Eating and feeding issues in older adults with dementia

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dementia series

Best Practices in Nursing Care to Older Adults with dementia

From The Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, and the Alzheimer's Association

Issue Number D11.2, Revised 2019

Editor-in-Chief: Sherry A. Greenberg, PhD, RN, GNP-BC Managing Editor: Robin Coyne, MSN, RN, AGACNP-BC New York University Rory Meyers College of Nursing

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

By: Melissa Batchelor-Murphy, PhD, RN-BC, FNP-BC, FAAN, George Washington University School of Nursing and Elaine J. Amella, PhD, RN, FAAN, Medical University of South Carolina College of Nursing

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

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

TARGET POPULATION: Older adults with diagnosed or suspected dementia.

MORE ON THE TOPIC: Best practice information on care of older adults: . AGS Choosing Wisely Workgroup. (2013). American Geriatrics Society identifies five things that healthcare providers and patients

should question. JAGS, 61(4), 622-631. Batchelor-Murphy, M., & Crowgey, S. (2016). Mealtime Difficulties in Dementia. In M. Boltz (Ed.), Evidence-Based Geriatric Nursing

Protocols for Best Practice (5th ed.) (pp. 417-429). New York, NY: Springer Publishing Company. Fischberg, D., Bull, J., Casarett, D., Hanson, L.C., Klein, S.M., Rotella, J., Storey, C.P. Jr., & Teno, J.M., American Academy of Hospice

and Palliative Medicine Choosing Wisely Task Force. (2013). Five things physicians and patients should question in hospice and palltive medicine. Journal of Pain and Symptom Management, 45(3), 595-605. Liu, W., Cheon, J., & Thomas, S.A. (2013). Interventions on mealtime difficulties in older adults with dementia: A systematic review. \ International Journal of Nursing Studies, 50, 463-464. Matusik, P., Tomaszewski, K., Chmielowska, K., Nowak, J., Nowak, W., Parnicka, A., Dubiel, M., Gasowski, J., & Grodzicki, T. (2012). Severe frailty and cognitive impairment are related to higher mortality in 12-month follow-up of nursing home residents. Archives of Gerontology and Geriatrics, 55(1), 22-24. Mitchell, S.L., Teno, J.M., Kiely, D.K., Shaffer, M.L., Jones, R.N., Prigerson, H.G., Volicer, L., Givens, J.L., & Hamel, M.B. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361, 1529-38 Watson, R., & Dreary, I.J. (1997a). A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. Journal of Advanced Nursing, 26(1), 25-32. Watson, R., & Dreary, I.J. (1997b). Feeding difficulty in elderly patients with dementia: confirmatory factor analysis. International Journal of Nursing Studies, 34(6), 405-414.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety for not-for-profit educational purposes only, provided that The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic

format, including PDA format. Available on the internet at . E-mail notification of usage to: nursing.hign@nyu.edu.

TIPS FOR AVOIDING AND REDUCING EATING AND FEEDING DIFFICULTIES (Matusik et al., 2012; Liu, Cheon, && Thomas, 2013): Although individuals with dementia differ greatly in their specific eating and feeding behaviors, the following general tips can help to avoid or reduce common problems.

Resident Ability ? Whenever possible assist the person with dementia to eat out of bed, seated in chair that promotes good posture and comfort. ? Assess and palliate pain (see Try This:? Assessing Pain in Persons with Dementia). ? Provide oral hygiene and allow the person to wash his/her hands. ? Allow time for blessing of food if this is the person's preference or habit. ? Assure that the person has his/her dentures and glasses, is properly positioned, and can see and reach the tray. ? Arrange the tray to facilitate self-feeding; rearrange items for easy access; remove plate and cup covers; unwrap utensils; open packets; cut up food; butter bread. ? Simplify the meal presentation; serve one food at a time; remove unnecessary utensils. ? Provide nutritional supplementation (calorie dense beverages) to assist in weight maintenance. ? Remove items that should not be eaten and hot items that could be spilled.

