Eating and Feeding Issues in Older Adults with Dementia:Part II: Interventions

Best Practices in Nursing Care for Hospitalized Older Adults with dementia from The John A. Hartford Institute for Geriatric Nursing and the Alzheimer's Association

Issue Number D11.2, 2007
Series Editor: Marie Boltz, PhD, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing
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WHY: Inadequate food and fluid intake can result in malnutrition, dehydration, skin breakdown, delirium, and increased morbidity and mortality.¹ In the hospital, patients with dementia are more likely than other older patients to lose self-care abilities, including self-feeding, in the hospital and much less likely to regain these abilities after discharge.^2,3 Consequently providing interventions that are tailored to the patients’ cognitive and related communication abilities can 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 patient’s self-feeding ability, to the extent possible.¹ Since the care will be carried out in part by certified nursing assistants (CNAs) and other staff, the nurse must communicate the plan and oversee and monitor its implementation. A patient’s eating and feeding behaviors often change during a hospital stay, requiring the nurse to reassess regularly and adjust the plan as needed. This Try This provides general guidelines that can be individualized to the patient’s needs.

TARGET POPULATION: Hospitalized older adults with diagnosed or suspected dementia.

REFERENCES:

1. Amella, E.J. (2004). Feeding and hydration issues for older adults with dementia. In M. Mezey, E. Capezuti, & T. Fulmer (Eds.). Care of Older Adults: Nursing Clinics of North America, 39(3), 607-623.
2. McCusker, J., Kakuma R., & Abrahamowicz, M. (2002). Predictors of functional decline in hospitalized elderly patients: A systematic review. Journal of Gerontology: Medical Sciences, 57A(9), M569-577.
3. Sands, L.P., Yaffe, K., Covinsky K., Chren, M., Counsel, S., Palmer, R., Fortinsky, R., & Landefeld, C.S. (2003). Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. Journal of Gerontology: Medical Sciences, 58A(1), 37-45.
4. Kayser-Jones, J. & Schell, E. (1997). Mealtime experience of a cognitively impaired elder: Ineffective and effective strategies. Journal of Gerontological Nursing, 27(7), 33-39.
5. Simmons, S.F., & Schnelle, J.F. (2004). Individualized feeding assistance care for nursing home residents: Staffing requirements to implement two interventions. Journal of Gerontology: Medical Sciences, 59A(9), 966-973.
6. Nichols, J.N. (2006). Windows to the heart: Creating an acute care dementia unit. In N. M. Silverstein, & K. Maslow (Eds.), Improving hospital care for people with dementia. NY: Springer Publishing Co., Inc.
7. Amella E.J. (1999). Factors influencing the proportion of food consumed by nursing home residents with dementia. JAGS, 47(7), 879-885.
8. Alzheimer’s Association. (2005). Assisted Oral Feeding and Tube Feeding, available at www.alz.org/Resources/FactSheets/FSOralfeeding.pdf.
9. Finucane, T.E., Christmas, C., & Travis, K. (1999). Tube feeding in patients with advanced dementia: A review of the evidence. JAMA, 282(14), 1365-1370.

MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org.

Kayser-Jones, J., & Pengilly, K. (1999) Dysphagia among nursing home residents. Geriatric Nursing, 20(2), 77-82.

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.

TIPS FOR AVOIDING AND REDUCING EATING AND FEEDING DIFFICULTIES:
Although patients with dementia differ greatly in their specific eating and feeding behaviors, the following general tips can help to avoid or reduce common problems.

• Reduce distractions; turn off the TV; avoid interruptions and people entering the room.
• Whenever possible assist the patient to eat out of bed, seated in chair that promotes good posture and comfort.
• Assess and palliate pain (see Try This; Assessing Pain in Persons with Dementia).
• Provide oral hygiene and allow the patient to wash his/her hands.
• Assure that the patient has his/her dentures and glasses, is properly positioned, and can see and reach the tray.
• Arrange the tray to facilitate self-feeding; rearrange items for easy access; remove plate and cup covers; unwrap utensils; open packets; cut up food; butter bread.
• Simplify the meal presentation; serve one food at a time; remove unnecessary utensils.
• Provide finger foods if the patient experiences difficulty managing eating utensils.
• Remove items that should not be eaten and hot items that could be spilled.
• Use verbal cueing and prompting to encourage self-feeding (for example, say ‘pick up your spoon,’ ‘take a bite,’ ‘chew,’ ‘swallow’).
• Demonstrate eating motions so the patient can imitate.
• Use hand-over-hand technique to initiate and guide self-feeding.
• If physical assistance is necessary, provide it and continue verbal cueing and encouragement.
• Consider a referral to a Speech-Language Pathologist for persons experiencing difficulties with eating.

Social Interaction: Eating is generally a social activity, and the social and environmental context of meals provides critical cues for recognition of food and appropriate eating behaviors in people with dementia1,7. While it is difficult to create a normal mealtime environment for hospital patients, staff who assist patients with eating and feeding should be at eye level and interact socially with each patient keeping the focus of the conversation on the meal.

Involving Families: Many family members are willing and able to assist at mealtimes. If they have assisted with eating and feeding at home, their involvement can help avoid eating problems and can provide a more familiar social context for the patient. Mealtimes provide an opportunity for families to learn more about nutritional issues and management of eating and feeding problems. Available resources include:

1. About Eating, available free at www.alz.org/Resources/FactSheets/FSEating.pdf, and in Spanish at www.alz.org/Resources/Diversity/downloads/HL_FSSpresentacion.pdf, and

2. Managing Nutrition in Dementia Care: A Supportive Approach for Caregivers, available for $5 from Alzheimer’s Association, Western New York Chapter, (716) 626-0600, or online at www.alzwny.org.

Training and Mentoring CNAs: CNAs and other staff who assist patients with eating and feeding and who are under pressure to assist many patients in a short time may resort to physical assistance too soon and then feed too fast. CNAs should be mentored to provide only the level of physical assistance that is needed, to continue using verbal cueing and prompting even if they are providing physical assistance, and to feed at a rate that is safe and comfortable for the patient.^1,4 These approaches take time.⁵ Nurses need to advocate with hospital administrators for policies and resources to achieve the dual objectives of adequate food and fluid intake and maintenance of patients’ self-feeding abilities (e.g., sufficient staff and time between tray delivery and pick up).⁶

Tube Feeding: Hospital patients with later stage dementia may have a feeding tube placed, often as a temporary measure to assure adequate nutrition. There is no evidence-base to show any change in outcomes with tube feeding and, it is often difficult to remove the tube later. Ethicists and clinicians generally agree that tube feeding is neither ethically required nor clinically beneficial for most patients with late-stage dementia.^8,9 Hospital policies and resources should be directed to help staff and families make informed decisions to initiate or continue tube feeding. Irrespective of placement of a feeding tube, hand feeding should be offered and care practices adapted to preserve patient dignity and maximize comfort.¹ 

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