How are the mealtime experiences of people in residential aged care facilities informed by policy and best practice guidelines? A scoping review

Background

Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impact their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Giddens’ (The constitution of society: outline of the theory of structuration, 1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents’ mealtime experiences.

Methods

Using Arksey and O’Malley’s (Int J Soc Res Methodol 8:19–32, 2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.

Results

Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.

Conclusions

Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03340-9.

The Effects of Age and Preoral Sensorimotor Cues on Anticipatory Mouth Movement During Swallowing

PURPOSE

The aim of this study was to investigate the effects of preoral sensorimotor cues on anticipatory swallowing/eating-related mouth movements in older and younger adults. It was hypothesized that these cues are essential to timing anticipatory oral motor patterns, and these movements are delayed in older as compared with younger adults.

METHOD

Using a 2 × 2 repeated-measures design, eating-related lip, jaw, and hand movements were recorded from 24 healthy older (ages 70-85 years) and 24 healthy younger (ages 18-30 years) adults under 4 conditions: typical self-feeding, typical assisted feeding (proprioceptive loss), sensory-loss self-feeding (auditory and visual loss/degradation), and sensory-loss assisted feeding (loss/degradation of all cues).

RESULTS

All participants demonstrated anticipatory mouth opening. The absence of proprioception delayed lip-lowering onset, and sensory loss more negatively affected offset. Given at least 1 preoral sensorimotor cue, older adults initiated movement earlier than younger adults.

CONCLUSIONS

Preoral sensorimotor information influences anticipatory swallowing/eating-related mouth movements, highlighting the importance of these cues. Earlier movement in older adults may be a compensation, facilitating safe swallowing given other age-related declines. Further research is needed to determine if the negative impact of cue removal may be further exacerbated in a nonhealthy system (e.g., presence of dysphagia or disease), potentially increasing swallowing- and eating-related risks.

Is knowledge and practice safer in England after the release of national guidance on the resuscitation of patients in mental health and learning disabilities?

This paper reports on the issue of resuscitation in mental health inpatient environments. It reviews the literature on national standards and best practice when emergency situations arise in mental health settings. The discussion on the best practice literature takes place alongside the reporting of a national evaluation of how National Patient Safety Agency improvement guidelines for the provision for life support, and resuscitation for mental health service users was effectively implemented across health-care providers in England. Methods used to establish the effective use of the guidelines include feedback from clinical staff and staff responsible for the implementation of the new national standards for resuscitation. Serious incident data were also compared prior to the release of the national guidelines and after the guideline release dates. This included looking at events around choking and cardiac/respiratory arrest in inpatient areas. There were five deaths post-implementation of the guidelines that were considered to have serious enough error associated with the resuscitation process. This was down from 18 prior to the release of the guidelines. However, our survey showed that despite organisations reporting 100% compliance with the implementation of the guidelines, around half of frontline clinical staff were not aware of them. Although our survey responses show a contradiction between organisational and clinical staff awareness, our analysis suggests a reduction in moderate and severe harm cases and of deaths. There is evidence of a reduction in the worst types of error resulting in death, albeit with small numbers. In 2008, the National Patient Safety Agency issued a Rapid Response Report (RRR) aimed at health-care organisations providing inpatient care for mental health and learning disability patients, requiring organisations to make proper provision for life support and resuscitation for these patients. This paper examines whether effective implementation of the RRR recommendations had occurred across health providers in England. The methods used in this paper are the following: (1) Questionnaires were distributed nationally to clinical staff and implementation leads; (2) A national comparison of the number and severity of pre- and post-RRR release-related incidents involving choking/cardiac/respiratory arrest in Mental Health and Learning Disabilities settings was conducted; (3) Organisational compliance with the patient safety alert for all National Health Service Organisations in England was measured. There were five deaths post-implementation of the RRR that were considered to have serious enough error associated with the resuscitation. This was down from 18 deaths pre the RRR release. Although our survey responses show a contradiction between organisational implementation and clinical staff awareness, our analysis suggests a reduction in moderate and severe harm cases and of deaths. There is evidence of a reduction in the worst types of error resulting in death, albeit with small numbers.

