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Staff awareness of food and fluid care needs for older people with dementia in residential care: A qualitative study
Abstract
Aims and objectives:
To examine awareness of aged care home staff regarding daily food and fluid care needs of older people with dementia.
Background:
Older people in residential care frequently are malnourished, and many have dementia. Staff knowledge of the food and fluid needs of people with dementia is limited. Qualitative research on this topic is scarce but can provide insight into how nutrition and hydration care may be improved.
Design:
Qualitative, interview-based study.
Methods:
Eleven staff in a range of positions at one care home were interviewed regarding their perceptions of current and potential food/fluid care practices. Transcripts were coded and analysed thematically.
Results:
Key food and fluid issues reported by these staff members were weight loss and malnutrition, chewing and swallowing difficulties (dysphagia), and inadequate hydration. Staff identified a number of current care practices that they felt to be effective in facilitating older people's food and fluid intake, including responsiveness to their needs. Staff suggestions to facilitate food and fluid intake centred on improved composition and timing of meals, enhanced physical and social eating environment, and increased hydration opportunities. Staff commented on factors that may prevent changes to care practices, particularly the part-time workforce, and proposed changes to overcome such barriers.
Conclusions:
Staff were aware of key food and fluid issues experienced by the older people in their care and of a range of beneficial care practices, but lacked knowledge of many promising care practices and/or how to implement such practices.
Relevance to clinical practice:
Staff need to be supported to build on their existing knowledge around effective food and fluid care practices. The numerous ideas staff expressed for changing care practices can be leveraged by facilitating staff networking to work and learn together to implement evidence-based change.
... We included 15 qualitative studies, 2 quantitative studies (Noble & Sweeney, 2018;Odgaard & Kothari, 2019), and two mixed-method studies (Brady et al., 2016;Robison et al., 2015). Out of the different aspects of ADL, we found six studies on eating and drinking (Carlsson et al., 2012;Forss et al., 2018;Heaven et al., 2013;Lea et al., 2017;Liu et al., 2018;Robison et al., 2015), five studies on mobility care , three studies on continence care (Borglin et al., 2020;Brady et al., 2016;Helewa et al., 2017), and two studies on two or more aspects of ADL care (King et al., 2018;Liebel et al., 2012). ...
... In addition to the perspectives of nursing professionals, we used the perspectives of care receivers, informal caregivers, or other disciplines as sources of information (Brady et al., 2016;Forss et al., 2018;Heaven et al., 2013;Helewa et al., 2017;King et al., 2018;Kuipers et al., 2016;Lea et al., 2017;Liebel et al., 2012;Robison et al., 2015;Taylor et al., 2014). ...
... If someone has no idea how to wash themselves, I can think that someone needs to get as independent as possible, but how do I get there? (WC2, Nursing professional) Another knowledge gap relates to the role of risk detection and prevention and insufficient awareness and knowledge about the use of care in ADL, as early detection of health problems and prevention, for example, lacking awareness of stimulating independence and physical activity are a proactive way to prevent health risks and problems (EP, WC).In education and training, nursing professionals identify gaps in almost all elements of ADL, including continence care(Borglin et al., 2020;Brady et al., 2016), eating and drinking(Lea et al., 2017), oral care(De Visschere et al., 2015), and mobility(Lavallee et al., 2018) ...
Introduction:
Supporting care receivers in Activities of Daily Living (ADL), irrespective of diagnosis, setting, or cultural background, lies at the heart of fundamental nursing care. The pursuit of quality ADL care becomes increasingly challenging with the changing complexity of care needs. ADL care delivery is often undervalued and is considered a low-status task despite its crucial importance to care receivers. This study aims to synthesize challenges in ADL care irrespective of the care setting.
Methods:
In the mixed qualitative methods study, we used expert panel consultations, world café sessions, and a rapid literature review. For data analysis, we simultaneously analyzed the three data sets using inductive and deductive inquiry.
Results:
We identified four challenges and their corresponding subthemes. They are (1) Undervalued common-sense work versus complex, high-skilled care provision; (2) Limitations in professional reflective clinical decision-making; (3) Missed opportunities for shared ADL decisions; and (4) Meeting ADL care needs in a high-throughput system.
Conclusion:
These challenges reveal the complexity of ADL care and how its paradoxical narrative relates to the conditions in which nursing professionals struggle to create opportunities, for reflective clinical reasoning and shared ADL decisions, by facing organizational and environmental barriers.
Clinical relevance:
This study is relevant to nursing professionals, care organizations, policymakers, and researchers aiming to improve ADL care and provide insights into challenges in ADL care. This study forms the starting point for a changing narrative on ADL nursing care and subsequent quality improvements in the form of, for example, guidelines for nursing professionals.
... There are many other factors which influence engagement in the eating process, beyond assessing the ability to move food from the plate or bowl to the mouth. The published literature revealed the importance of a person-centred approach to mealtime care, namely: considering persons' food preferences, the time of day and related dementia symptoms individual to each person, the meaning and cultural significance of food to that person, and the presence of familiar people at the mealtime (Lin et al. 2010;Gilmore-Bykovskyi 2015;Hanssen and Kuven 2016;Nell et al. 2016;Chang et al. 2017;Lea et al. 2017;Murphy et al. 2017). ...
... Other publications identified in the literature search supported the value of person-centred mealtime care in improving eating performance. Interviews and focus groups were recently conducted with residential home care givers in New Zealand (Nell et al 2016), the UK and Australia (Lea et al. 2017 Part of a person-centred approach is to involve people who are familiar to the person with dementia in mealtimes within the institution they are based. Lin et al. (2010) noticed a significant difference in food intake when the frequency of family visits increased. ...
... Contextual factors, such as the surroundings and eating environment, were widely considered to be significant in influencing mealtimes for people with dementia (Reed et al. 2005;Chang et al. 2006;Change and Roberts 2008;Hung and Chaudhury 2011;Slaughter et al. 2011;Chang 2012;Hanssen and Kuven 2016;Nell et al. 2016;Chang et al. 2017;Lea et al. 2017;Liu et al 2017). ...
b>Background and aims
Poor food and fluid intake in older people with dementia is reported in acute hospitals globally. Poor intake can lead to increased mortality rates and longer hospital stays. Mealtimes are a key component of nutritional care in hospitals and involve complex cognitive processes. Additional sensory, behavioural and physical challenges make the process of eating difficult for people with dementia. There is limited research identifying factors influencing mealtime experience and engagement in the eating process for people with dementia during admission to an acute hospital ward. This research project is the first to explore the phenomena of mealtimes for people with dementia in hospital from the perspective of an Occupational Therapist.
The aims of this research project were addressed in two phases. Phase 1 aimed to describe factors observed to influence mealtime experience and engagement in the eating process. Phase 2 explored hospital staff perspectives of factors influencing mealtime experience and engagement. The research project also aimed to identify any interventions or strategies to improve mealtimes for people with dementia in the participating hospitals.
Methods
A fixed, sequential mixed methods design was applied to the research project, which was conducted in two phases. Phase 1 adopted a concurrent mixed methods design. Structured observations, using Dementia Care Mapping, described levels of well-being and engagement at mealtimes. Qualitative field notes supplemented this data to add depth and meaning to the quantitative coding. Quantitative and qualitative data were merged to present a joint display of the combined findings. Phase 2 was informed by the findings from phase 1. Semi-structured
interviews were conducted with staff caring for people with dementia on the participating hospital wards.
Findings
Participants were observed to experience mealtimes positively and engage well in the eating process for 24% of the time. For 19% of the time people experienced mealtimes negatively and were disengaged from the eating process. Factors influencing experience and engagement at mealtimes derived from a plethora of complex variables. System-driven factors, with a task-focused approach to care, negatively influenced engagement in the eating process. Person-centred care, promoting meals as a meaningful occupation for individuals, encouraged positive experiences and focused engagement in the eating process at mealtimes. The hospital environment is not always conducive to encouraging cognitive access to mealtimes.
Conclusions and implications for practice
The findings were applied to the Person-Environment-Occupation Fit model. The closer the three elements fit, the greater the positive influence on occupational performance, specifically engagement in the eating process. Recommendations are outlined from the findings, which can be applied to the model, to promote mealtimes as a meaningful occupation. These include family and carer visitor involvement in the meal process, the use of volunteers, a separate dining environment, training and education for staff, improving food selection processes and using Occupational Therapy expertise in providing mealtime care.
... To improve fluid intake, it might be an opportunity to include nursing staff and care providers. Increasing staff awareness and especially knowledge regarding the detection of low-intake dehydration, interventions, as well as the adequate amount of fluid intake per day, seems essential [36,37]. Maybe not only by educating, but by actively increasing awareness and facilitation [38]. ...
... Furthermore, drinking (and eating) has a social aspect and as many older adults have reduced social contacts, it might be an opportunity to develop supporting interventions. According to caregivers' perception, interventions focusing on the social aspect of food and fluid intake might be useful [36,37]. ...
Low-intake dehydration is a common and often chronic condition in older adults. Adverse health outcomes associated with low-intake dehydration in older adults include poorer cognitive performance, reduced quality of life, worsened course of illness and recovery, and a high number of unplanned hospital admissions and increased mortality. The subjective methods to assess (risk of) dehydration are not reliable, and the evidence about preventive measures are also limited. So is the knowledge about the optimal intake of beverages per day. This narrative review presents the state of the science on the role of low intake hydration in older adults. Despite its simple cause—the inadequate intake of beverages—low-intake dehydration appears to be a very complex problem to address and much more research is needed in the area. Based on the existing evidence, it seems necessary to take setting specific differences and individual problems and needs into account to tackle dehydration in older adults. Further, it is necessary to increase awareness of the prevalence and severity of low-intake dehydration among older adults and in nursing staff in care homes and hospitals as well as among caregivers of older adults living at home.
... Actualmente, pocos estudios han aludido al conocimiento formal que tienen o deberían tener sobre estos aspectos los técnicos en enfermería con mención en geriatría; como principales resultados se han hallado dificultades relacionadas con la falta de información en su proceso formativo o de estrategias utilizables en estos contextos y problemas en la identificación de sintomatología asociada con los trastornos de la deglución (15)(16)(17)(18). ...
... Basándose en los datos recolectados por el personal entrevistado de cada Eleam, hay falta de conocimiento sobre cómo aplicar técnicas, maniobras, ejercicios, cambios posturales, entre otras, que potencien una deglución sana, segura, efectiva y contextualizada a los usuarios, lo cual es concordante con otros estudios internacionales (15)(16)(17)(18). En cuanto a la detección, son capaces de reconocer si el adulto mayor residente presenta algún tipo de cambio cuando la manifestación es evidente y de importancia (cianosis, tos, carraspeo o falta de aire); pero la valoración y relevancia que se le da a este hallazgo que desencadena el problema deglutorio es infravalorado por parte del personal, lo que coincide con lo documentado tanto en el estudio de Kayser-Jones y Schell como en el de Pelletier (15,16). ...
Introducción:
se busca profundizar acerca del manejo cotidiano de las complicaciones de la deglución en centros del adulto mayor, las cuales generalmente asume el técnico o auxiliar de enfermería (TENS), quienes son los encargados de su alimentación.
