WHY: Older adults with dementia are at high risk for eating and feeding difficulties, resulting in low food and fluid intake. Depending on the severity of cognitive impairment, they may forget to eat, forget they have eaten, or eat things that are not food. Independent eating performance is also compromised, resulting in difficulty with specific tasks (e.g., inability to use utensils, difficulty moving food or fluid to their mouth, chewing, and swallowing) (Aselage, 2010; Volkert et al., 2024). With an estimated 7.4 million Americans age 65 and older now living with some form of dementia, nurses in every setting will care for people with these difficulties (Alzheimer’s Association, 2026). Eating difficulties may have existed before hospitalization, but they are likely to worsen in the hospital because people with dementia often become more confused in an unfamiliar place.

Factors that reduce appetite and food and fluid intake in other older patients (e.g., pain, medications, nausea, dental and oral problems, and special diets) also affect patients with dementia, who are less able to understand and cope with them. Because of their cognitive and related communication impairments, patients with dementia may not be able to tell anyone they are hungry or that they need help eating or more time to chew and swallow. When staff members try to help, some patients with dementia resist, push the food away, refuse to open their mouths, or spit food out. These should be interpreted as signals of a problem, not necessarily a refusal to eat (Batchelor et al., 2025; Faraday et al., 2021)

BEST TOOL: Assessment can be challenging because of patients’ cognitive and related communication impairments. The Edinburgh Feeding Evaluation in Dementia scale (EdFED) is a valid and reliable observational instrument that nurses can use to identify eating and feeding difficulties and determine the level of assistance needed (Watson & Deary, 1994). The EdFED was developed and tested extensively with nurses in  psychogeriatric units, nursing homes and is being translated for use outside of English-speaking groups, including Canadian-French, Chinese, Italian, Spanish, and Turkish to date (Bagnasco et al., 2015; Côté et al., 2018; Lin & Chang, 2003; Saucedo Figueredo et al., 2018; Uyar et al., 2022). A recent systematic review of 45 instruments that assess eating ability and mealtime behaviors in persons living with dementia rated the EdFED among the three highest-quality instruments available (Lee et al., 2024).

TARGET POPULATION: Older adults with diagnosed or suspected moderate to late-stage dementia.

VALIDITY AND RELIABILITY: The EdFED scale was developed through Mokken scaling of items and factor analysis. Factor analysis of responses in a study of 196 older persons with dementia demonstrated that items could be reduced to three groups of indicators and the three groupings were found to be the best fit through Structural Equation Modeling in 345 patients (Watson & Deary, 1997a, 1997b). These indicators include: nursing interventions (first three items); patient behavior – obstinacy/aversion and passivity (next seven items) and, an indicator of feeding difficulty (last item). This instrument has been used clinically in nursing home settings and in several community-based studies and among 24 pairs of raters was found to have more than acceptable inter-rater (r = .59, p = 0.013) and intra-rater (r = .95, p < 0.0001) reliability (Watson et al., 2001). More recently, a Turkish validation study of 200 people with dementia confirmed the original three-factor structure without modification and reported a content validity index of 0.95 (Uyar et al., 2022).

STRENGTHS AND LIMITATIONS: The EdFED is not clinically diagnostic, but it allows the assessor to determine the level of impairment as well as evaluate the need for the handfeeding support; psychosocial and clinical interventions, such as referrals for speech therapy; environmental modification; dietary alterations; and communication techniques. Mokken scaling of the seven behavior items (items 4-10) forms a hierarchy of mealtime behavior so that interventions can be tailored to observed behaviors. The EdFED may be used as both a caregiver report and observational instrument. Because eating and assistance with meals is by definition a dyadic relationship (caregiver and care receiver) and it occurs within an established environment (home, institution, restaurant), the nature of the relationship as well as the environmental culture and context needs to be evaluated if the individual with dementia is having poor outcomes (Batchelor et al., 2025; Faraday et al., 2021; Wu et al., 2020)

MORE ON THE TOPIC:

Alzheimer’s Association. (2026). 2026 Alzheimer's disease facts and figures. Alzheimer’s & Dementia, 22(4), Article e71345. https://doi.org/10.1002/alz.71345

Aselage, M. B. (2010). Measuring mealtime difficulties: Eating, feeding and meal behaviours in older adults with dementia [Review]. Journal of Clinical Nursing, 19(5-6), 621-631. https://doi.org/10.1111/j.1365-2702.2009.03129.x 

Bagnasco, A., Watson, R., Zanini, M., Rosa, F., Rocco, G., & Sasso, L. (2015, Nov). Preliminary testing using Mokken scaling of an Italian translation of the Edinburgh Feeding Evaluation in Dementia (EdFED-I) scale. Appl Nurs Res, 28(4), 391-396. https://doi.org/10.1016/j.apnr.2015.02.003 

Batchelor, M. (2020). Optimizing Mealtimes for Persons Living With Dementia. In M. Boltz, L. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based Geriatric Nursing Protocols for Best Practice (6th ed., pp. 527-544). Springer Publishing Company, LLC. 

Batchelor, M., Smaoui, S., Passos, L., & Lui, W. (2025). Behavioral Challenges and Adaptive Strategies in Providing Mealtime Care to Residents with Dementia: A Qualitative Study of Nursing Home Clinical and Administrative Staff. Journal of Applied Geronology. 

