Optimize Mealtimes in Dementia

Guiding Principles

A.  Adequate intake of nutrients is necessary to maintain physical and emotional health.

B.  Mealtimes are critical to socialization as well as maximizing nutritional intake; therefore, mealtime rituals, cultural norms, and food preferences will be observed to the extent possible.

C.  Caregivers must be aware of sensory changes that occur in dementia and adapt care to include verbal, nonverbal (visual), and sensorimotor cues to optimize meal intake.

D.  Persons should be encouraged to self-feed as long as possible, and level of support should be adjusted to compensate for the person’s ability through Handfeeding techniques.

E.  As persons require more assistance with eating, dignity will be maintained.

F.   The quality of mealtime interactions is an indicator of quality of life and care provided to individuals.

BACKGROUND

A.  Definitions

Basic

  1. Feeding is “the process of getting the food from the plate to the mouth. It is a primitive sense without concern for social niceties” (Katz et al., 1970, p. 23).
  2. Eating is “the ability to transfer food from plate to stomach through the mouth” (Katz et al., 1970, p. 23). Eating involves the ability to recognize food, the ability to transfer food to the mouth, and the phases of swallowing.
  3. Dysphagia is “an abnormality in the transfer of a bolus from the mouth to the stomach” (Groher, 1997, p. 2).

Impact of dementia on independent meal management

Cognition

  1. Attention and executive function are impaired. As it relates to eating, the person with dementia may have difficulty staying focused on the meal and initiating and maintaining self-feeding until the meal is consumed.
  2. Agnosia is the inability to recognize familiar items when sensory cuing is limited. As it relates to feeding, a utensil (e.g., spoon or fork) is not recognized as an object for moving food from the plate to the person’s mouth.
  3. Aphasia is the inability to communicate effectively, and may be receptive or expressive. As it relates to feeding, spoken language may not be spoken or understood.

Function

  1. Apraxia is an inability to carry out voluntary muscular activities related to neuromuscular damage. As it relates to eating and feeding, it involves loss of the voluntary stages of swallowing or the manipulation of eating utensils.
    • “Skill fingers” ability: The person with dementia possesses the fine motor skill to use the first two fingers and thumb to hold and manipulate the utensil.

Handfeeding Techniques

For all techniques, the feeding assistant assesses the person with dementia for (a) skill finger ability and (b) upper extremity range of motion. Handfeeding technique use is in response to these abilities, which may fluctuate from meal to meal and day to day. Feeding assistants sit on the dominant side of the person with dementia, place their hand on the person’s shoulder for touch cue, and provide feeding assistance through the middle of the person with dementia’s body (self-feeding is naturally delivered through the body’s midline).

NOTE: Direct Hand should be used last, and only when necessary. It is the least engaging technique for a person with dementia and can create excess disability if used when the person with dementia can still engage in the act of eating.

  1. Over Hand: The person with dementia still possesses the fine motor skill needed to hold the utensil. The caregiver puts his/her hand over the hand of the person with dementia and guides it toward the individual’s mouth. The person being assisted is active in the process, but may misinterpret the assistant as controlling and push assistance away (Batchelor-Aselage et al., 2015).
  2. Under Hand: The person with dementia no longer possesses the fine motor skill needed to hold the utensil, so the caregiver holds the fork or spoon, and places his or her hand under the hand of the person with dementia. From the perspective of the person with dementia, this type of assistance may convey a feeling of control over the movement and provides fine motor assistance when it no longer exists (Batchelor-Aselage et al., 2015).
    • Modify technique if person with dementia has limited upper extremity range of motion.
  3. Direct Hand: The caregiver does all of the work: The caregiver holds the fork or spoon and moves food from plate to mouth; the person being assisted is passive in the interaction (Batchelor-Aselage et al., 2015).
    • Modification: The caregiver using this technique should ensure visual cues are being received by the person with dementia through eye contact with food and/or the person opening his or her mouth before putting it in.

For a video demonstration depicting the three techniques and modifications, please visit the following website: http://melissabphd.com/nosh (Batchelor-Murphy, 2018)

B.  Etiology

Mealtime difficulties Can have multiple causes from sensory, cognitive, functional, psychological, and iatrogenic origins. Health professionals need to consider multiple etiologies and not assume that difficulties are related only to increased confusion from a cognitive decline.