Materiales y métodos:
se llevó a cabo un estudio con enfoque cualitativo basado en la teoría fundamentada. Se realizaron grupos de discusión y entrevistas en profundidad a dieciocho TENS de tres establecimientos de larga estadía en la Araucanía (Chile). Se analizaron los datos a través de codificación abierta y axial, con los cuales se obtuvieron seis categorías analíticas sobre esta situación.
Resultados:
los TENS y los auxiliares de la alimentación reportaron desconocimiento del uso y pertinencia de estas; además, comentaron que dichas maniobras las aprendieron mediante la observación a otros profesionales itinerantes dentro del centro, y no producto de la formación o trabajo interdisciplinario. Conclusión: dado el contexto y las limitaciones derivadas de la formación de los TENS, surge la necesidad de incrementar sus conocimientos y mejorar sus prácticas relacionadas con la deglución y alimentación, con el objetivo de disminuir el riesgo de ocurrencia de situaciones que agraven la salud de los adultos mayores. Se discute, así mismo, la pertinencia de que estos centros cuenten con profesionales capacitados en cuanto al abordaje de los trastornos de la deglución, pues ello contribuirá a mejorar este aspecto, en función del trabajo coordinado con el resto del equipo.
... Regardless of whether the experience of the care staff in palliative care at which is being felt by the care staff in regional locations. There seems to be the need for recognition of the support needed by the care staff in the hierarchy of the system and the resources required for them to be able to provide culturally appropriate care (Lea et al., 2017). It was apparent that key to the role of care staff in caring for the CALD service users at the end of life was in creating a supportive organisational culture for the care staff who seem to be battling and striving to succeed against the odds. ...
... The current study contributes to the international literature by identifying the barriers to providing culturally appropriate care to the Punjabi Indians and similar CALD groups experienced by this valuable sector of the aged care workforce. The current study further contributes by confirming the need of organisational support to build on care staff's cultural knowledge through targeted training and education, which has also been identified in the literature (Chisholm et al., 2011;Lea et al., 2017). ...
This research project deals with the important topic of palliative care services in regional New South Wales (NSW), Australia. There is an increasing emphasis on meeting the healthcare needs of culturally and linguistically diverse (CALD) communities in Australia. Negotiating the point of culturally appropriate care and the transition to palliative care requires effective communication and sensitivity to socio-cultural, religious, spiritual and linguistic needs. This can be a challenging process for clinicians, patients, and families.
Employing Leininger’s Trans-Cultural Theory, Engel’s biopsychosocial model and Fricker’s concept of “epistemic injustice” in context with healthcare for marginalised migrant groups, this exploratory empirical case study was undertaken in three towns of the Riverina region of NSW (Wagga Wagga, Griffith, and Albury). A burgeoning population group of Punjabi Indians residing in the Riverina region was chosen for this study. Group interviews were conducted with six locally based Punjabi Indian families that had experienced care services at their local residential aged care services. To complement and provide a more comprehensive picture, group interviews were also conducted with care staff (nurses and personal care assistants) of residential aged care facilities (RACFs) in the same towns.
In line with the exploratory nature of this research, a qualitative approach was adopted utilising an interpretive phenomenological methodology in the design, implementation and presentation of findings of the research. The informants in the research were selected through a non-random, purposeful selection process. Thematic analysis was used to determine the major findings of this study.
The study identified barriers to appropriate and equitable palliative care and services for regionally based Punjabi Indians, with important implications for the wider CALD population. The study argues that the dominant medical knowledge base in context to palliative care services does not adequately account for experiences of the CALD population. To build a stronger foundation for the quality of culturally appropriate care, the palliative care sector must undertake fundamental change. Central to this re-envisioned approach is respect for cultural and religious practices that one is required to follow at end of life. The study proposes strategies to strengthen palliative care delivery models in regional areas of NSW by providing insight from consumers’ and care providers’ perspectives on processes that continue to be recommended in state and national policies as best-practice palliative care for people from diverse backgrounds. The study recommends a human rights framework where stronger ethics of care and cultural respect is demonstrated through the palliative care service delivery model.
... While NAs perceive optimal mealtime care as a priority, they face competing demands and goals during mealtimes (Palmer, Parker, Berlowitz, Snow, & Hartmann, 2018). NAs report lacking knowledge and skills to manage challenging mealtime behaviors and overcome residents' functional declines through assessment and intervention (Hammar, Swall, & Meranius, 2016;Lea, Goldberg, Price, Tierney, & McInerney, 2017). Current mealtime assistance and staff training programs primarily focus on the use of hand feeding skills, rather than person-centered care approaches including positive engagement, motivation, quality communication, and dyadic interaction to enhance resident participation and eating performance (Batchelor- Murphy et al., 2017;Chen et al., 2016;Liu et al., 2014;. ...
... Qualitative studies have been conducted among staff, families, and residents related to mealtime care in residential care settings. Perspectives on feeding beliefs (Pelletier, 2005), textured food (Austbo Holteng, Froiland, Corbett, & Testad, 2017), person-centered nutritional care (Murphy, Holmes, & Brooks, 2017), awareness of nutritional needs (Lea et al., 2017), and resident choice (Palmer et al., 2017) have been explored in a variety of care staff including nurses, dietary, NAs, administrators, and activity personnel. Perspectives of families and residents have also been explored regarding the mealtime experience (Milte et al., 2017), mealtime ethics (Hammar et al., 2016), and mealtime culture following the transition to residential care (Henkusens, Keller, Dupuis, & Schindel Martin, 2014). ...
Background and objectives:
Cognitively impaired individuals are at increased risk for functional and behavioral difficulties at mealtimes, leading to compromised eating performance, low food and fluid intake, and negative functional and nutritional outcomes. Nursing assistants are the most critical front-line care staff and best positioned to manage the personal and environmental factors that influence resident eating performance. Identifying nursing assistants' perceptions of barriers and facilitators to engaging residents in eating will provide important experientially based foundation for developing and testing evidence-driven interventions to promote mealtime care.
Methods:
A qualitative descriptive study was conducted in three sites: two nursing homes and one hospital gero-psychiatric inpatient unit. Six focus groups were conducted with a purposive sample of 23 nursing assistants who regularly provided mealtime care to residents with cognitive impairment. Interview questions addressed barriers and facilitators at resident, caregiver, environmental (facility), and policy levels in optimizing mealtime care. Audio recordings of focus groups were transcribed and analyzed using qualitative descriptive content analysis. Both barriers and facilitators were organized into a hierarchical taxonomy based on similarities and differences framed by the Social Ecological Model.
Results:
The majority of barriers and facilitators were at the caregiver level. Caregiver-level barriers included lack of preparation and training, competing work demands, time pressure, and frustration. Caregiver-level facilitators included caregiver preparation and motivational, technical, informational, and instrumental assistance. Environmental-level barriers and facilitators related to the physical, social, and cultural environment and facility practices. Only barriers to optimizing mealtime care were identified at resident and policy levels.
Conclusions:
Nursing assistants identified multilevel barriers as well as a wide range of caregiver and environmental facilitators to optimizing dementia mealtime care. Findings can inform the development and implementation of multifaceted innovative mealtime assistance and staff training programs to promote resident eating performance while fostering person-centered individualized mealtime care practice.
... Responsibilities of HCAs are often task centred and the task of assisting residents to eat is generally delegated to those without specific training in supporting residents with dysphagia to eat and drink safely (Greene et al., 2018;Lea et al., 2017;Payne & Morley, 2018;Wilson et al., 2019). In addition, we found that key elements of care such as prompting swallowing, pacing the rate at which food is offered and avoiding the use of spouted beakers, which are important to enhance the safety and experience of nutrition and hydration care for residents with dysphagia (Hansjee, 2019;RCSLT, 2022), were generally not mentioned in care plans or SLT recommendations. ...
Introduction
Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered.
Methods
Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents’ care plans and speech and language therapist recommendations.
Results
Written recommendations predominantly focused on food and fluid modification. Observations ( n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision.
Conclusion
Care homes need to be supported to establish a safe swallowing culture to improve residents’ safety and care experience.
What this paper adds
What is already known on this subject?
Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents.
There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia.
Care for nursing home residents at mealtimes is often task‐centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia.
What this study adds?
Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification.
Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas.
Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported.
What are the clinical implications of this work?
Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission.
Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia.
The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines.
Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely.
Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.
... They also endeavor to cultivate agreeable and gratifying meal experiences for persons living with dementia, encompassing the creation of a comfortable dining milieu [8,13]. This conducive setting serves as a cornerstone for nurturing the bond and rapport between caregivers and care recipients [14]. ...
This cross-sectional study explores caregivers’ perceptions of feeding/eating difficulties in persons living with dementia, their support provisions, and the associated burdens. Cognitive decline, behavioral symptoms, and physical issues contribute to the deterioration of feeding/eating activities in people with dementia. Inadequate support during mealtimes has adverse consequences. This study includes 31 caregivers who completed an online questionnaire with three sections: sociodemographic information, feeding/eating problems and required support for individuals with dementia, and caregiver burden and distress. The questions on feeding and eating problems were adapted from the Appetite and Eating Habits Questionnaire (APEHQ). The results show that nearly all persons living with dementia had symptoms of feeding/eating problems, requiring caregiver support, ranging from verbal assistance to full physical assistance. The caregivers reported high distress, which was positively correlated with dementia severity. The findings emphasize the importance of raising caregiver awareness about dementia’s impact on eating behavior, identifying effective mealtime care strategies, meeting nutritional needs, and emphasizing personal self-care. This research provides insights for healthcare professionals to develop targeted interventions, alleviate caregiver burden, improve mealtime experiences, and ensure adequate nutrition for persons living with dementia.
... A more in depth understanding regarding the perceptions and knowledge of food service staff is needed since they are the ones navigating the transition toward fostering a healthier and more sustainable food environment. Qualitative research may be useful in illuminating gaps in understanding, where interviewees do not raise important issues or practices unless they are prompted [23]. Therefore, this study aims to map out the perceived barriers and facilitators by food service staff in nursing homes to establish a transition towards a healthier and sustainable food environment. ...
Background
Healthy and sustainable food environments are urgently needed, also in nursing and residential care homes. Malnutrition in care homes is becoming an increasing problem as populations worldwide are ageing and many older people do not consume sufficient protein, fibre, fruit, and vegetables. Nursing homes also often experience a lot of food waste. A transition in the food environment like a nursing home, involves the participation of facility management and food service staff members. This study aims to map out their perceived barriers and facilitators for this transition.
Methods
A qualitative study using semi-structured interviews was conducted with food service staff members (n = 16), comprising of kitchen staff (n = 4), wait staff (n = 10), and facility management (n = 2) of two nursing homes in the Netherlands. Thematic analysis was used to derive content and meaning from transcribed interviews.
