeding Evaluation in Dementia (EdFED) Scale identifies FEDIF of patients with dementia by studying their behaviours while eating or being fed. It also indicates areas of potential clinical interventions.

METHODS AND ANALYSIS

Prospective multicentre observational study carried out in nursing homes, Alzheimer's day care centres and primary healthcare centres. The study population will be dyads composed by the patient (diagnosed of dementia, over 65 years of age and who have feeding difficulties) and their family caregiver. Sociodemographic variables and nutritional status (body mass index, Mini Nutritional Assessment, blood test and calf and arm circumference) will be assessed. The Spanish version of the EdFED Scale will be completed and the presence of nursing diagnoses related to feeding behaviours will be collected. Follow-up will take place for 18 months.

ETHICS AND DISSEMINATION

All data will be carried out respecting European legislation 2016/679 in data protection, and the Spanish 'Organic Law 3/2018 of December 2005'. The clinical data will be kept segregated and encrypted. The informed consent has been obtained. The research has been authorised by the Costa del Sol Health Care District on 27 February 2020 and the Ethics Committee on 2 March 2021. It has obtained funding from the Junta de Andalucía on 15 February 2021. Findings of the study will be presented at provincial, national and international conferences and published in peer-reviewed journals.

The feasibility and acceptability of a dementia care training program for registered dietitian nutritionists

There is a need for more Registered Dietitian Nutritionists (RDNs) trained to provide nutritional care to older adults with dementia who experience mealtime difficulties. The purpose of this single-arm, pre/post pilot study was to adapt a generalized dementia care curriculum to the learning needs of RDNs who work with individuals with dementia and to determine the feasibility and acceptability of the adapted program. Using an existing evidence-based dementia care curriculum, the research team identified learning objectives and content pertinent to the scope of RDNs. The adapted program was piloted with RDNs who work with older adults with dementia. Twenty-five RDNs registered for the training while 80% (20) attended the training and completed the post-training survey. All participants agreed that the module met the learning needs of RDNs who work with older adults with dementia, the two-hour workshop was a good use of their time, and the experience and skills gained would be useful in their work as an RDN. Implementation costs totaled $1,310. Based on the post-training feedback, the adapted program was deemed feasible and acceptable by RDN participants, who also expressed interest in using the module to train other caregivers on providing mealtime assistance to older adults with dementia.

Non-Pharmacological Interventions for Feeding and Eating Disorders in Persons with Dementia: Systematic Review and Evidence Summary

BACKGROUND

Feeding and eating disorders related to cognitive and psycho-behavioral symptoms are strongly associated with health status in persons with dementia (PWD). Non-pharmacological interventions have been the priority selection to address this significant issue. However, the direct targets of non-pharmacological interventions are unclear and there is no consistent evidence of recommendations on the intervention of different dementia stages and the settings of intervention practice.

OBJECTIVE

To provide caregivers with a set of self-help non-pharmacological interventions for feeding and eating disorders in PWD.

METHODS

Based on the process of evidence summary, a systematic literature search was performed on dementia websites and seven databases. Two researchers screened the studies independently and appraise the quality. The evidence was graded by Joanna Briggs Institute Grades of Recommendation.

RESULTS

Twenty-eight articles were included. Twenty-three non-pharmacological intervention recommendations were categorized into six themes containing oral nutritional supplementation, assistance with eating and drinking, person-centered mealtime care, environmental modification, education or training, and multi-component intervention. These interventions corresponded to three direct targets including improving engagement, making up for loss ability, and increasing food intake directly. They were applied to different stages of dementia and most interventions were targeted at PWD in long-term care institutions.

CONCLUSION

This article summarized the direct targets and the specific implementation of recommendations at different stages of dementia to provide caregivers with self-help non-pharmacological interventions. The practice of recommendations was more applicable to institutionalized PWD. When applied to PWD at home, caregivers need to identify the specific feeding and eating conditions at different stages and adopted the interventions in conjunction with the wishes of the PWD and professional advice.