  1. Sensory/Cognitive: Changes related to Alzheimer’s disease and related dementia, including loss of peripheral vision, agnosia, and aphasia; Parkinson’s disease; amyotrophic lateral sclerosis; stroke.
  2. Functional: Changes related to Alzheimer’s disease and related dementia, including apraxia; Parkinson’s; stroke; deconditioning, including loss of upper extremity range of motion, strength, and/or endurance.
  3. Psychological/Physiological: Depression, anxiety, constipation, infection.
  4. Iatrogenic: Lack of adaptive equipment; use of physical restraints that limit the ability to move, position, or self-feed; improper chair or table surface, or discrepancy of chair to table height; use of wheelchair in lieu of table chair; being assisted to eat while lying in bed; use of disposable dinnerware, especially for patients with cognitive or neuromuscular impairments.

PARAMETERS OF ASSESSMENT

A.  Physical examination

  1. Look for reversible causes of low meal intake: Pain? Constipation? Infection?
  2. Psychological factors: Depression? Anxiety?

B.  Meal observation

  1. Cognitive challenges: Able to initiate eating? Able to maintain attention to the meal? Behaviors that may indicate sensory deficit (e.g., reaching across table to eat another person’s food may indicate decreased peripheral vision and inability to see meal/meal tray directly in front of them).
  2. Functional challenges: Self-feeding ability versus response to Handfeeding assistance? Trouble with utensils?
  3. Feeding behaviors: EdFED scale: Observe a few mealtimes at different times of the day using the EdFED scale to examine the presence of feeding behaviors and possible meaning of behavior (Watson, 1996):
    • Turning head away, clamping mouth shut: Are these behaviors indicating a dislike of food offered, or desire for fluids at that moment? When choice is honored, does meal intake continue?
    • Refusing to open mouth/not swallowing/allowing food to drop out of mouth: Does speech therapy need to evaluate swallowing problem? Dental consult?
    • Spillage of food: Does person need stabilization of utensils with Over Hand or Under Hand feeding technique(s)?
    • Spitting food out: Spits food into hand? Is it related to the food taste, temperature, or texture?
  4. Dysphagia: Coughing? Not swallowing food? Involve speech therapy, or observe for optimized cueing by feeding assistants.
  5. Wandering/Elopement from dining room: Timing of tray delivery? Finger food while walking, rather than making person sit at the table?

C.  Care record review

  1. Medication reconciliation: Any new or missing medication? Medications given only for current medical diagnoses?
  2. Review recent lab values and urinalysis
  3. Patterns of intake and output:
    • Meal intake record for patterns of increased or decreased intake. Clinical investigation should occur to determine underlying cause, as these patterns may indicate:
      • Acute illness/onset of infection (e.g., meal intake decreased few days prior)
      • Daily patterns of meal intake (e.g., breakfast always 100%, dinner 25%).
    • Review bowel movement records and auscultate for bowel sounds: look for patterns of 3 days with equivalent of a “large” bowel movement.
      • Constipation will affect appetite. A “large” bowel movement is equivalent to the length of the lower arm, from elbow to fist (the length of the colon). Daily “small” bowel movements do not empty the colon, resulting in constipation.

NURSING INTERVENTIONS

A.  Change the Person

  1. Allow time for rituals before meals (e.g., handwashing and toilet use); dressing for dinner; saying blessing of food or grace, if appropriate.
  2. Observation of religious rites or prohibitions observed in preparation of food or before meal begins (e.g., Muslim, Jewish, Seventh-Day Adventist; consult pastoral counselor or family as needed).
  3. Cultural or special cues: family history, special holiday occasions, especially rituals surrounding meals
  4. Preferences about end-of-life decisions regarding withdrawal or administration of food/fluids in the face of incapacity, or request of designated healthcare proxy; ethicist or social worker may facilitate process.
  5. Develop interdisciplinary care plan for any chronic, treatable conditions such as constipation, depression, or anxiety that may impact meal intake.