Results
Four main themes were identified. Theme 1: ‘Communication, transparency and accountability in the chain’, highlighting the lack of effective communication flows and a fragmented overview of the food service chain as a whole. Theme 2: ‘Understanding, knowledge and ability of the concepts healthy and sustainable’, revealing the gap in staff’s understanding of these abstract concepts, despite perceiving themselves as having sufficient knowledge and ability. Theme 3: ‘The pampering service mind-set’, highlighting the contradiction in the staff’s shared goal of proving the highest quality of life for residents while also pampering them in ways that may not align with promoting healthy and sustainable food choices. Theme 4: ‘Transition is important but hard to realize’, describing the barriers such as existing routines and a lack of resources as challenges to implementing changes in the food service.
Conclusions
Facilitators to transitioning nursing homes towards a healthy and sustainable food environment as perceived by staff members included transparent communication, accountability in the food supply chain, staff’s perceived ability and shared goal, while barriers included lack of understanding of the concepts healthy and sustainable, the current pampering mindset, and top-down decision-making. These findings provide valuable insights for nursing homes seeking to transition towards a healthier and more sustainable food environment.
... Regarding role content, the results of this study indicated that (Beck et al., 2021;Lea et al., 2017;Levinson, 2014;Thomas, 2020). ...
Aim
Examining the perspectives of formal and informal caregivers and residents on roles, mutual expectations and needs for improvement in the care for residents with (a risk of) dehydration.
Design
Qualitative study.
Methods
Semi‐structured interviews with 16 care professionals, three residents and three informal caregivers were conducted between October and November 2021. A thematic analysis was performed on the interviews.
Results
Three topic summaries contributed to a comprehensive view on the care for residents with (a risk of) dehydration: role content, mutual expectations and needs for improvement. Many overlapping activities were found among care professionals, informal caregivers and allied care staff. While nursing staff and informal caregivers are essential in observing changes in the health status of residents, and medical staff in diagnosing and treating dehydration, the role of residents remains limited. Conflicting expectations emerged regarding, for example, the level of involvement of the resident and communication. Barriers to multidisciplinary collaboration were highlighted, including little structural involvement of allied care staff, limited insight into each other's expertise and poor communication between formal and informal caregivers. Seven areas for improvement emerged: awareness, resident profile, knowledge and expertise, treatment, monitoring and tools, working conditions and multidisciplinary working.
Conclusion
In general, many formal and informal caregivers are involved in the care of residents with (a risk of) dehydration. They depend on each other's observations, information and expertise which requires an interprofessional approach with specific attention to adequate prevention. For this, educational interventions focused on hydration care should be a core element in professional development programs of nursing homes and vocational training of future care professionals.
Impact
The care for residents with (a risk of) dehydration has multiple points for improvement. To be able to adequately address dehydration, it is essential for formal and informal caregivers and residents to address these barriers in clinical practice.
Reporting Method
In writing this manuscript, the EQUATOR guidelines (reporting method SRQR) have been adhered to.
Patient or Public Contribution
No patient or public contribution.
... Therefore, staff are not prepared to provide optimal mealtime care to residents with dementia due to lack of effective trainings that focus on 1) assessment and management of resident positive, neutral and challenging behaviors, and 2) use of person-centered care vs. task-centered care approaches. 4,45,54 Staff report mealtime care of residents with dementia as challenging and frustrating due to lack of training with person-centered care, and staff learn new skills and accumulate experiences during routine care practices. 4,55 While emerging evidence supports the use of person-centered care, a gap exists in creating and empirically evaluating effective, person-centered care interventions. ...
Background and Objectives
Optimal dyadic interactions are critical to quality mealtime care and outcomes. Prior work supports associative relationships between staff approaches and individual mealtime behaviors, yet evidence on temporal relationships is limited. This study examined temporal associations between staff approaches and resident behaviors during mealtimes.
Research Design and Methods
Videotaped mealtime observations (N=160) involving 36 staff and 27 residents (53 staff-resident dyads) in 9 nursing homes were analyzed. Sequential analyses using 5-, 10-, and 15-second time windows were conducted for resident positive, neutral, and challenging behaviors as antecedents as well as consequences of staff person-centered and task-centered approaches.
Results
Residents exhibited positive verbal (35.0%) and positive/neutral nonverbal (12.6%) behaviors, as well as challenging behaviors including functional impairments (27.7%) and resistive behaviors (24.7%). Staff primarily used person-centered approaches (54.1% verbal, 40.3% nonverbal); task-centered approaches were less frequent (5.6%). Immediately (within 5-seconds) after staff person-centered approaches, resident positive/neutral and resistive behaviors were more likely and functional impairments less likely. After staff task-centered approaches, resident positive verbal and resistive behaviors were less likely. After resident positive/neutral behaviors, staff person-centered approaches were more likely. After resident functional impairments, staff person-centered verbal approaches were less likely and task-centered approaches more likely. After resident resistive behaviors, all staff approaches were more likely. The strength of temporal relationships diminished in 10-second and 15-second time windows.
Discussion and Implications
Staff-resident positive interactions were associated with more subsequent positive interactions. Person-centered care was associated with fewer subsequent resident functional impairments and more subsequent resistive behaviors. Resident resistive behaviors were associated with more subsequent person-centered and task-centered care. Findings confirm the importance of facilitating positive staff-resident interactions and managing functional impairments using person-centered care. Resistive behaviors require additional awareness and attention beyond commonly used person-centered care approaches. Further investigation of temporal relationships is needed using larger diverse samples.
... Organisational support structures may enable staff to build knowledge and learn together to implement best practice and new ideas, but hierarchical staffing structures also pose barriers to staff who have ideas for improvement [134]. Organisational processes inform whether PCC is prioritised [11], and how staff enact teamwork to manage mealtimes [150], but a lack of clarity about RACF responsibilities to enact best practice has increased recommendations for multidisciplinary mealtime management to be explicitly regulated [22,67,109]. ...
Background
Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impact their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Giddens’ (The constitution of society: outline of the theory of structuration, 1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents’ mealtime experiences.
Methods
Using Arksey and O’Malley’s (Int J Soc Res Methodol 8:19–32, 2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.
Results
Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.
Conclusions
Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.
... Nevertheless, it will soon pose new challenges if action is not taken to advance the current monitoring technology, as older adults necessitate more care and medications. One challenge in our healthcare system is dehydration, which is a recurrent issue in older adults [2,3]. Dehydration is mainly provoked by a diminished thirst sensation with ageing and mobility or memory impairments [4,5]. ...
Nowadays, society is experiencing an increase in the number of adults aged 65 and over, and it is projected that the older adult population will triple in the coming decades. As older adults are prone to becoming dehydrated, which can significantly impact healthcare costs and staff, it is necessary to advance healthcare technologies to cater to such needs. However, there has not been an extensive research effort to implement a device that can autonomously track fluid intake. In particular, the ability of surface electromyographic sensors (sEMG) to monitor fluid intake has not been investigated in depth. Our previous study demonstrated a reasonable classification and estimation ability of sEMG using four features. This study aimed to examine if classification and estimation could be potentiated by combining an optimal subset of features from a library of forty-six time and frequency-domain features extracted from the data recorded using eleven subjects. Results demonstrated a classification accuracy of 95.94 ± 2.76% and an f-score of 94.93 ± 3.51% in differentiating between liquid swallows from non-liquid swallowing events using five features only, and a volume estimation RMSE of 2.80 ± 1.22 mL per sip and an average estimation error of 15.43 ± 8.64% using two features only. These results are encouraging and prove that sEMG could be a potential candidate for monitoring fluid intake.
... The quality of this data might be influenced by staff ratio, time and communication [27] and should therefore be used and interpreted with care. However, research indicates that nurses are attentive to key aspects of food intake and body weight [42,43]. Third, individualisation of our intervention was only possible to a limited extent. ...
Dietary intake and requirements in nursing home (NH) residents vary individually, but concepts for individualised interventions are currently lacking. Therefore, we present an individualised modular nutritional intervention concept for NH residents with (risk of) malnutrition and describe its application and acceptability. Three enrichment modules—a sweet and a savoury protein cream (40 g, 125 kcal, 10 g protein) and a protein-energy drink (250 mL, 220 kcal, 22 g protein)—were offered to residents of two German NHs single or in combination in five levels of enrichment from level 0 (no enrichment) to 4 (all enrichment modules) to compensate for individual energy and protein deficiencies. Residents with chewing and/or swallowing difficulties received reshaped instead of usual texture-modified meals. The intervention concept was applied to 55 residents (Mean age of 84 ± 8 years, 76.0% female, 25.5% malnutrition). Despite (risk of) malnutrition, 18.2% received no enrichment (level 0). Level 1 was allocated to 10.9%, level 2 to 27.3%, level 3 to 20.0% and level 4 to 23.6% of the residents. 32.7% received reshaped texture-modified meals (RTMM). Participants consuming RTMM were more often assigned to level 4 than residents receiving usual meals (38.8% vs 16.2%). We proposed and successfully applied an individualised modular nutritional intervention concept to NH residents with (risk of) malnutrition. In the next step, the effects of the concept and its transferability to other NHs need to be demonstrated.
... protein-and energy enrichment or texture-modified meals), and only two of these five actions are food related. Literature reveals a need to build on healthcare professionals' knowledge in order for them to become better educated about malnutrition and the nutritional needs of older adults [25,28,29]. However, the incentive for practising and spreading evidence-based knowledge might have deteriorated due to a continuous decline in the number of community dietitians in Swedish elderly care [30]. ...
... protein-and energy enrichment or texture-modified meals), and only two of these five actions are food related. Literature reveals a need to build on healthcare professionals' knowledge in order for them to become better educated about malnutrition and the nutritional needs of older adults [25,28,29]. However, the incentive for practising and spreading evidence-based knowledge might have deteriorated due to a continuous decline in the number of community dietitians in Swedish elderly care [30]. ...
Malnutrition constitutes a serious and challenging problem in elderly care. In 2015, a Swedish regulation that aims to prevent and treat malnutrition came into effect. This study set out to explore associations between level of adoption of the regulation reported as: no, started, yes, in a previous survey, and registrations in a national quality registry. Registry data on screening and actions extracted from the first trimester in 2014 (n=18967), 2016 (n=20318) and 2017 (n= 25669) represented 209, 197 and 199 of 290 Swedish municipalities respectively. A repeated measures ANOVA showed that there was no effect on screened nutritional status, Pearson's chi-square that there were minor differences in types of actions, and regression analysis that the number of actions increased on average by 0.3 due to a higher level of adoption of the regulation. Over the years studied, five actions were prominent regardless of level of adoption or screened nutritional status. Hence, to date, no firm conclusions regarding effects of the regulation can be drawn. Despite the regulatory nature, it appear as if the regulation and the level of adoption reported so far is routine in theory, although not yet leveraged to an implemented practice visible in the quality registry but instead decoupled from practice.
... This could be due to the fact that the MNA and IADL scores are influenced by multiple factors, including elder personal characteristics. The nursing home staff awareness of elderly people dietary requirements is another important factor as emphasized by Lea et al. [41] in a study in Australia. It could also be due to the bias of ecologic fallacy inherent in this type of analysis. ...