A Biopsychosocial Model of Mealtime Management in Persons with Dementia, an Asset-Based Approach to Patient-Centered Care

Considering the rapid increase in the population over the age of 65, there is increasing need to consider models of care for persons with dementia (PWD). One common deficit associated with dementia progression is difficulty with successful participation in mealtimes. Difficulty participating in mealtimes in PWD is not the result of one factor, but rather a confluence of biological, psychological, and social characteristics common in dementia. Factors leading to mealtime difficulties for PWD may include changes in cognitive status, altered sensorimotor functioning, and increased reliance on caregiver support. The complex nature of biological, psychological, and social factors leading to mealtime difficulty highlights the need for a pragmatic model that caregivers can utilize to successfully support PWD during mealtimes. Existing models of dementia and mealtime management were reviewed and collated to create a model of mealtime management that considers this complex interplay. The Biopsychosocial Model of Mealtime Management builds on past research around patient-centered care and introduces an asset-based approach to capitalize on a PWD's retained capabilities as opposed to compensating for disabilities associated with dementia. We hope this model will provide a framework for caregivers to understand what factors impact mealtime participation in PWD and provide appropriate means on intervention.

Improving nutrition and hydration in older people with dementia in care homes

Dementia can have significant adverse effects on people's ability to eat and drink sufficiently. People with dementia can experience malnutrition and unintentional weight loss at any stage of the condition, but these occur more often in the middle and late stages. It is important that nurses and care staff working in care homes have the appropriate knowledge and skills to provide optimal nutritional care to residents, thereby improving their health, well-being and quality of life. This article provides an overview of nutrition and hydration issues commonly experienced by people with dementia. It explores common causes of suboptimal nutrition and hydration, outlines tools for nutritional screening and assessment and discusses interventions to improve the nutritional care of care home residents with dementia.

Resistance to Eating in People with Dementia Living in Long-term Care Facilities: Gaps between Common and Good Practices

OBJECTIVES

The present study aims to explore the perception of common and best practices for dealing with resistance to eating of persons with dementia living in long-term care facilities.

METHODS

Forty-two staff members working in long-term care facilities were interviewed. They worked in four Spanish long-term care facilities; 21 were nursing assistants and 21 technical staff. Participants heard a vignette in which person with dementia showed resistance to eating. Participants were asked how a situation like that is commonly managed by their workmates, and how the situation should be managed. Responses were content-analyzed.

RESULTS

Strategies mentioned by participants were quite diverse and did not converge on common ground that harmonizes their responses. Less than half of the participants considered person-centered strategies as a best practice. Those strategies were lower on assistant carers, compared to technical staff.

CONCLUSIONS

Resistance to eating is a common situation faced by professionals. Nonetheless, there is not a common procedure to deal with this situation. Resistance to eating was seen more as a problem to be eradicated than a behavior to be understood.

CLINICAL IMPLICATIONS

Staff development initiatives are necessary in relation to mealtime situations. They should consider work position and competencies needed by assistant carers.

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.

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.

Mealtime caregiving approaches and behavioral symptoms in persons living with dementia: a longitudinal, observational study

Background

Behavioral symptoms during mealtime can prohibit persons living with dementia from obtaining sufficient nutrition. However, little research has examined the relationship between behavioral symptoms and caregiving approaches. This study examines this relationship and further explores which specific caregiver behaviors were related to behavioral symptoms among persons living with dementia.

Methods

A secondary data analysis was performed using 86 mealtime videos from a longitudinal, observational study. The videos were repeatedly taken at months 0, 3, and 6 with 30 persons living with dementia in one of four long-term care facilities. Video coding was performed using coding schemes modified from the Cohen-Mansfield Agitation Inventory for behavioral symptoms and the Person-/Task-Centered Behavior Inventory for caregiving approaches. Coding schemes for behavioral symptoms consisted of four categories: total duration, aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. Caregiving approaches consisted of ten-verbal/seven-nonverbal person-centered behavior codes, four-verbal/four-nonverbal task-centered behavior codes, and no-verbal/no-nonverbal interaction codes. A mixed-effect model was conducted using variables such as demographics, medical information, cognitive status, depression, function, and caregiving approaches as fixed effects, participant as a random effect, and four categories of behavioral symptoms as dependent variables.