Caregiver Interaction ? Use verbal cueing and prompting to encourage self-feeding (for example, say `pick up your spoon,' `take a bite,' `chew,' `swallow'). ? Demonstrate eating motions so the person can imitate. ? Provide additional sensorimotor cues using the Over Hand or Under Hand techniques to initiate and guide self-feeding (Batchelor-Murphy et al., 2016). ? If physical assistance is necessary, provide it and continue verbal cueing and encouragement. ? Physical assistance should be provided on the person with dementia's dominant hand, assisting through the midline of the body, and ensuring food offered is within the visual field of the person being assisted. ? Watch for cues that would indicate that the individual is being rushed or is having trouble swallowing to include turning the head, pushing away, spitting, pocketing food, coughing, throat-clearing, gagging or choking. Slow down, modify technique or stop and notify the licensed nurse.

Environment ? Reduce distractions; turn off the TV; avoid interruptions and people entering the room.

Other ? Consider the following referrals: Nutritionist/dietitian for appropriate consistency and types of calorie dense foods and fluids; Speech-Language Pathologist for persons experiencing difficulties with eating; Occupational Therapist for adaptive eating equipment and positioning devices; and Dental professional for oral health issues that may affect eating.

Social Interaction: Eating is generally a social activity, and the social and environmental context of meals provides critical cues for recognition of food and appropriate eating behaviors in people with dementia (Matusik et al., 2012). While it is difficult to create a normal mealtime environment for institutionalized individuals, staff who assist people with eating and feeding should be at eye level and interact socially with each person keeping the focus of the conversation and the meal.

Involving Families: Many family members are willing and able to assist at mealtimes. If they have assisted with eating and feeding at home, their involvement can help avoid eating problems and can provide a more familiar social context for the individual. Mealtimes provide an opportunity for families to learn more about nutritional issues and management of eating and feeding problems. Available resources include: Food, Eating and Alzheimer's. Available online at Assisted Feeding and Tube Feeding: Common Questions. Available online at: Alzheimer's-Disease-Postion-Paper.pdf

Training and Mentoring Certified Nursing Assistants (CNAs): In a recent review of the best studies regarding mealtimes, training CNAs and other staff who assist individuals with eating and feeding produced some of the best outcomes (Liu, Cheon, && Thomas, 2013). However, these staff who are often under pressure to assist many people in a short time may resort to physical assistance too soon, feed too fast, or abandon the process. CNAs should be mentored by licensed staff to provide the level of physical assistance that is needed based on the individual's day to day changes, to continue using verbal cueing and prompting even if they are providing physical assistance, and to assist at a rate that is safe and comfortable for the individual (Matusik et al., 2012). These approaches take time. Nurses need to advocate with management for policies and resources to achieve the dual objectives of adequate food and fluid intake and maintenance of individual self-feeding abilities (e.g., sufficient staff and time between tray delivery and pick up). Quality improvement projects could be devised around this issue.

Tube Feeding: While percutaneous gastrostomy tubes (PEG) are essential in the care of certain individuals, for example, those with head and neck cancer, or some persons with stroke, those with late-stage dementia who have a declining intake are not recommended for this procedure. Two groups ? the American Geriatrics Society (AGS Choosing Wisely Workgroup, 2013) and the Hospice and Palliative Medicine (Fischberg et al., 2013) in their Choosing Wisely Statements, both stated that PEG tubes should be avoided in persons with late stage dementia. Instead, supportive hand feeding methods should be used. Personal choices and religious/cultural values should be respected.

The Hartford Institute for Geriatric Nursing would like to acknowledge one of the original authors of this issue: James F. Lawrence, PhD, APRN, BC

dementia series

Best Practices in Nursing Care to Older Adults with dementia

A series provided by The Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing

EMAIL: Nursing.HIGN@nyu.edu HARTFORD INSTITUTE WEBSITE: CLINICAL NURSING WEBSITE:

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