Background and objective: Dietary habits and patterns have been shown to have strong influence on the mental wellbeing of elderly. Aim of the study: to compare the current nutritional status and independence in instrumental activities of daily life (IADL) in the elderly living in nursing homes and community dwellings.Methods: The study was carried out in nursing homes and elderly clubs in Cairo using descriptive comparative design. It involved a group of 125 institutionalized elderly from six nursing homes in Cairo and a second group (community dwellers) of 250 elderly from social clubs or elderly daycare centers in Cairo. The data collection tools were an interview questionnaire including the Mini Nutritional Assessment (MNA), the IADL, and the 24-hour recall for dietary intake in addition to an inventory checklist for the nursing homes. The data collection lasted from October 2016 to December 2017.Results: The institutionalized elderly had significantly higher median age, more divorced /widows, from urban areas, with higher education, and more insufficient income; they were more obese (p = .02). In MNA 62.0% of those in community dwellings were normal compared to only 17.6% of institutionalized (p < .001), but significantly more institutionalized elders had deficient caloric intake (80.0%) compared to 69.6% of those in community dwellings (p = .03). The IADL were significantly better among those in community dwellings. In multivariate analysis, having recreations was a positive predictor of MNA score, while smoking and institutionalization were negative predictors. As for the IADL score, the level of education was its positive predictor, whereas age and institutionalization were negative predictors. Body mass index (BMI) was positively predicted by female gender, educational level, and having recreations, and negatively predicted by age. For institutionalized elderly, income was a positive predictor of the MNA score, whereas the length of institutionalization was a negative predictor.Conclusion and recommendations: Malnutrition and dependency in IADL are more prevalent among elderly in nursing homes, and are related to the duration and characteristics of the institutionalization. The study recommends improving the dietary services in nursing homes, with training programs for their staff and regular monitoring of food services.
Background
Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.
Objective(s)
To explore variations in the care home nursing and support workforce; how resident and relatives’ needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents’ needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.
Design
Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 – two evidence syntheses (one realist); WP2 – cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 – analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 – secondary analysis of care home regulator reports; WP5 – social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.
Setting
English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.
Participants
Managers, residents, families and care home staff.
Findings
Staffing’s contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop ‘familial’ relationships between staff and residents, and staff–staff reciprocity, ‘knowing’ residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act.
Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.
Limitations
Many of our findings stem from self-reported and routine data with known biases – such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.
Conclusions
Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible – rather than available – inputs and outcomes.
Study registration
This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.
Many people living with dementia have difficulties at mealtimes, which can result in serious complications for physical and mental health, leading to hospital admissions and even death. However, current training in mealtime care for staff working with this population has been found to be poorly reported, with variable effectiveness. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to explore current practice in mealtime care for this population, identify good practice, and understand the factors influencing mealtime care. Approximately 28 h of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care staff and residents living with dementia. Twenty-five semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. A constant comparative approach was taken, to probe emergent findings and explore topics in greater depth. Key thematic categories were identified, including: tensions in mealtime care; the symbolic nature of mealtime care; navigating tensions via a person-centred approach; contextual constraints on mealtime care; and teamwork in mealtime care. The findings indicated that a person-centred approach helps carers to find the right balance between apparently competing priorities, and teamwork is instrumental in overcoming contextual constraints. This evidence has contributed to development of a training intervention for care home staff. Future research should investigate the feasibility of mealtime care training in care homes.
Introduction
For medical students, food is rarely discussed from the clinical perspective. Yet, in hospitals reduced food intake poses the risk of malnutrition, along with increased morbidity and mortality. The issue of food waste, a cause of inadequate dietary intake and a common issue within the National Health Service, is rarely addressed. The implementation of protected mealtimes has done little to solve this. This quality improvement project aimed to reduce the average amount of inpatient food waste by 20% by May 2022.
Methods
A standardised meal size intervention was tested. Meals were weighed before and after meal services to collect baseline and postintervention data. The percentage consumed and the percentage wasted were then calculated. Finally, the overall average of the percentage wasted across both meal services was determined.
Results
Quantitative data showed a change in the average amount of food waste from 70.16% to 65.75%, a decrease of 4.41%. Survey results also found an increase of 3% in patient satisfaction with meal sizes.
Conclusion
Standardising meal sizes is shown to improve inpatient food waste and may serve as a starting point for healthcare providers to devise further strategies to reduce wastage in hospitals.
Background
Aspiration pneumonia (AP) is a subset of pneumonia caused by the aspiration of food and fluids to the lungs and is highly prevalent in the older population. Oropharyngeal dysphagia (OD) is one of the risk factors for AP and it is also associated with malnutrition, dehydration and poor functional outcomes. As pneumonia is the second most common infection in nursing homes (NHs) and OD represents a major concern to NH staff, good practices for the prevention of AP in older adults at risk of OD are needed.
Purpose
The aim of this modified e‐Delphi study is to build consensus among a panel of experts regarding a set of recommendations for NH staff on good practices to prevent AP in older adults at risk of OD living in NHs. The objective of this paper is to establish the methodology inherent to the Delphi study.
Methods
An online modified Delphi study will be developed in three rounds. Criteria for the Delphi panel participants include holding a master's or doctoral degree in OD or speech and language therapy; or having 10 or more years of experience in OD; or having at least one scientific publication related to OD. A previously described modified Delphi methodology will be used to achieve consensus (75% agreement). An additional round will be performed to collect the experts’ perspectives regarding the priority for application of each recommendation previously validated.
Discussion
This protocol aimed to describe the methodology of a future Delphi study on the prevention of AP, seeking to fulfil the gap in the literature regarding this topic. The modified Delphi technique is a widely used method for collecting experts’ opinion in health sciences, but the absence of standardised guidelines allows some heterogeneity between studies with the same aim.
WHAT THIS PAPER ADDS
What is already known on the subject
Aspiration pneumonia (AP) is related to three main risk factors: impaired safety of swallow, impaired nutritional status and poor oral health. It is known that being dependent for feeding is one of the main risk factors for AP and around 50% of nursing home (NH) residents need feeding assistance. Thus, it is important to promote specialised intervention and care by the NH staff for preventing AP.
What this paper adds to existing knowledge
It is hypothesised that increasing the knowledge of NH staff regarding the best practices for preventing AP in older adults at risk of oropharyngeal dysphagia (OD) will improve outcomes such as quality of life, incidence of AP and mortality.
What are the potential or actual clinical implications of this work?
The recommendations resulting from this study will address a current gap in healthcare practice of NH staff regarding older adults at increased risk for OD and, consequently, for AP.
Background:
Persons with dementia are at risk of developing nutritional problems. Theoretical models on nutritional problems have been developed, but have not been evaluated with healthcare professionals.
Objective:
This study aimed to explore the comprehensiveness and applicability of a theoretical model of nutritional problems in persons with dementia for daily nursing home practice.
Methods:
A qualitative design employing a combined deductive and inductive approach was used. Healthcare professionals were eligible to participate if they 1) had expert knowledge of and experience with nutritional problems related to dementia, and 2) worked in a nursing home affiliated with an academic network covering the east and south of the Netherlands. Three focus group interviews with 20 healthcare professionals from seven professions were held. We conducted thematic analysis and we compared themes with existing theoretical models from the literature.
Results:
We identified six themes, four of which corresponded with the existing models (observing and analysing nutritional problems; consequences of nutritional problems; functioning of the person with dementia; environmental factors). Interprofessional collaboration and ethical factors were identified as new themes. The analyses indicated interactions within each theme, between themes, and a bidirectional connection between themes.
Conclusions:
This study demonstrated the relevance of interprofessional collaboration and ethical considerations in nutritional problems related to dementia. It uncovered complex bidirectional relations within and between factors regarding nutritional problems. All aspects should be taken into account to minimize the consequences of nutritional problems for persons with dementia.
People with intellectual disabilities generally have poorer health outcomes com- pared with those who do not, including outcomes related to nutrition-related non- communicable diseases. Carers support people with intellectual disabilities in many aspects including habitual shopping and preparation of food, but their own nutrition knowledge and the influence this may have on dietary intakes of clients is unknown. We explored the nutrition knowledge of carers of people with intel- lectual disabilities in residential care settings, their dietary habits and their influ- ence on clients' food shopping and preparation and therefore the diet consumed by their clients. Ninety-seven carers belonging to a large independent care sec- tor organisation specialising in the care of people with an intellectual disability completed a validated general nutrition knowledge and behaviour questionnaire. Seventeen carers from the residential care settings were interviewed to contex- tualise practice. Knowledge about key dietary recommendations scored highly. Carers who had more work experience were found to have higher scores in ‘mak- ing everyday food choices’ (p = 0.034). Daily consumption of fruit and vegetables (at least one portion per day) was observed (for fruit by 46% of the carers and for vegetables by 60% of the carers), whilst most carers reported avoiding consum- ing full-fat dairy products, sugary foods and fried foods. The concept of a healthy diet; typical dietary habits of clients; role in food acquisition; and training in nutri- tion emerged as themes from the interviews. Carers discussed various topics including the importance of a balanced diet, cooking fresh foods and control of food portion sizes for clients relative to the care philosophy of a client-centred approach, which encapsulates client autonomy. Gaps in knowledge around spe- cific nutrients, making healthy choices and cooking skills remain. Carers have an influence on clients' dietary choices; they are able to provide healthy meals and share good dietary habits with clients. Further training in nutrition is recom- mended for impact on clients' health.
Aims and objectives:
This study examined the sequential relationships of food intake and the moderating role of the characteristics of intake and resident conditions.
Background:
Nursing home residents commonly experience insufficient food intake. While multilevel factors influence intake, evidence on sequential relationships is lacking.
Design:
The study was an observational study using secondary, behavioural analyses following the STROBE Statement.
Methods:
Videotaped observations (N = 160) collected from a dementia communication trial during 2011-2014 were coded using the refined Cue Utilisation and Engagement in Dementia Mealtime Video-coding Scheme during 2018-2019. The 160 videos involved 27 residents living with dementia and 36 staff in 9 nursing homes. Independent variables were the state (solid intake, liquid intake, no intake) of an intake episode occurring during mealtime (current episode), eating technique (resident-initiated, staff-facilitated) used in the next episode occurring after the current episode (subsequent episode), interval between adjacent episodes, and resident comorbidities and dementia stage. The dependent variable was the state of subsequent episode.
Results:
Successful liquid and solid intake increased odds of subsequent liquid and solid intake. Comorbidities were associated with decreased odds of subsequent liquid and solid intake for staff-facilitated episodes. When liquid intake occurred, staff-facilitation decreased odds of subsequent liquid intake; longer intervals between adjacent episodes increased odds of subsequent solid intake.
Conclusion:
Food intake was strongly and sequentially associated, and such temporal relationships were dependent on characteristics of the intake process and resident conditions.
Relevance to clinical practice:
The study findings supported that initiating successful intake facilitates continuity of successful intake during mealtime. Behavioural interventions tailored by comorbidities that modify characteristics of the food intake process may improve food intake.