Training support staff to modify fluids to appropriate safe consistencies for adults with intellectual disabilities and dysphagia: an efficacy study

BACKGROUND

Modifying the consistency of food and drink is a strategy commonly used in the management of dysphagia for people with intellectual disabilities (ID). People with ID often depend on others for the preparation of food and drink and therefore depend on those caregivers achieving the correct consistency to keep them safe and avoid discomfort during mealtimes. Clinical experience and prior research have demonstrated that although training can improve modification, carers often find modification difficult and potentially stressful and recommend additional support for carers. Fluid consistency is often modified through the addition of powdered thickener. This study investigates the efficacy of typical training and use of consistency guides, the Thickness Indicator Model (TIM) tubes, in helping carers to modify fluids accurately.

METHOD

A 3 × 3 pre-post experimental design with a control group was employed to compare the observed accuracy of modification across three groups and at three time points (pre-intervention baseline, immediately post-training intervention and 3-10 months post-training). Sixty-two paid carers who supported people with ID were recruited to participate in the study and each was randomly allocated to one of the three groups: a control group given written guidance only, a group who received typical training and written guidance and a group who received training, written guidance and the TIM tubes.

RESULTS & CONCLUSIONS

Typical training resulted in significantly greater carer accuracy in modifying fluid consistencies when compared with written guidance alone. Use of the TIM tubes also significantly improved accuracy in the modification of drinks compared with the group who modified with the aid of written guidance alone. At 3-10-month follow-up only the group who received typical training alongside the TIM tubes were significantly more accurate than the Written Guidance group. Further research is warranted to ascertain the effectiveness of the training and the utility of the TIM tubes in improving accuracy over a longer time scale and in individuals' usual living environments.

Thickened fluids for people with dementia in residential aged care facilities

AIM

This systematic review aimed to establish best practice in relation to thickened fluids for people with dementia living in residential aged care facilities.

METHODS

This review considered all types of studies that examined the prescription and administration of thickened fluids to people with dementia in residential aged care facilities. English-language articles published from 1995 to 2008 were sought in a comprehensive search of an extensive range of databases, online sources and unpublished literature. Two independent reviewers critically appraised each article using the relevant Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI) instruments, then data were extracted from those articles that met the inclusion criteria. No meta-analysis was possible because of significant clinical and methodological heterogeneity, therefore results are reported narratively.

RESULTS

From 112 papers originally identified, 14 met the inclusion criteria and formed the basis of the findings. Nine studies recommend the use of thickened fluids as a strategy to maintain adequate fluid intake for persons with dementia with dysphagia in residential aged care and four papers recommend their use for people with dementia in general. One paper reported that the use of thickened fluids was found to be acceptable to older people in the event of dementia and dysphagia.

CONCLUSIONS

From the retrieved data, evidence-based best practices cannot be concluded. It can, however, be cautiously inferred that thickened fluids may be effective for residents with dementia if set guidelines are instituted.

Negotiating candidacy: ethnic minority seniors' access to care

The 'Barriers to Access to Care for Ethnic Minority Seniors ' (BACEMS) study in Vancouver, British Columbia, found that immigrant families torn between changing values and the economic realities that accompany immigration cannot always provide optimal care for their elders. Ethnic minority seniors further identified language barriers, immigration status, and limited awareness of the roles of the health authority and of specific service providers as barriers to health care. The configuration and delivery of health services, and health-care providers' limited knowledge of the seniors' needs and confounded these problems. To explore the barriers to access, the BACEMS study relied primarily on focus group data collected from ethnic minority seniors and their families and from health and multicultural service providers. The applicability of the recently developed model of 'candidacy', which emphasises the dynamic, multi-dimensional and contingent character of health-care access to ethnic minority seniors, was assessed. The candidacy framework increased sensitivity to ethnic minority seniors' issues and enabled organisation of the data into manageable conceptual units, which facilitated translation into recommendations for action, and revealed gaps that pose questions for future research. It has the potential to make Canadian research on the topic more co-ordinated.

Thickened fluids for people with dementia in residential aged care facilities: a comprehensive systematic review

BACKGROUND

Dementia is an umbrella term for a large group of conditions that cause a progressive decline in a person's functioning. Dementia is a progressive condition which causes cognitive and functional decline and, as part of this, the ability to swallow diminishes, a condition known as dysphagia. Aspiration of fluids is a common result of dysphagia and is a significant problem, both in terms of its effect on the patient and its cost to the community. In order to increase the viscosity of drinking fluids and thereby minimise the likelihood of aspiration, people with dementia living in residential aged care facilities (RACFs) are often prescribed thickened fluids.