Results

The total duration of the Cohen-Mansfield Agitation Inventory was associated with no verbal response (β = 9.09) and task-centered verbal behavior (β = 8.43), specifically verbal controlling (β = 7.87). Physically nonaggressive behavior was associated with no verbal response (β = 9.36). Verbally agitated behavior was associated with task-centered nonverbal behavior (β = 51.29), and specifically inappropriate touch (β = 59.05).

Conclusions

Mealtime is indispensable to dementia care for ensuring adequate nutrition and promoting personhood. Our findings revealed caregivers’ task-centered behaviors and no interaction were related to behavioral symptoms of persons living with dementia. When caregivers encounter behavioral symptoms during mealtime, it is recommended to avoid no response and task-centered behaviors, especially verbal controlling and inappropriate touch, and to promote person-centered behaviors.

Assessing Caregivers' Skills in Assisting People with Dementia during Mealtime: Portuguese Cultural Adaptation of the Feeding Skills Checklist

In advanced dementia, individuals usually develop feeding difficulties. The Feeding Skills Checklist (FSC) is an instrument to assess caregivers’ skills when assisting people with dementia (PwD) at mealtimes. This study aimed to adapt and culturally validate a European Portuguese version of the FSC (FSC-PT) and test its reliability. Initially, translation and cultural validation of the FSC, with estimation of the content validity index (CVI), was conducted. Then, the FSC was applied to 23 female nursing assistants (mean age 44.73 ± 10.42 years) while offering lunch (n = 41 meals) to institutionalized PwD. Inter-rater reliability was determining using Cohen’s Kappa. FSC-PT showed excellent content validity, with item-content validity index ranging from 0.85 to 1, scale level average CVI = 0.94 and universal agreement CVI = 0.54. It also showed very satisfactory inter-observer reliability, with Cohen’s Kappa = 0.844. Of the 41 meals analyzed, only 37.7% of the actions/good practices in feeding PwD were observed. A positive and moderate correlation was found between the length of time working as nursing assistance and the FSC environment dimension (r_s = 0.435; p = 0.038). The results supported the content validity of the FSC-PT, which shows considerable potential to be an instrument for verifying caregivers’ skills when helping PWD to eat and should be increasingly studied.

Ease of use, feasibility and inter-rater reliability of the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme

AIMS

To refine the Cue Utilization and Engagement in Dementia mealtime video-coding scheme and examine its ease of use, feasibility, and inter-rater reliability in assessing the food intake process and dyadic verbal and nonverbal interactions.

DESIGN

This study was a secondary analysis of 110 videotaped observations of mealtime interactions collected under usual care conditions from a dementia communication trial during 2011-2014.

METHODS

The videos involved 29 staff and 25 residents with dementia (42 unique staff-resident dyads) in nine nursing homes. Data coding and analysis were performed in 2018-2019. Logs of coding challenges with matched solutions and coding time were collected. Inter-rater reliability was examined through rating of randomly selected 22 videos across four trained coders.

RESULTS

It took a mean of 10.81 hr to code a one-hour video using the refined coding scheme. Coding challenges, including identification of key intake process characteristics and differentiation of similar verbal or nonverbal behaviours, were identified with appropriate solutions. The refined coding scheme had good inter-rater reliability (Cohen's Kappa range = 0.93 - 0.99, 95% CI = 0.92 - 0.99).

CONCLUSION

Findings supported preliminary evidence on feasibility, usability and inter-rater reliability of the refined coding scheme. Future psychometric testing is needed in diverse populations with dementia across different care settings.

IMPACT

Existing tools assessing the food intake process and dyadic interactions are few and have limited feasibility and/or reliability and fail to capture the complexity and dynamics of mealtime care. The refined coding scheme showed preliminary feasibility, usability, and inter-rater reliability. In consideration of the balance between time intensity and the richness of data obtained, the tool may be appropriate and useful in addressing certain research inquires (e.g., characterizing and clustering dyadic behaviours, temporal relationship between behaviours and intake) pertaining older adults with or without dementia and their formal or informal caregivers.