People with dementia are at high risk of malnutrition as a result of progressive symptoms that affect eating. Maximising opportunities to enhance nutrition and strategies to encourage eating are a crucial part of providing care. Caregiver knowledge and a person-centred approach to eating is essential to reduce symptom burden and maintain quality of life. There is currently limited research investigating first person perceptions of eating with dementia, particularly beyond small sample sizes. Therefore, this paper aims to explore community perceptions of how best to encourage eating for people with dementia using findings from an online course. Within the Understanding Dementia Massive Open Online Course, responses to the following statement were collected: ‘If I had dementia, the things that might help me to eat include…’. A total of 3,651 participant responses were collected from the 2018 and 2019 course enrolments and analysed using structural topic modelling and secondary thematic analysis. The majority of participants were female, tertiary educated Australians over 50 years old. A third were paid caregivers. Thirteen topics were isolated from topic modelling that can be reduced into six broad categories: food type personalisation, meal choice, meal presentation, eating environment, eating assistance and end of life nutrition. Participant responses demonstrated diverse awareness of important aspects to encourage eating in dementia. Findings support the need for improved uptake of nutritional strategies in practice and education on eating with dementia to support caregivers.
Background. Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impacts their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Gidden’s (1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents’ mealtime experiences.
Methods. Using Arksey and O’Malley’s (2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included for in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.
Results. Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.
Conclusions. Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.
Intravenous fluid (IV)This chapter highlights several considerations in the use of intravenous fluids in the geriatric patient, specifically sodium and water. It emphasizes that these key elements of routine intravenous fluid orders are also body nutrients, required in limits to avoid the adverse consequences of either excess or deficit. A review of basic sodium and water distribution, regulation, and excretion is provided. The sodium content of various salt-containing fluids and supplements are presented as well as general principles underlying sodium administration. The goal of intravenous fluid (IV) administration is to carefully achieve and maintain a euvolemic and isotonic environment within the body as well as to provide for a variety of nutritional and pharmacologic interventions. The selection of an appropriate IV solution is dependent upon the fluid volume and electrolyte status of the individual patient as well as any additional specific therapeutic goals.
Background
As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.
Objective
To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.
Design
A systematic review of qualitative research.
Data sources
The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.
Review methods
Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.
Findings
A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, social worker, professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.
Conclusions
Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients’ preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.
Background
Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.
Objectives
To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.
Design
A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.
Setting
Long-term residential care facilities
Participants
Long-term care facility staff, residents, and relatives
Methods
The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.
Results
66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents’ needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.
Conclusion
Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.
Dehydration is prevalent in hospitalised older people and residents in care homes, and older people with dementia are particularly at risk. A literature review was conducted to determine the evidence-based interventions used to prevent and manage dehydration in older people with dementia. Three databases were searched for relevant literature: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, and MEDLINE, alongside hand-searching. In-depth reading of the 12 studies included in this literature review was undertaken. Five themes were identified in relation to the hydration of older people: physical and social environment; staff communication strategies; access to drinks; drinking vessels; and individual preferences. The evidence suggests that dehydration in older people with dementia is an ongoing concern that needs to be addressed. There is evidence supporting the use of essential nursing interventions to improve hydration, such as coloured cups and verbal prompts, but less is known about the barriers preventing nurses from implementing these evidence-based interventions.
Objectives:
To assess the quality of research evidence for the different activity components for the psycho-social Namaste Care intervention for care home residents with advanced dementia.
Design:
Namaste Care is a multi-component intervention delivered on a daily basis to people living with advanced dementia or people at end of life with dementia. A significant part of its operationalisation within care homes is the delivery of a number of activities delivered by trained in-house Namaste Care workers to a group of residents with similar high dependency needs. The Namaste Care workers focus on touch, music, nature, sensory experience, aromas and interactions with objects delivered in a way to enhance feelings of enjoyment and wellbeing. This review evaluated the evidence for using these activities with people living with advanced dementia. A systematic search of peer-reviewed research articles was conducted between November 2016 and September 2018 using search terms of activities used in Namaste Care. The quality of each accepted article was rated using the Rapid Evidence Assessment scale.
Results:
The initial literature search returned 1341 results: 127 articles including 42 reviews were included. The majority of activity interventions yielded between 10 and 20 peer-reviewed papers. The use of smells and aromas, interacting with animals and dolls, the use of various forms of music (e.g. background music, singing, personalised music), nature, lighting, various forms of touch/massage and sensory interventions (including Snoezelen) all appear to have proven efficacy with people living with advanced dementia.
Conclusions:
There is generally a limited number of research papers and reviews in this area, but overall there is a good evidence base for including these activities within Namaste Care for people living with advanced dementia.
Background:
Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.
Methods:
We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis.
Results:
Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions.
Conclusions:
We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes.
Systematic review registration:
The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero [1].
The aging process involves changes in physiological, pathological, social, and psychological conditions of a person. Nutrition is an important element of health among the elderly, and it affects the whole process of aging. The prevalence of malnutrition is increasing in this population and is associated with a decline in functional status, impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, higher hospital readmission rates, and mortality. Due to changing socioeconomic environment, elderly people are often left alone to fend for themselves to maintain their health, which may interfere with the maintenance of a good nutritional status. Regular diagnosis of malnutrition among older patients increases the need for more education regarding nutritional status in older patients, and the purpose of this article is to provide information with an educational overview of essential nutritional aspect associated with changes in aging. Copyright © 2014, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved.
The number of people with dementia is increasing rapidly worldwide. Commensurate with population ageing, the use of nursing homes in Australia (known as residential aged care facilities) for individuals with dementia is growing. As a terminal condition, dementia is best managed by instituting a palliative approach to care. A good knowledge of dementia, including its progression and management, among staff and families of people living with dementia is essential for clear decision making and the provision of appropriate care. Yet there is limited information regarding relative levels of dementia knowledge. This paper reports the results of a study that assessed dementia knowledge among these two cohorts using the Dementia Knowledge Assessment Tool; the study surveyed 279 staff members and 164 family members of residents with dementia. Dementia knowledge deficits were evident in both cohorts across a range of areas. It is critical that dementia knowledge deficits are identified and addressed in order to support evidence-based dementia care.
Background
This paper explores the serendipity of residents accessing adequate food and fluids in aged care facilities. It draws on the findings of two discrete but interrelated research projects conducted in 2009 and 2011 relating to the experience of living in, or having a friend or family member living in, residential aged care.
Methods
Participants were recruited through media outlets. Indepth interviews with participants were audiotaped, transcribed verbatim and thematically analysed.
Findings
This paper discusses a theme that was iterated by participants in both projects that is, the difficulty residents in aged care facilities experienced in receiving adequate and acceptable food and fluids. Unacceptable dining room experiences, poor quality food and excessive food hygiene regulations contributed to iatrogenic malnutrition and dehydration. Implications for staffing, clinical supervision, education of carers and the impact of negative attitudes to older people are discussed.
Conclusion
The inability of dependent residents in aged care facilities to receive adequate nourishment and hydration impacts on their health and their rights as a resident, and is an ongoing issue in Australian residential aged care.
Objectives:
To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship.
Design:
This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement.
Setting:
Care homes.
Participants:
75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time.
Measurements:
A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency.
Results:
The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation.
Conclusion:
The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.
Twenty mid-stage Alzheimer's patients at the Jewish Home and Hospital in the Bronx participatedfor 12 weeks each in four groups offive in a five-day-a-week program of structured multi-modality group communication intervention called “The Breakfast Club.” Twenty matched patients participated in a standard conversation group and served as controls. The Breakfast Club attempted to incorporate all that was currently known about the residual communication strengths of Alzheimer's patients and about previous treatments shown to be effective with this population. Results showed that Breakfast Club participants improved significantly on measures of language performance, functional independence and use of social communication while control subjects did not. Breakfast Club members also showed significant increases in “interest and involvement” and the use of procedural memories over the 12-week period.
Malnutrition occurs frequently in the frailest groups of the population, especially in people who are on a low income and elderly subjects, overall if they are institutionalized. The aim of this study was to assess the prevalence of malnutrition in a sample of elderly people living in different settings and to identify the determinants of malnutrition.
Methods
A total of 718 subjects, 472 females (F) and 246 males (M), were recruited from nursing homes or were free living in three different regions in Italy. Nutritional status, depression, social, functional and cognitive status, were evaluated.
Results
According to the Mini Nutritional Assessment (MNA), a high prevalence of malnutrition was found out in both genders: 26% of F and 16.3% of M were classified as being malnourished (MNA
There is growing evidence that a palliative approach to care provision for people with dementia in residential aged care facilities improves their quality of life and provides support for family members. Despite the development of Guidelines for a Palliative Approach in Residential Aged Care (hereafter the Guidelines), there is limited evidence that these have been adopted. To date, little research has been undertaken to explore processes which could assist aged care staff to develop their practice consistent with the intent of the Guidelines.
This project utilized an action research method, through which staff members from a residential dementia special care unit (SCU) undertook an investigation into their practice to explore how they could develop strategies to support a palliative approach to care provision. A key focus was related to addressing the information needs of family members of residents on the SCU.
Aged care staff involved in this project had little understanding of available evidence that could assist them to better support family members, including the existence of the Guidelines. Through their engagement in successive action research cycles, these staff accessed evidence-based resources and developed strategies to address the information needs of family members.
When provided with an opportunity to reflect on and critique their practice, aged care staff were better positioned to engage with evidence concerning a palliative approach and to execute change in their practice to improve care provision for family members.
Nutritional deficiency can have dramatic effects on the physical and psychological status of older adults. Although food supplements can enhance nutritional status, several authors suggest that more ecological means could also have beneficial impacts. Therefore, a natural experiment was conducted to study the impact of changed mealtime experiences for people with Alzheimer-type dementia. Two special care units (in separate facilities) in France were included in this study: one implemented shared meal times between residents and caregivers and the other served as a comparison group. Weight was measured and staff observations were collected. Positive outcomes were observed for the experimental group. Implications for practice are discussed.
Background Older adults are susceptible to dehydration due to age-related changes. This study aimed to investigate the prevalence of clinically diagnosed dehydration in older adult medical emergency hospital admissions and assess the impact on length of hospital stay (LOS) and mortality. Methods Data were retrieved from the hospital's electronic database relating to all emergency admissions of patients aged ≥ 65 years between 1 April 2011 and 31 October 2013. The Charlson comorbidity index, LOS and mortality were calculated. Results Of the 42,553 patients identified, 32,980 (77.5%) were admitted to medical specialties. Dehydration was noted in 2,932 (8.9%) patients and was the primary cause of admission in 190 (0.6%). The prevalence of dehydration also increased with age and comorbidity. Acute kidney injury was reported in 47.7% of patients with dehydration, compared with 15.9% of patients without dehydration, P < 0.001. The median (interquartile range) LOS in patients diagnosed with dehydration was 8 (4–19) days compared with 3 (1–8) days in those without dehydration, P < 0.001. Patients admitted with a primary diagnosis of dehydration had a 17% 30-day mortality and 44% one-year mortality compared with 7% and 25% respectively in patients without dehydration, P < 0.001. Patients diagnosed with dehydration during hospitalisation were twice more likely to die in hospital, HR 2.11 (95% CI 1.92–2.32), P < 0.001, independent of age, gender and comorbidities. Conclusion A small but significant proportion of hospitalised older adults was diagnosed with dehydration, which was associated with an increase in LOS and mortality, independent of age, gender and comorbidities. © 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society
The use of external labour such as temporary agency workers in the general workforce has increased in recent decades, but comparatively little is known about their impact within the aged care workforce. This article analyses quantitative data from a census of aged care facilities and a large-scale survey of their workforce regarding the use and impact of temporary agency workers on internal workers. It demonstrates that employing temporary agency workers helps address labour shortages generally and skill shortages in particular. However, it has a negative impact on the job satisfaction of internal personal care workers – a predictor of an increase in intention to leave. In contrast, there was little impact on internal nurse satisfaction. The use of temporary agency workers could therefore create a paradox: increasing personal care worker numbers in the short term, but negatively impacting on their retention in the long term. Given the need for an expanded and sustainable aged care workforce, this finding has important implications for organisations, policy and unions.