OBJECTIVES

The overall objective of this comprehensive systematic review was to establish best practice in relation to thickened fluids for people living in RACFs to: establish factors associated with the prescription and administration of thickened fluid for people with dementia living in RACFs; assess the effectiveness of administering thickened fluids for people with dementia in RACFs in terms of adequate hydration, mortality, morbidity and patient comfort; identify attitudes of people with dementia in RACFs and their family/carers regarding the administration of thickened fluids; and identify attitudes of staff regarding the administration of thickened fluids for people with dementia in RACFs.

SEARCH STRATEGY

English language articles published from 1995 to 2008 were sought in a comprehensive search of an extensive range of databases, online sources and unpublished literature.

SELECTION CRITERIA

The review considered all types of studies which included the oral administration of fluids with the addition of commercial thickening agent to the liquid which may include: energy/nutritional supplements, juice, water, tea, coffee, cordial, milk drinks, etc., for the purpose of increasing the viscosity of the liquid to minimise the chance of aspiration for persons with dementia in residential aged care.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. Any disagreements were adjudicated by a third reviewer.

MAIN FINDINGS

CONCLUSION: There appears to be little specific data on the effectiveness of thickened fluids for people with dementia in residential aged care. Most included studies had mixed populations of demented and non-demented residents, making dementia-specific results impossible to quantify. From the retrieved data, evidence-based best practices cannot be concluded. It may, however, be cautiously inferred that thickened fluids may be effective for residents with dementia if set guidelines are instituted.

Nursing Home Statutes: Mistreatment Definitions

INTRODUCTION

Forty-nine states and the District of Columbia have adult protective services (APS) related statutes that define adult/elder mistreatment found in domestic settings. Institutional adult/elder mistreatment laws are administered by the nursing home licensing agencies and may contain different or duplicate APS-related mistreatment definitions. The purposes of this paper are to describe and summarize the mistreatment definitions in the nursing home licensure statutes and compare those definitions with the definitions found in the APS-related statutes.

METHODS

Westlaw and Lexis-Nexis law database systems were used to retrieve all adult protective services statutes and institutional licensure statutes. Each statute's text was reviewed and coded by two researchers.

RESULTS

Institutional mistreatment definitions are addressed in 14 of the states and District of Columbia's nursing home statutes. No one state has a list of the 27 different definitions of mistreatment identified in the literature search. The common types of mistreatment described were physical and emotional abuse, neglect, financial and property exploitation, and sexual abuse.

CONCLUSION

Standardized definitions of resident-to-resident and institutional specific types of mistreatment need to be included in nursing home statutes.

Elder mistreatment in the nursing home: a systematic review

Because of their significant dependence on others for their care, nursing home residents are potentially vulnerable to abuse and/or neglect. The topic of elder mistreatment, whether in the nursing home or other living environments, received little attention from clinicians and researchers until the past 2 decades. Original research is now emerging that sheds light on the scope of the problem and the challenges to timely prevention, identification, and management. Practitioners may use this information to recognize and change factors associated with a higher likelihood of nursing home mistreatment.

Compliance with Dysphagia Recommendations by Carers of Adults with Intellectual Impairment

Health risks associated with dysphagia in adults with intellectual impairment are well documented. There is little research into compliance with dysphagia recommendations in environments where care is provided for adults with intellectual impairment. This is a pilot study into carer compliance with Speech-Language Pathology recommendations. We aimed to investigate the level of compliance with dysphagia recommendations in day centers and the factors that might affect compliance using a questionnaire. Twenty-seven clients were observed. Results showed an overall high level of compliance with recommendations (82%), with figures ranging from 64% compliance with appropriate utensils to 100% with direct support recommendations. Areas of noncompliance were evident, with level of dependence of clients and training of carers being key issues. Implications for practitioners are discussed.

Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia

BACKGROUND

Adults with learning disabilities referred for assessment of their eating and drinking are frequently reported to cough and choke when eating and drinking. The research literature investigating dysphagia has often overlooked asphyxiation risk, highlighting coughing and choking as indicators of aspiration only. This is a notable oversight due to the prevalence of asphyxia as a cause of mortality in this population.

AIM

This study aims to identify the physiological and environmental factors that predict asphyxiation risk in adults with intellectual disabilities and dysphagia.

METHOD

Data were collected from dysphagia-trained speech and language therapists (SLTs) working with the participant adults with intellectual disabilities and dysphagia. The SLTs used case notes, clinical assessment and videofluoroscopic assessment reports to gather the data.

RESULTS

Speed of eating, cramming food and premature loss of the bolus into the pharynx were identified as significant predictors of asphyxiation risk in this population.

CONCLUSIONS

The findings highlight the importance of maladaptive eating strategies in exacerbating the risk of asphyxiation and choking. These factors should be considered in the assessment of asphyxiation and choking risk and management. Finally, the need for joint assessment and management with other members of the multidisciplinary team is advocated.

Predicting lawsuits against nursing homes in the United States, 1997-2001

OBJECTIVES

To examine how nursing home characteristics impacted the number of lawsuits filed against the facilities in the United States during 1997-2001.

DATA SOURCES/STUDY SETTING

A stratified random sample of 2,378 nursing home in 45 states from 1997-2001. Data were obtained from Westlaw's Adverse Filings: Lawsuits database, the Centers for Medicare and Medicaid Services' (CMS) Online Survey, Certification, and Reporting (OSCAR) database, state complaint surveys, and through primary data.

STUDY DESIGN

Negative binomial regression was used to explain total lawsuit variance by year. Explanatory variables included (a) facility characteristics-including staffing, number of beds, multistate system membership, for-profit ownership, (b) quality indicators-including total number and type of quality survey deficiencies, pressure sore development, and (c) market area-state has resident rights statutes, state complaint information. Resident acuity levels and year effects were controlled for.

DATA COLLECTION/EXTRACTION METHODS

Nursing homes were identified and linked to Westlaw data that was searched for the number of lawsuits filed against the home, and then linked to OSCAR data and a primary data analysis of multistate chain membership.

PRINCIPAL FINDINGS

Staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs) and multistate chain membership were negatively related with higher numbers of lawsuits. More deficiencies on the licensing survey, larger, for-profit nursing homes, and being located in resident rights states were positively related with higher numbers of lawsuits.

CONCLUSION

This study suggests that nursing homes that meet long-stay staffing standards and minimum quality indicators, are nonprofit, smaller, and not located in resident rights states will experience fewer lawsuits.

Factors Predicting Lawsuits Against Nursing Homes in Florida 1997-2001

PURPOSE

We explore how nursing home characteristics affect the number of lawsuits filed against the facilities in Florida during the period from 1997 to 2001.

DESIGN AND METHODS

We examined data from 478 nursing homes in 30 Florida counties from 1997 to 2001. We obtained the data from Westlaw's Adverse Filings: Lawsuits database, the Online Survey, Certification, and Reporting system database from the Centers for Medicare and Medicaid Services, and state complaint surveys, and we also used primary data. We used negative binomial regression to explain total lawsuit variance by year. We controlled for acuity and year effects, and our explanatory variables included (a) facility characteristics--including staffing, number of beds, multistate system membership, and for-profit ownership--and (b) quality measures--including total number and type of state licensing survey deficiencies, pressure-sore development, and medication errors per resident.

RESULTS

Higher registered nurse and certified nursing assistant staffing levels were associated with fewer lawsuits. More deficiencies on the licensing survey and larger and for-profit nursing homes were positively related with higher numbers of lawsuits.

IMPLICATIONS

This study suggests that nursing homes that meet long-stay staffing standards, meet minimum quality measures, are not for profit, and are smaller will experience fewer lawsuits.

Refrigerator content and hospital admission in old people

We assessed whether the refrigerator contents of elderly people could be related to subsequent admission to hospital. 132 patients aged over 65 years had a thorough assessment of their refrigerator contents and the numbers and dates of admission were recorded. Elderly people with empty refrigerators were more frequently admitted (p=0.032) in the month after assessment and three times sooner than those who did not have empty refrigerators (34 vs 100 days, p=0.002).