WHY: Inadequate food and fluid intake can result in malnutrition, dehydration, skin breakdown, delirium, and increased morbidity and mortality (Mitchell et al, 2009). In the nursing home, residents with frailty (including inability to perform activities of daily living) and cognitive impairments are more likely than other older residents to die within a year (Matusik et al., 2012). Consequently, providing interventions that are tailored to the individual’s cognitive and related communication abilities may dramatically impact both immediate as well as long-term health and function. 

BEST PRACTICE: Best practice requires an individualized plan of care with the dual objectives of providing adequate food and fluid intake and maintaining the individual’s self-feeding ability, to the extent possible (Batchelor-Murphy et al., 2016). Since care may be provided in part by unlicensed staff in the institution or family caregivers at home upon discharge, the nurse must communicate the plan to all members of the care team including the patient and family, and oversee and monitor its implementation in the institution. An individual’s eating and feeding behaviors often change based on physical, emotional and contextual issues, requiring the nurse to reassess regularly and adjust the plan as needed. This Try This:® provides general guidelines that can be person-centered to the  individual’s needs.

TARGET POPULATION: Older adults with diagnosed or suspected dementia. 

VALIDITY AND RELIABILITY: The EdFED-Q 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 (Watson & Deary, 1997a) and the three groupings were found to be the best fit through Structural Equation Modeling in 345 patients (Watson & Deary, 1997b). These indicators include: patient behavior – obstinacy/aversion and passivity (seven items); nursing interventions (three items); and, an indicator of feeding difficulty (one item). This instrument has been used clinically in nursing home settings and in one community-based study 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 < .0001) reliability (Watson, McDonald, & McReady, 2001).

MORE ON THE TOPIC:

AGS Choosing Wisely Workgroup. (2013). American Geriatrics Society identifies five things that healthcare providers and patients should question. JAGS, 61(4), 622-631.

Batchelor-Murphy, M., & Crowgey, S. (2016). Mealtime Difficulties in Dementia. In M. Boltz (Ed.), Evidence-Based Geriatric Nursing Protocols for Best Practice (5th ed.) (pp. 417-429). New York, NY: Springer Publishing Company.

Fischberg, D., Bull, J., Casarett, D., Hanson, L.C., Klein, S.M., Rotella, J., Storey, C.P. Jr., & Teno, J.M., American Academy of Hospice and Palliative Medicine Choosing Wisely Task Force. (2013). Five things physicians and patients should question in hospice and palltive medicine. Journal of Pain and Symptom Management, 45(3), 595-605.

Liu, W., Cheon, J., & Thomas, S.A. (2013). Interventions on mealtime difficulties in older adults with dementia: A systematic review. International Journal of Nursing Studies, 50, 463-464.

Matusik, P., Tomaszewski, K., Chmielowska, K., Nowak, J., Nowak, W., Parnicka, A., Dubiel, M., Gasowski, J., & Grodzicki, T. (2012). Severe frailty and cognitive impairment are related to higher mortality in 12-month follow-up of nursing home residents. Archives of Gerontology and Geriatrics, 55(1), 22-24.

Mitchell, S.L., Teno, J.M., Kiely, D.K., Shaffer, M.L., Jones, R.N., Prigerson, H.G., Volicer, L., Givens, J.L., & Hamel, M.B. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361, 1529-38.

Watson, R., & Dreary, I.J. (1997a). A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. Journal of Advanced Nursing, 26(1), 25-32.

Watson, R., & Dreary, I.J. (1997b). Feeding difficulty in elderly patients with dementia: confirmatory factor analysis.  International Journal of Nursing Studies, 34(6), 405-414.