Aims and objectives:
To describe whether an action research approach can be used to build capacity of residential aged care facility staff to support undergraduate nursing students' clinical placements in residential aged care facilities, using development of an orientation programme as an exemplar.
Background:
Aged care facilities are unpopular sites for nursing students' clinical placements. A contributing factor is the limited capacity of staff to provide students with a positive placement experience. Strategies to build mentor capability to shape student placements and support learning and teaching are critical if nursing students are to have positive placements that attract them to aged care after graduation, an imperative given the increasing care needs of the ageing population worldwide.
Design:
Action research approach employing mixed-methods data collection (primarily qualitative with a quantitative component).
Methods:
Aged care facility staff (n = 32) formed a mentor group at each of two Tasmanian facilities and met regularly to support undergraduate nursing students (n = 40) during placements. Group members planned, enacted, reviewed and reflected on orientation procedures to welcome students, familiarise them with the facility and prepare them for their placement. Data comprised transcripts from these and parallel student meetings, and orientation data from student questionnaires from two successive placement periods (2011/2012).
Results:
Problems were identified in the orientation processes for the initial student placements. Mentors implemented a revised orientation programme. Evaluation demonstrated improved programme outcomes for students regarding knowledge of facility operations, their responsibilities and emergency procedures.
Conclusion:
Action research provides an effective approach to engage aged care facility staff to build their capacity to support clinical placements.
Relevance to clinical practice:
Building capacity in the aged care workforce is vital to provide appropriate care for residents with increasing care needs.
Aging is often accompanied by lower intakes of food energy and consequent negative effects on health. To some extent this is due to declines in physiological ability, including the sensory responsiveness to regulate food intake. Fortunately, environmental factors may still influence food intake in older adults. Factors such as social facilitation, modeling, and nutrition knowledge and skills have been shown to stimulate their food intake. While environmental factors such as the eating location, portion size, food presentation, and labeling are known to influence eating behavior, their effectiveness in stimulating food intake in older persons is not well delineated. It is suggested that improving the environmental stimuli that promote food intake is a viable strategy to overcome age-related declines in nutrient intakes. This strategy is so promising that further research is warranted.
Objective The aim of this paper is to highlight some of the challenges faced by the nursing profession in response to increased casualisation of its workforce and why the presence of casualisation needs to be viewed in a positive light. Setting The nursing workforce worldwide. Subjects Nurses who need or want to work as casuals. Primary argument The care-giving responsibilities of a predominantly female workforce and the ageing of the nursing workforce worldwide means some nurses are choosing or need to work as casual employees in order to remain in the workforce. Historically, casuals have been viewed in a negative light particularly in discussions around commitment and continuity-of-care. Without a change in attitude towards nurses who work as casuals, a significant portion of the nursing workforce may be lost. Conclusions An ageing nursing workforce coupled with a worldwide shortage of nurses means that employers need to ensure options are available to accommodate nurses requiring flexible rosters in order to encourage recruitment and retention. Policies are needed to ensure that all staff, regardless of their contribution in hours, feel valued and supported and are able to contribute to their profession. Maintaining a portion of the workforce in a flexible form will allow increased staffing options and ensure that sufficient experienced staff are available in order to maintain quality patient care and outcomes.
Patients with end-stage dementia remain underserved by hospice services despite overwhelming evidence that dementia is a terminal illness. Consequently, many patients with end-stage dementia do not receive the care they deserve and would want. This article reviews four key components to ensuring patients with endstage dementia receive proper care. First, the challenge of prognostication, a leading barrier to hospice care, is reviewed. Second, care planning strategies (eg, advance directives) are examined. A good, open relationship between the clinician and the patient's family is of paramount importance to prevent the use of aggressive and undesirable interventions, such as tube feedings. Third, strategies for managing complications of dementia, such as behavioral problems, sleep disturbances, and pain, are reviewed. These and other complications must be adequately addressed to reduce distress and improve quality of life. Finally, strategies for helping patients and families through the bereavement process are examined, as skillful end-of-life care will leave a legacy of dignity and peace for the family.
Aims:
The aim of this study was to examine the association of specific personal and environmental factors with eating performance among long-term care residents with moderate-to-severe cognitive impairment.
Background:
Eating is the one of the most basic and easiest activities of daily living to perform. While multilevel factors can be associated with eating performance, the evidence among those with dementia was insufficient.
Design:
A secondary analysis of baseline data collected between March and September in 2012 from 199 residents in eight long-term care facilities.
Methods:
Eating performance was conceptualized using the single self-care 'feeding' item in the Barthel Index and was scored based on four levels of dependence and assistance required. Binary logistic regression was used to examine the adjusted association of specific factors with eating performance.
Results:
Almost one-third of the residents needed help with eating. After adjusting the type of facility, number of comorbidities, chair-sitting balance, agitation and depression, compromised eating performance was associated with severe cognitive impairment and low physical capability.
Conclusion:
This study supported the association of eating performance with cognitive impairment and physical capability among long-term care residents with moderate-to-severe cognitive impairment. Targeted interventions should be implemented to reduce the impact of cognitive decline on eating performance and promote physical capability to optimize eating performance. Future work need to use validated multiple-item measures for eating performance and test the association of personal and environmental factors with eating performance among a larger heterogeneous group of long-term care residents to enhance understanding of the factors.
Background:
Water-loss dehydration in older people is associated with increased mortality and disability. We aimed to assess the prevalence of dehydration in older people living in UK long-term care and associated cognitive, functional, and health characteristics.
Methods:
The Dehydration Recognition In our Elders (DRIE) cohort study included people aged 65 or older living in long-term care without heart or renal failure. In a cross-sectional baseline analysis, we assessed serum osmolality, previously suggested dehydration risk factors, general health, markers of continence, cognitive and functional health, nutrition status, and medications. Univariate linear regression was used to assess relationships between participant characteristics and serum osmolality, then associated characteristics entered into stepwise backwards multivariate linear regression.
Results:
DRIE included 188 residents (mean age 86 years, 66% women) of whom 20% were dehydrated (serum osmolality >300 mOsm/kg). Linear and logistic regression suggested that renal, cognitive, and diabetic status were consistently associated with serum osmolality and odds of dehydration, while potassium-sparing diuretics, sex, number of recent health contacts, and bladder incontinence were sometimes associated. Thirst was not associated with hydration status.
Conclusions:
DRIE found high prevalence of dehydration in older people living in UK long-term care, reinforcing the proposed association between cognitive and renal function and hydration. Dehydration is associated with increased mortality and disability in older people, but trials to assess effects of interventions to support healthy fluid intakes in older people living in residential care are needed to enable us to formally assess causal direction and any health benefits of increasing fluid intakes.
OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.
The international literature shows that there are considerable deficits in nutritional care provision in nursing homes. Limited knowledge and negative attitudes can contribute to these deficits but international studies on knowledge and attitudes among nursing staff are rare.
The study aimed to assess the knowledge and attitudes of registered nurses and nurse aides towards malnutrition care in nursing homes.
This study followed a multicentre, cross sectional design.
The study was performed in 66 Austrian nursing homes with 1152 participants.
The validated Knowledge of Malnutrition-Geriatric (KoM-G) questionnaire and the Staff Attitudes to Nutritional Nursing Care Geriatric (SANN-G) scale were used for data collection.
On average, 60.6% of the respondents answered the questions correctly, whereas registered nurses knew significantly more (65.6%) than nurse aides (57.3%). The question that was answered correctly by most dealt with the factors that positively affect oral nutritional intake (87.2%) while the question which was incorrectly answered by most was on the professions involved in malnutrition treatment (26.1%). 39.2% of respondents had positive attitudes towards nutritional care. Registered nurses displayed more positive attitudes (48.1%) than nurse aides (33.6%). The most positive attitudes were shown in the 'Intervention' subscale while the least positive attitudes were indicated in the 'Norms' subscale. A medium positive correlation between knowledge and attitudes was found (r=.423, p<0.000).
This study identified specific knowledge deficits and areas of negative attitudes in registered nurses and nurse aides, which will enable tailored training programmes to be developed.
In this case study, the authors investigated how a long-term care (LTC) community transformed its culture of dining from traditional, institutional meals to resident-centered meals and relational dining. Christie Gardens is a continuum of care in Toronto, Ontario, Canada. It is home to 320 Independent and Assisted Living residents and 85 Courtyard Community (LTC) residents. Guided by the Life Nourishment Theory, a case study evaluation and qualitative data analysis were employed to synthesize information obtained with the following methods: 27 dining room observations; 38 interviews with leadership, staff, residents, and family members; and review of 45 relevant documents. The authors describe the resident-centered steps that led the home's dining culture change, the evolution of care and meals in the home, the challenges and resistance to change that were encountered, and suggestions for overcoming these challenges. Strong yet nurturing leadership, visionary thinking, and translation of relational dining throughout a LTC home are essential for causing change to an ingrained culture.
The authors would like to thank all the residents, staff and relatives from the four care homes for all the information and the support they provided at all stages of this research project. They would also like to acknowledge the support and interest of the Meals Project organising group at Norfolk County Council who devised and delivered the food and drink changes: Alison Allen, Jane Bayliss, Harold Bodmer, John Butler, Phil Carter, Chris Chambers, Katrina Dixon, Fiona Harley, Lesley Lambert, Sue Lloyd, Roger Morgan, Jason Parker, Fiona Scott, Penny Stokes, Glenis Tudor, Elizabeth Turner, Lisa Utting, Carol Warden, Liz Wainwright, Howard Wynn and Jane Ziara.
The research was funded by Norfolk County Council. Norfolk County Council were not involved in the qualitative study design, or in collection, analysis or interpretation of data. They were not involved in writing the report or the decision to submit the paper for publication. Andrea Kenkmann has worked for Norfolk County Council as a care worker. This link did not affect the way that the data are presented.
Purpose:
Mealtime management in Residential aged care facilities (RACFs) should be holistic and comply with the principles of person-centred care (PCC) to ensure residents' medical, nutritional and psychosocial mealtime needs are met. However, this is not always achieved and multiple issues with mealtime management in RACFs exist. The aim of the current study was to compare documented, reported and observed mealtime management to explore factors influencing optimal mealtime care.
Method:
Data were triangulated from: (a) review of 14 resident files; (b) observation of 41 mealtimes; (c) questionnaires with 14 residents; and (d) questionnaires with 29 staff.