B.  Change the People

  1. Provide an adequate number of well-trained staff.
  2. Deliver an individualized approach to meals, including choice of food and, tempo of assistance.
  3. If meal patterns indicate one meal eaten better than other (100% breakfast intake, 25% dinner), provide double meal portions for the preferred meal.
  4. Position of caregiver relative to older adult: caregiver seated beside older adult, on older adult’s dominant side; eye contact; older adult able to see facial expressions and feeding behaviors emulated by the caregiver with visual cueing.
  5. Self-feeding: Encouragement to self-feed with multiple methods based on functional ability; allow time for person to complete task, rather than provide assistance to minimize time.
  6. Cueing:
    • Verbal: Short statements of simple commands to direct meal behavior (e.g., here is your corn, open your mouth, swallow the food).
    • Visual: Mimic behavior you want person to do (e.g., pretending to move food from plate to food to imitate eating).
    • Sensorimotor: Using Handfeeding techniques with modifications based on person’s cognitive, sensory, and functional abilities.
  7. Mealtime rounds: Interdisciplinary team to examine multifaceted process of meal service, environment, and individual food preferences.

C.  Change the Place

  1. Odor: Food prepared in area adjacent to or in dining area. The smell and sounds of food being prepared can facilitate understanding of impending mealtime and stimulate appetite.
  2. Adaptive equipment: Available, appropriate, and clean; caregivers and/or older adult knowledgeable in use; occupational therapist assists in evaluation.
  3. Noise level: Environmental noise from music, caregivers, and television is minimal; personal conversation related between person and caregiver is encouraged.
  4. Music: Pleasant, preferred by patient.
  5. Light: Adequate and nonglaring versus dark, shadowy, or glaring.
  6. Dining or patient room: Encourage the older adult to eat in the dining room to increase food intake, personalize the dining room; no treatments or other activities occurring during the mealtime; no distractions.
  7. Tableware: Use of standard dinnerware (e.g., glasses, cups, saucers, flatware) versus disposable tableware and bibs.
  8. Contrasting background/foreground: Use contrasting background and foreground colors with minimal design to aid person with decreased vision.
  9. Furniture: Older adult seated in stable armchair; table of appropriate height versus eating in wheelchair or in bed.

EVALUATION/EXPECTED OUTCOMES

A.  Change the Person

  1. Corrective and supportive strategies reflected in plan of care.
  2. Quality-of-life issues emphasized in maintaining social aspects of dining.
  3. Culture, personal preferences, and end-of-life decisions regarding nutrition respected.

B.  Change the People

  1. System disruptions at mealtimes minimized.
  2. Family and staff informed and educated to patient’s special needs to promote safe and effective meals.
  3. Maintenance of normal meals and adequate intake for the patient reflected in care plan.
  4. Competence in diet assessment; knowledge of and sensitivity to cultural norms and preferences for mealtimes reflected in care plan.

C.  Change the Place

  1. Documentation of nutritional status and eating and feeding behavior meets expected standard.
  2. Alterations in nutritional status; eating and feeding behaviors assessed and addressed in a timely manner.
  3. Involvement of interdisciplinary team (geriatrician, advanced practice nurse, dietitian, speech therapist, dentist, occupational therapist, social worker, pastoral counselor, ethicist) appropriate and timely.
  4. Nutritional, eating, and/or feeding problems modified to respect individual preferences and cultural norms.
  5. Adequate number of well-trained staff who are committed to delivering knowledgeable and individualized care.

FOLLOW-UP MONITORING

A.  Providers’ competency to monitor eating and feeding behaviors.

B.  Documentation of eating and feeding behaviors.

C.  Documentation of care strategies, and follow-up of alterations in nutritional status and eating and feeding behaviors.

D.  Documentation of staffing and staff education; availability of supportive interdisciplinary team.

ABBREVIATION

EdFED        Edinburgh Feeding Evaluation in Dementia

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

Batchelor-Aselage, M., Bales, C., Amella, E., & Rose, S. (2015). Dementia-related mealtime difficulties: Assessment and management in the long-term-care setting. In C. Bales, J. Locher, & E. Salzman (Eds.), Handbook of clinical nutrition and aging (3rd ed., pp. 287–302). New York, NY: Springer. Evidence Level V.

Batchelor-Murphy, M. (2018). 2018 update of the handfeeding demonstration video [Video file]. Retrieved from https://-melissabphd.com/NOSH

Groher, M. (1997). Dysphagia: Diagnosis and management. Boston, MA: Butterworth-Heinemann.

Katz, S., Downs, T., Cash, H., & Grotz, R. (1970). Progress in the development of the index of ADL. The Gerontologist, 10(1), 20–30. doi:10.1093/geront/10.1_part_1.20. Evidence Level IV.

Watson, R. (1996). The Mokken scaling procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia. International Journal of Nursing Studies, 33(4), 385–393. doi:10.1016/0020-7489(95)00058-5. Evidence Level IV.