Côté, C., Gagnon, C., & Payette, H. (2018, Dec). Adaptation transculturelle en français du Edinburgh Feeding Evaluation in Dementia (EdFED) Scale : un questionnaire pour évaluer les difficultés à s'alimenter de personnes âgées présentant des troubles cognitifs en centre d'hébergement. Can J Aging, 37(4), 474-481. https://doi.org/10.1017/s0714980818000351 

Faraday, J., Abley, C., Beyer, F., Exley, C., Moynihan, P., & Patterson, J. (2021, Nov). How do we provide good mealtime care for people with dementia living in care homes? A systematic review of carer-resident interactions. Dementia (London), 20(8), 3006-3031. https://doi.org/10.1177/14713012211002041 

Lee, K., Kim, S., & Liu, W. (2024, Jul-Aug). Assessing eating ability and mealtime behaviors of persons living with dementia: A systematic review of instruments. Geriatr Nurs, 58, 76-86. https://doi.org/10.1016/j.gerinurse.2024.05.005 

Lin, L.-C., & Chang, C.-C. (2003, 2003/10/01). A Chinese Translation of the EdFED-Q and Assessment of Equivalence. Alzheimer Disease & Associated Disorders, 17(4), 230-235. 

Saucedo Figueredo, M. C., Morilla Herrera, J. C., San Alberto Giraldos, M., López Leiva, I., León Campos, Á., Martí García, C., García Mayor, S., Kaknani Uttumchandani, S., & Morales Asencio, J. M. (2018). Validation of the Spanish version of the Edinburgh Feeding Evaluation in Dementia Scale for older people with dementia. PLoS One, 13(2), e0192690. https://doi.org/10.1371/journal.pone.0192690 

Uyar, F., Özmen, D., & Watson, R. (2022, Nov). The Edinburgh feeding evaluation in dementia (EdFED) scale: A Turkish validity and reliability study. Int J Older People Nurs, 17(6), e12470. https://doi.org/10.1111/opn.12470 

Volkert, D., Beck, A. M., Faxén-Irving, G., Frühwald, T., Hooper, L., Keller, H., Porter, J., Rothenberg, E., Suominen, M., Wirth, R., & Chourdakis, M. (2024, Jun). ESPEN guideline on nutrition and hydration in dementia - Update 2024. Clin Nutr, 43(6), 1599-1626. https://doi.org/10.1016/j.clnu.2024.04.039 

Watson, R., & Deary, I. J. (1994). Measuring feeding difficulty in patients with dementia: multivariate analysis of feeding problems, nursing intervention and indicators of feeding difficulty. Journal of Advanced Nursing, 20(2), 283-287. https://doi.org/10.1046/j.1365-2648.1994.20020283.x 

Watson, R., & Deary, I. J. (1997a, Dec). Feeding difficulty in elderly patients with dementia: confirmatory factor analysis. Int J Nurs Stud, 34(6), 405-414. https://doi.org/10.1016/s0020-7489(97)00033-3 

Watson, R., & Deary, I. J. (1997b, Jul). A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. Journal of Advanced Nursing, 26(1), 25-32. https://doi.org/10.1046/j.1365-2648.1997.1997026025.x 

Watson, R., MacDonald, J., & McReady, T. (2001). The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2): inter- and intra-rater reliability. Clinical Effectiveness in Nursing, 5(4), 184-186. https://doi.org/10.1054/cein.2001.0234 

Wu, Q., Qian, S., Deng, C., & Yu, P. (2020). Understanding Interactions Between Caregivers and Care Recipients in Person-Centered Dementia Care: A Rapid Review. Clin Interv Aging, 15, 1637-1647. https://doi.org/10.2147/cia.S255454 

 

Edinburgh Feeding Evaluation in Dementia scale (EdFED)*

Score answers to questions 1-10: never (0), sometimes (1), often (2)

 

Item

Does the patient require close supervision while feeding?

Does the patient require physical help with feeding?

Is there spillage while feeding?

Does the patient tend to leave food on the plate at the end of the meal?

Does the patient ever refuse to eat?

Does the patient turn his head away while being fed?

Does the patient refuse to open his mouth?

Does the patient spit out his food?

Does the patient leave his mouth open allowing food to drop out?

Does the patient refuse to swallow?

 

(Total scores range from 0 to 20, with 20 being the most serious. Scores can be used to track change.)

Score indicates appropriate level of assistance required by patient: supportive-educative; partly compensatory; wholly compensatory

* Used with permission of author, R. Watson.

 

Other Essential Assessment Guidelines

 

Assess Pre-event/ long-term care placement eating and feeding behaviors: The nurse should ask the family or other caregivers whether the patient usually feeds themself and what assistance is generally provided. This information is essential to establish a realistic target for maintaining the patient's self-feeding ability and should be included in any care transitions as the person moves between settings.

Complex Behaviors Requiring Additional Assessment: Feeding behaviors are only part of the puzzle caregivers must manage. People with dementia and eating difficulties face cognitive challenges (due to memory loss, difficulty paying attention, and the decreasing ability to use and understand language) and functional challenges (due to progressive sensory loss [vision, hearing, taste, smell] and the return of the palmar reflex [touch] in advanced dementia) that are often unrecognized and inadequately supported. These challenges can lead to a person with dementia being labeled as aggressive, uncooperative, and difficult to feed. Additionally, nursing home staff identify wandering and dysphagia as a common challenge during mealtimes so the behaviors could be related to the person’s inability to sit still for meals or swallow (Batchelor, 2020; Batchelor et al., 2025).