Result:
Results revealed multiple discrepancies between data sources leading to the delivery of sub-optimal mealtime care. Poor documentation impacted staff knowledge of required mealtime practices resulting in occasions of inconsistent and inappropriate care. Observational and interview data highlighted discrepancies between residents' mealtime preferences and actual practice. In many instances observed care was not holistic nor consistent with PCC.
Conclusion:
Given the significant medical, nutritional and psychosocial risks associated with poor mealtime management, systematic changes in policy, staff training and multidisciplinary care are needed.
Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.
Purpose of review:
Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. This review examines the recent literature and suggests implications for research and practice.
Recent findings:
Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. Depression, cognitive impairment, functional impairment, and swallowing difficulty were consistently associated with malnutrition. Mortality was the major consequence of malnutrition among nursing home residents, whereas higher BMIs had lower risks of mortality. Beneficial interventions to reduce malnutrition in the nursing home included dietary supplements, greater resident role in food choice, and staff training programs.
Summary:
To truly tackle the issue of malnutrition in the nursing home setting, a consistent definition is needed. We strongly recommend that an expert consensus panel identify a standard set of measures to more accurately compare the prevalence across countries. Given the mortality consequences of malnutrition and the paucity of intervention studies, research on interventions for malnutrition in the nursing home needs to be a higher priority for facilities, researchers, and funding agencies.
In France, in most nursing homes, the composition of menus, the time and the place at which meals are served, the choice of one's place at the table are imposed on residents. Yet, the act of eating cannot be restricted to nutritional and sensory aspects alone. It also includes a psycho-affective dimension, which relates to the context in which the meal is served. We tested the impact of four contextual factors, considered individually, on food intake and meal pleasure in elderly people living in nursing homes: the way the main course was named on the menu, the size and the variety of portions of vegetables served to residents, the presence or not of condiments in the middle of the table and the presence or not of elements to modify the surroundings such as a decorative object on the table or background music. Twelve experimental meals were served to 42 nursing home residents. For each factor, we compared a control condition with two experimental conditions. Our study showed that changing a single contextual element of the meal in nursing homes could be sufficient to improve residents' satisfaction with their meals and increase the quantities of meat or vegetables consumed, as long as this factor had a direct impact on what was going to be consumed (increased variety on the plate, condiments on the table). Factors affecting the context of the meal (names of dishes, decor) proved to be ineffective. Given the budgetary constraints faced by nursing homes, this study proposes interesting and inexpensive ideas to increase satisfaction with meals and food intake in elderly people who are dependent on others for their meals.
AimThe increasing prevalence of dementia and the nutritional complications associated with dementia suggest an increasing need for health care that focuses on nutrition and dietetic support. The aim of this paper was to summarise existing evidence relating to nutrition in the aetiology, prevention and management of dementia in order to help inform dietitians in the provision of care to people with dementia, their families and carers.MethodsA literature search was undertaken to identify relevant research that investigated the nutritional aetiology of dementia, the effectiveness of nutrition in the prevention and treatment of dementia, or strategies used by carers to provide nutrition-related support to people with dementia.ResultsThere is currently insufficient evidence to support specific nutrition-related dementia causality. The role of specific nutrients in slowing cognitive decline in people with dementia is also unclear. People with dementia rarely maintain a stable body weight and often incur numerous feeding-related challenges that contribute to the risk of malnutrition. High-calorie dietary supplements may enhance the short-term energy intake of people with dementia but are unlikely to improve long-term weight management or other dementia-related outcomes.Conclusions
Practical, achievable strategies that focus on food items and eating environments to promote oral intake of people with dementia while minimising carer burden should be a focus for nutrition and dietetic interventions.
Objective:
To examine the time, frequency and duration of each direct care activity conducted by personal carers in Australian residential aged care homes.
Methods:
A time-motion study was conducted to observe 46 personal carers at two high-care houses in two facilities (14 days at Site 1 and 16 days at Site 2). Twenty-three direct care activities were classified into eight categories for analysis.
Results:
Overall, a personal carer spent approximately 45% of their time on direct care, corresponding to 3.5h in an 8-h daytime shift. The two sites had similar ratios of personal carers to residents, and each resident received 30 min of direct care. No significant differences between the two sites were found in the time spent on oral communication, personal hygiene and continence activities. Personal carers at Site 1 spent significantly less time on toileting and mobility activities than those at Site 2, but more time on lunch activity. Although oral communication took the longest time (2h), it occurred concurrently with other activities (e.g. dressing) for 1.5h.
Conclusions:
The findings provide information that may assist decision makers in managing the operation of high-care residential aged care facilities, such as planning for task allocation and staffing. What is known about the topic? Overall, 30%-45% of the care staff's time is spent on direct care in residential aged care facilities. What does this paper add? This paper adds knowledge about how much time is required to conduct each direct care activity and the frequency and duration of conducting these activities to meet residents' day-to-day care needs in two high-care houses in two aged care facilities. What are the implications for practitioners? On average, a resident with high-care needs requires 30 min direct care. There may exist a basic minimum desirable ratio of personal carers to residents in high-care facilities. Residents' toileting needs are high after meals. Communication with residents represents an essential role in providing care.
The purpose of this study was to determine: (a) the frequency of family visitation during mealtime and (b) whether the presence of family during meals had an impact on the quality of feeding assistance care and resident intake. Participants included 74 nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region. Mealtime periods in which family was present were compared with mealtime periods when family was not present for the same resident. Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake. Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents' quality of life and well-being.
The sensory and gastrointestinal changes that occur with ageing affect older adults' food and liquid intake. Any decreased liquid intake increases the risk for dehydration. This increased dehydration risk is compounded in older adults with dysphagia. The availability of a non-invasive and easily administered way to document hydration levels in older adults is critical, particularly for adults in residential care. This pilot study investigated the contribution of bioelectrical impedance analysis to measure hydration in 19 older women in residential care: 13 who viewed themselves as healthy and six with dysphagia. Mann-Whitney U analyses documented no significant between-group differences for Total Body Water (TBW), Fat Free Mass (FFM), Fat Mass (FM), and percentage Body Fat (%BF). However, when compared to previously published data for age-matched women, the TBW and FFM values of the two participant groups were notably less, and FM and %BF values were notably greater than expected. If results are confirmed through continued investigation, such findings may suggest that long-term care facilities are unique environments in which all older residents can be considered at-risk for dehydration and support the use of BIA as a non-invasive tool to assess and monitor their hydration status.
Recent research has focused on the design of special care units for residents with dementia, often identifying the social benefits of residentially scaled kitchen and dining areas. This qualitative case study examines how the environmental design features of two dining settings in one special care unit impact residents’ patterns of socialization and interaction at meal times. The first setting is a central dining room for 50 to 60 residents. The second setting is a small office with a residentially scaled kitchen, where once a week, the activity director invites six residents for lunch once a week. Within an ecological theoretical framework, the study findings reveal that, while mealtimes in both settings are highly anticipated, it is the complex relational ties between the operational, managerial, and environmental features of the settings which determine residents’ social interaction and satisfaction with their mealtime experiences.
Background:
Undernutrition, weight loss and dehydration are major clinical issues for people with dementia in residential care, with excessive weight loss contributing to increased risk of frailty, immobility, illness and premature morbidity. This paper discusses a nutritional knowledge and attitudes survey conducted as part of a larger project focused on improving nutritional intake of people with dementia within a residential care facility in Brisbane, Australia.
Aims:
The specific aims of the survey were to identify (i) knowledge of the nutritional needs of aged care facility residents; (ii) mealtime practices; and (iii) attitudes towards mealtime practices and organisation.
Methods:
A survey based on those used in other healthcare settings was completed by 76 staff members. The survey included questions about nutritional knowledge, opinions of the food service, frequency of feeding assistance provided and feeding assessment practices.
Results:
Nutritional knowledge scores ranged from 1 to 9 of a possible 10, with a mean score of 4.67. While 76% of respondents correctly identified risk factors associated with malnutrition in nursing home residents, only 38% of participants correctly identified the need for increased protein and energy in residents with pressure ulcers, and just 15% exhibited correct knowledge of fluid requirements. Further, while nutritional assessment was considered an important part of practice by 83% of respondents, just 53% indicated that they actually carried out such assessments. Identified barriers to promoting optimal nutrition included insufficient time to observe residents (56%); being unaware of residents' feeding issues (46%); poor knowledge of nutritional assessments (44%); and unappetising appearance of food served (57%).
Conclusion:
An important step towards improving health and quality of life for residents of aged care facilities would be to enhance staff nutritional awareness and assessment skills. This should be carried out through increased attention to both preservice curricula and on-the-job training.
Implications for practice:
The residential facility staff surveyed demonstrated low levels of nutrition knowledge, which reflects findings from the international literature. This has implications for the provision of responsive care to residents of these facilities and should be explored further.
This article presents findings of a study which assessed the nutritional knowledge levels of nursing students as nurses are in a better position to serve as nutrition educators and counselors by engaging their clients in discussions that would increase their knowledge about disease prevention and management through nutrition. This was a descriptive cross-sectional study, where a selfadministered questionnaire was completed by 166 undergraduate consenting third (3rd) and final (4th) year nursing students in a public university in Ghana who answered 20 multiple choice general nutrition questions. An average score of 8.95 ± 2.01 corresponding to 44.8%, below average, was obtained by the respondents. It was determined that the nutrition knowledge of 3.6%, 62.7% and 33.7% of the study participants was good, adequate and inadequate respectively. It was found that the differences with respect to the nutrition knowledge levels between the age groups, gender, work experience and educational background of respondents were not statistically significant at p < 0.05. The findings of this study support other reports that nurses need more training in nutrition and therefore have important implications for professionals planning curricula for nursing education at the undergraduate level in the university.
In the UK and Europe, malnutrition in older people is a significant and continuing problem. Malnutrition predisposes to disease, impedes recovery from illness, increases mortality and is costly to society. Despite the high number of older people potentially at risk, malnutrition in care homes has been under explored. There is concern that national guidelines regarding the nutritional care of older people in residential care homes are not always implemented. This qualitative study explored the factors that influence the nutritional care provided to residents in two different types of local authority residential care homes (providing personal care) in Wales. One home had communal dining rooms; the other had eight bedded units with their own kitchen and dining facilities. The sample of 45 participants, comprised 19 staff (managers, care and catering staff), 16 residents and 10 residents’ relatives. Data were collected using semi-structured interviews, focus groups, observation and documentary review between August 2009 and January 2010. This paper focuses on how staff assessed and addressed residents’ nutritional needs. In both care homes, staff strove to be responsive to residents’ dietary preferences, provided person-centred care and worked in partnership with residents and their families to provide nutritious food in a homely environment. Neither home conducted nutritional screening to identify those at risk of malnutrition, contrary to national guidelines, but relied on ad hoc observation and monitoring. The staff’s knowledge of special dietary needs was limited. A need for further training for care home staff regarding the importance of nutrition in maintaining health in older people, use of nutritional screening and special dietary needs was identified. Shared nutrition training between health and social care staff needs expansion and policy implications in terms of an enhanced regulatory focus on maintaining nutritional needs in care homes are proposed.
