Assessment and Management of Mealtime Behaviors, Function, and Nutrition in Older Adults Living With Dementia

 

OVERVIEW

The number of people living with dementia is increasing dramatically worldwide. Mealtime is a critical activity of daily living. Assessment and management of mealtime behaviors, function, and nutrition are among the most challenging and time-consuming care responsibilities.

 

BACKGROUND

A. Mealtimes are critical to ensure adequate food intake and functional performance, as well as an opportunity for social interaction and engagement; therefore, mealtime rituals, cultural norms, and food preferences should be respected to the extent possible.

B. Residents’ positive, neutral, and challenging behaviors during mealtime are all ways of expressing their enjoyment or emotions; communicating their unmet needs, preferences, or wants; and/or responding to care or other stimuli. High-quality care should be provided to manage challenging behaviors as well as improve positive behaviors in residents with dementia.

C. Suboptimal mealtime care may result in resident-level functional, nutritional, and other consequences, as well as adverse caregiver- and institutional-level outcomes.

MULTILEVEL FACTORS OF MEALTIME OUTCOMES

A. Multilevel factors at resident, staff, environmental, and institutional levels influence resident mealtime behaviors, function, and nutritional intake.

B. Caregivers need to understand the impact of multilevel factors and adapt care to accommodate resident remaining abilities, promote dyadic interactions and social engagement, and enhance dining environment elements to optimize mealtime experiences and outcomes.

ASSESSMENTS OF MEALTIME-RELATED OUTCOMES

A. The Edinburgh Feeding Evaluation in Dementia, the Mealtime Difficulty Scale for Older Adults With Dementia, and the Dementia Hyperphagic Behavior Scale have moderate psychometric quality for assessing mealtime challenging behaviors.

B. The Eating Behavior Scale has moderate psychometric quality for assessing eating ability.

C. The Repetitive Saliva Swallowing Test, the Swallowing Rating Scale, and the Dysphagia Severity Scale have moderate psychometric quality for swallowing ability.

D. The Mealtime Engagement Scale has moderate psychometric quality for caregiver mealtime engagement behaviors.

MANAGEMENT OF MEALTIME BEHAVIORS, FUNCTION, AND NUTRITION

A. Existing mealtime interventions include nutritional supplements, training/education programs for residents and staff, environment/routine modifications, mealtime assistance, and multicomponent intervention.

  1. Nutritional supplements have some evidence to increase food intake, weight, and body mass index.
  2. Resident training programs have some evidence to decrease mealtime challenging behaviors and improve eating function and eating time.
  3. Staff training programs have some evidence to increase eating time and decrease mealtime challenging behaviors.
  4. Staff mealtime assistance and environmental/routine modifications have some evidence to improve eating function.

B. Effective mealtime care interventions should adopt multilevel, multicomponent, individualized care approaches.

C. Person-centered mealtime care, a philosophy of individualized care that engages and motivates residents in mealtime and addresses residents’ abilities, preferences, and needs, is highly recommended and should be context-based and resident-oriented.

D. Person-centered mealtime care may be achieved using the RECIPE principles: (a) showing Respect, (b) creating Environment, (c) offering Choices, (d) supporting Independence, (e) acknowledging Preferences, and (f) maintaining Engagement, which captures the multilevel features of mealtime care.

E. Staff training on person-centered mealtime care is fundamental to (a) reframing their understanding of resident challenging behaviors from “negative behaviors to avoid/minimize” to “behaviors communicating needs and preferences that require attention and responses”; and (b) increasing their skills and awareness to appropriately respond to resident challenging behaviors as an approach of communicating with and engaging residents with dementia.

F. Examples of person-centered mealtime care strategies include verbal strategies (e.g., giving orientations, getting attention, asking for cooperation, showing approval, providing choices, acknowledging preferences) and nonverbal strategies that support resident abilities (e.g., offering liquid food when residents struggle with solid food), optimize dyadic interactions (e.g., adjusting proximity), and improve dining environments (e.g., minimizing traffic and noise).

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 13, Liu, W. (2025) Assessment and Management of Mealtime Behaviors, Function, and Nutrition in Older Adults Living With Dementia

 

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