Feasibility of a Mobile Meal Assistance Program for Direct Care Workers in Long-Term Care Facilities in South Korea

Purpose

The purpose of this study was to assess the feasibility and examine the preliminary effectiveness of a mobile application-based meal assistant training program (APP) for use by direct care workers (CAs) assisting residents with dementia in long-term care facilities in South Korea.

Methods

We adopted a mixed methods research design, which included a pre- and post-intervention study and focus group interviews for the feasibility assessment. Participants included 23 dyads of older adults with dementia and their CAs from a long-term care facility in South Korea. Upon completion of the APP intervention, focused group interviews were conducted with six CAs and five nurses.

Results

The results of paired t-tests showed that the effects of the APP intervention on the older adults with dementia and their CAs were not significant; however, the results of the focused group interviews support the potential usefulness of the APP for CAs.

Conclusion

The APP may be applicable to long-term care workers who need meal assistant skills education.

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.

Use of an Errorless Learning Approach in a Person With Concomitant Traumatic Spinal Cord Injury and Brain Injury: A Case Report

: Individuals with concomitant spinal cord injury and traumatic brain injury have cognitive deficits that may limit the ability to learn novel motor tasks necessary for functional independence. Errorless learning has been shown to improve cognitive task performance in persons with brain injury but little is known about its usefulness for improving novel motor task learning.

CASE DESCRIPTION

A 44-year-old man with traumatic spinal cord and brain injuries from a motor vehicle accident was admitted to an inpatient rehabilitation hospital. His spinal cord injury was classified as T4 American Spinal Injury Association Impairment Scale (AIS) A, and his cognitive status was level IV on the Ranchos Los Amigos Scale. Initially, the patient required maximal assistance from 2 clinicians to complete a slide board transfer, propelled his wheelchair 25 ft with minimal assistance, and scored 9/56 on the Function in Sitting Test.

INTERVENTION

The therapist applied traditional motor-learning approaches during the first 37 days of the patient's inpatient rehabilitation facility stay without meaningful gains in functional mobility. A subsequent change to errorless learning was made for the following 32 days until discharge.

OUTCOMES

After use of errorless learning, the patient performed novel mobility-related tasks of slide board transfers with minimal assistance and wheelchair propulsion without physical assistance up to 150 ft; the Function in Sitting Test score improved to 18/56. His sensorimotor system progressed to an AIS classification of AIS B, while his cognition emerged to a level V on the Ranchos Los Amigos Scale.

DISCUSSION

Errorless learning may have facilitated acquisition of novel transfer and mobility skills in this individual with dual diagnoses. This approach may have value for patients with neurologic conditions who have both motor and cognitive impairment.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A201).

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.

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.

Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Managing Person-Centered Dementia Care in an Assisted Living Facility: Staffing and Time Considerations

Background and Objectives

To describe (a) the unlicensed staff time necessary to provide quality activities of daily living (ADL) care to residents receiving dementia care within an assisted living facility and (b) a staff management approach to maintain quality ADL care.

Research Design and Methods

Supervisory staff used a standardized observational method to measure ADL care quality and the staff time to provide care during the morning and evening across 12 consecutive months. Staff were given individual feedback about the quality of their care provision following each observation.

Results

The average staff time to provide ADL care averaged 35 (± 11) minutes per resident per care episode with bathing and 18 (± 6) minutes/resident/care episode without bathing. Morning ADL care required significantly more staff time than evening care. There was not a significant relationship between residents' levels of cognitive impairment or ADL dependency and the staff time to provide ADL care. Quality ADL care was maintained for 12 months.

Discussion and Implications

This study provides novel data related to the amount of staff time necessary to provide quality ADL care for persons with dementia in an assisted living care setting. This study also describes a standardized approach to staff management that was effective in maintaining quality ADL care provision. Assisted living facilities should consider these data when determining the necessary unlicensed staffing level to provide person-centered ADL care and how to effectively manage direct care providers.

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

Background

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

Method

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

Results

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

Conclusions

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

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

Background and Objectives

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

Methods

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

Results

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

Conclusions

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