This study aimed to examine whether an action research approach was effective in reducing the isolation of staff in 2 residential aged care facilities, within the context of an evidence-informed falls prevention program. A Falls Action Research Group comprising 12 nursing/nonnursing staff across 2 residential aged care facilities was established and engaged in critical dialogue and action over 12 months to improve their fall prevention activities. Through the group members' engagement, a research community was established that diminished staff isolation by engaging members in a sustained process of collaboration around falls prevention, which worked to disrupt occupational silos and challenge traditional staff hierarchies.
Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.
More than 3 million individuals are estimated to be at risk of malnutrition in the UK, of whom about 93% live in the community. BAPEN's Nutrition Screening Week surveys using criteria based on the 'Malnutrition Universal Screening Tool' ('MUST') revealed that 28% of individuals on admission to hospital and 30-40% of those admitted to care homes in the previous 6 months were malnourished (medium+high risk using 'MUST'). About three quarters of hospital admissions and about a third of care home admissions came from their own homes with a malnutrition prevalence of 24% in each case. Outpatient studies using 'MUST' showed that 16-20% patients were malnourished and these were associated with more hospital admissions and longer length of stay. In sheltered housing, 10-14% of the tenants were found to be malnourished, with an overall estimated absolute prevalence of malnutrition which exceeded that in hospitals. In all cases, the majority of subjects were at high risk of malnutrition. These studies have helped establish the magnitude of the malnutrition problem in the UK and identified the need for integrated strategies between and within care settings. While hospitals provide a good opportunity to identify malnourished patients among more than 10 million patients admitted there annually and the five- to six-fold greater number attending outpatient departments, commissioners and providers of healthcare services should be aware that much of the malnutrition present in the UK originates in the community before admission to hospitals or care homes or attendance at outpatient clinics.
Reminiscence therapy has been utilized for many years in the treatment of dementia in older people. Purposes of the research included examining different methods of promoting interactivity, social participation, cognitive function improvement in those with dementia, and the effectiveness in reducing symptoms of depression following group treatment. This study used pretest and posttest electroencephalography (EEG) measurements to test reminiscence therapy efficacy on participants. This research organized a social group work with 12 elderly clients with dementia (mild to moderate stage) selected from among 90 residents of an older persons care facility in Pingtung. Eleven agreed to join the study, and 10 completed successfully all treatment sessions. Eight sessions of reminiscence cooking lessons were conducted. The effectiveness of interventions was evaluated by comparing presession and postsession EEG, mental health status, depression scale, and feeling of participation scale scores. Significant differences in values, particularly for EEG, were found between the two sets of scores. The average value of participants' fast waves rose from 43.88 to 55.12, whereas average slow-wave values fell from 56.12 to 44.13. After analysis using the Wilcoxon matched paired signed rank test, significant differences were noted. Findings and suggestions include the following: (a) The rise in Mini-Mental State Examination and reduction in depression scale scores, although noted, were not significant, and (b) the self-achievement, emotional stability, family atmosphere, and physical needs of participants were met. The authors recommend that reminiscence group work be promoted in the home for older persons and that childhood cooking sessions twice each week may be the ideal format for reminiscence group work.
To determine the prevalence of malnutrition and investigate nutritional issues in a sample of older people living in residential aged care facilities (RACFs).
This study forms the descriptive component of a pretest post-test designed study conducted in eight RACFs. The Subject Global Assessment tool was used to determine the prevalence of malnutrition in 350 residents.
Nearly 70% of residents were women and 79.4% of all residents were classified as high care. Half the residents were well nourished (50.5%) with 43.1% moderately malnourished and 6.4% severely malnourished. Prevalence of malnutrition was significantly higher for residents receiving higher level care (odds ratio (OR) = 2.9 (95% confidence interval (CI): 1.7-5.2; P < 0.001)) and older than 90 years (OR = 3.0 (95% CI: 1.8-5.1; P < 0.001)). Of the residents considered to be malnourished, very few (17.8%) had been seen by a dietitian in the past 6 months or were receiving commercial supplements (29.2%).
There is a need for systematic, coordinated and multidisciplinary approaches to nutritional care for older people in residential care.
This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times.
Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states.
The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations.
These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.
Inadequate staffing has serious consequences for the nutritional care of nursing home residents. A sufficient number of well-educated and supervised staff members are critical to improving care.
Residential aged care staff play a significant role in the day-to-day lives of residents yet are faced with many barriers to providing care that promotes resident wellbeing.
Action research is a useful approach for clarifying issues, identifying education and training needs, and identifying, and in some cases overcoming, organizational barriers to change. The Well for Life project aimed to enhance the social and physical health and well being of residents of aged care settings by empowering the staff of facilities to make change. The project had a particular focus on nutrition and physical activity. This paper reports on the action research group process undertaken during Phase I of the Well for Life project. Five residential aged care settings participated in the action research process facilitated by project staff independent of the facilities. The action plan and outcomes from one of these settings is used to illustrate the process and outcomes.
The main findings of the project indicate that using a process that encourages staff involvement in identification of issues and actions can facilitate change in the practice of resident care. The action research groups identified specific gaps in knowledge and skill leading to targeted education that addressed areas of need. The importance of presenting information and learning opportunities for staff in a variety of formats was also recognized, as was the importance of organizational context, management support and empowerment of staff to make change.
The purpose of this research is to ascertain nursing home (NH) staffs' perspectives of the problem of dehydration in NHs (skilled nursing facilities) and have them identify clinically practical interventions to ensure that NH residents consistently take adequate fluids. Four focus groups with 28 NH staff members in attendance are held in three NHs in metropolitan Los Angeles. The majority of participants are certified nursing assistants; however, licensed vocational nurses, registered nurses, and other NH staff also attend the groups. Content analytic techniques are used to analyze the data. Three themes emerge focusing on residents' reasons for not drinking, signs and symptoms of dehydration, and strategies for improving hydration in NH residents. NH staff members identify the complexity of providing adequate hydration that was influenced by the resident's relationship with family and NH staff and communication between staff members.
Social facilitation and meal ambiance have beneficial effects on food intake in healthy adults. Extrapolation to the nursing home setting may lead to less malnutrition among the residents. Therefore, we investigate the effect of family-style meals on energy intake and the risk of malnutrition in Dutch nursing home residents.
In 2002 and 2003, a randomized controlled trial was conducted among 178 residents (mean age 77 years) in five Dutch nursing homes. Within each home, two wards were randomized into an intervention (n = 94) and a control group (n = 84). For 6 months, the intervention group received their meals family style, and the control group received the usual individual preplating services. Outcome measures were intakes of energy (kJ), carbohydrates (g), fat (g), and protein (g) and Mini Nutritional Assessment (MNA) score (0-30).
The change in daily energy intake between the control and intervention group differed significantly (991 kJ; 95% confidence interval [CI], 504-1479). The difference in intake of macronutrients was 29.2 g (95% CI, 13.5-44.9) for carbohydrate, 9.1 g (95% CI, 2.9-15.2) for fat, and 8.6 g (95% CI, 3.4-13.6) for protein. The percentage of residents in the intervention group classified by the MNA as malnourished decreased from 17% to 4%, whereas this percentage increased from 11% to 23% in the control group.
Family-style meals stimulate daily energy intake and protect nursing home residents against malnourishment. Therefore, replacement of the preplating meal services with family-style meals in nursing homes is recommended.
The Redesigning Care initiative at Flinders Medical Centre aimed to improve access to timely, consistent, quality care. This led to the creation of an Acute Assessment Unit (AAU) where all patients are assessed by the Allied Health team on admission. This study aimed to: (i) determine the nutritional status of patients admitted to the AAU using the scored Patient Generated-Subjective Global Assessment (PG-SGA); and (ii) determine the association between nutritional status and length of stay (LOS).
A prospective, observational study was conducted in 64 patients (mean age 79.9 +/- 11 years, 76% female). Nutritional status was assessed within 48 h of admission and LOS data were collected prospectively.
According to PG-SGA global rating, 53% (n = 34) of patients were malnourished. There was a weak association between PG-SGA score and LOS (r = 0.250, P = 0.046). The malnourished patients had a longer LOS by 1 day compared to well-nourished patients, and while this did not reach statistical significance (Z = -0.988, P = 0.323), it has implications for health care costs. LOS overall was short at a median of 4.5 days (range 1-24).
A significant proportion of patients admitted to the AAU is malnourished. There was a trend for these patients to have a longer LOS, indicating a critical need for nutritional management; however LOS as a whole was short. While nutrition support in hospital is useful in reinforcing dietary education, the short LOS emphasized the importance of discharge education and follow-up.
Many diseases have multifactorial origins. There is increasing evidence that mild dehydration plays a role in the development of various morbidities. In this review, effects of hydration status on acute and chronic diseases are depicted (excluding the acute effects of mild dehydration on exercise performance, wellness, cognitive function, and mental performance) and categorized according to four categories of evidence (I-IV). Avoidance of a high fluid intake as a precautionary measure may be indicated in patients with cardiovascular disorders, pronounced chronic renal failure (III), hypoalbuminemia, endocrinopathies, or in tumor patients with cisplatin therapy (IIb) and menace of water intoxication. Acute systemic mild hypohydration or dehydration may be a pathogenic factor in oligohydramnios (IIa), prolonged labor (IIa), cystic fibrosis (III), hypertonic dehydration (III), and renal toxicity of xenobiotica (Ib). Maintaining good hydration status has been shown to positively affect urolithiasis (Ib) and may be beneficial in treating urinary tract infection (IIb), constipation (III), hypertension (III), venous thromboembolism (III), fatal coronary heart disease (III), stroke (III), dental disease (IV), hyperosmolar hyperglycemic diabetic ketoacidosis (IIb), gallstone disease (III), mitral valve prolapse (IIb), and glaucoma (III). Local mild hypohydration or dehydration may play a critical role in the pathogenesis of several broncho-pulmonary disorders like exercise asthma (IIb) or cystic fibrosis (Ib). In bladder and colon cancers, the evidence on hydration status' effects is inconsistent.
To evaluate strategies designed to improve nutrition in elderly hospitalised patients with dementia.
Observation phase followed by sequential interventions.
A Short stay assessment unit.
Hospital Inpatients with a variety of conditions causing dementia.
Phase 1: Observation. Phase 2: Encouraging dietary, 'Grazing'. Phase 3: Using volunteers to feed patients. Phase 4: Improving dining room ambience by playing soothing music.
Body Mass Index (BMI), mid arm circumference, mini nutrition index and caloric intake by plate waste measurement.
BMI fell in the Observation phase 0.6 +/- 0.68 kg/m2 (p < 0.001), but increased in each of the Intervention phases. Phase2 0.3 +/- 0.86 kg/m2 (p < 0.04), Phase 3 0.37 +/- 0.4 kg/m2 (p < 0.04), Phase 4 0.39 +/- 0.7 kg/m2 (p < 0.007). Caloric intake increased in the intervention phases.
Simple, inexpensive and easy to implement strategies can improve nutrition in hospital inpatients with dementia.
Application of reminiscence treatment on older people with dementia: A case study in Pingtung, Taiwan [corrected] [published erratum appears in J NURS RES 2009 Sep; 17(3):231]
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