Geriatric Nursing and Mealtime Difficulties

 Assessment of Nutritional Problems and Nursing Care

Nutritional issues and their assessment in older adults improving intake.Health care staff training and environmental factors.

    Nutrition has long been recognized as a key element in promoting good health and recovery from illness across the life span; this is especially true as an individual age. However, the process of eating and the entire ritual of meals, which together are largely culturally determined, are given little attention when nutritional problems are identified.

     This is especially notable at a time when interest in food and its presentation has become a national craze, with many claiming to be “foodies” and chefs raised to the status of media stars (Food Network Chef Bios, 2011). 

    However, in institutions, restrictive diets are sometimes barely palatable, the eating environment ranges from a cluttered hospital room to a large, noisy dining room, and staff treat the meal as a task to complete rather than a process to enjoy. This chapter will address both barriers and enablers to overcoming mealtime difficulties and evidence-based strategies to support that process.

Nutritional Problem

    Nutrition is critical to maintaining health, and nowhere is this more important than among older adults. The ingestion of the proper balance of macronutrients and micronutrients results in a pattern of eating that persists into old age and affects an individual's risk for chronic illness, especially type 2 diabetes, heart disease, osteoarthritis, and some cancers (US Centers for Disease Control and Prevention (CDC), 2009a). 

    When older persons with multiple morbidities are hospitalized, their nutritional status is often compromised related to a complex interplay of issues from social isolation, depending on others whether at home or in a nursing home, to depression or dementia (Arora et al., 2007) .Then, as a result of these barriers to nutritional health, they are more likely to remain in hospital longer with higher rates of complications and mortality (Arora et al., 2007). 

    Within the revised Healthy People 2020, determinants of health beyond individual behaviors are examined to include both the social environment, such as limitations that make it challenging for older adults to stay at home, health services related factors such as accessibility to providers with needed expertise ; and community factors such as poverty, violence, and access to healthy food (US Department of Health and Human Services [USDHHS]), 2011); these factors directly affect nutritional issues and disproportionately affect minorities and targeted underserved groups.

     A good diet in old age can be influenced by multiple factors, one study found, not surprisingly, that higher socioeconomic status, ingestion of regular fruits and vegetables since childhood, and not smoking were primary predictors (Maynard et al., 2006).

     Of the top 10 causes of death in the older cohort, a lifetime of good nutrition would positively improve nine causes: heart disease, cancer, stroke, chronic lower respiratory disease, Alzheimer's disease, diabetes, influenza/pneumonia, nephritic syndrome/nephritis, and septicemia, with accidents being the outlier (CDC, 2009b).

     However, although the examination of nutrition and maintenance of a healthy diet are primary assessment criteria, the issue of how older people choose, prepare, serve, and ingest food, or others do it for them-the phenomenon of meals-is often overlooked. 

    Meal is defined as “the food served and eaten, especially at one of the customary, regular occasions for taking food during the day, as breakfast. lunch, or supper, one of these regular occasions or times for eating food” (Flexner & Hauck, 1987). Meals are custom driven and contextually based; even the time that food is eaten and what is eaten at each meal can be dictated by culture and habit.

    Within a “foreign” environment such as a hospital or long-term care institution, a different culture exists one that focuses on patient safety and quality, which has been broadly defined as preventing harm to patients and delivering quality health care (Mitchell, 2008 ). The overarching concern for systems outcomes may override individual needs; this has led in the long-term care environment to the “culture change” movement that focuses on quality of life as well as quality of care ( Koren , 2010).

     Deeply embedded within this paradigm shift, which is championed by national lay and professional stakeholders, is a regard for mealtimes that reflects the comforts of home (Pioneer Network, nd). 

    With a growing concern for shifting the paradigm away from solely a concern for calories consumed to a comprehensive approach to the entire phenomenon of eating, we need to explore the assessment and management of mealtimes through a new lens using a model that asks the health care provider to examine the entire context of meals for all older adults; the way that the meal assistance is rendered by caregivers.

    If needed, especially in the face of acute exacerbations of chronic illness and cognitive impairment; and health factors that may influence the older adult's functional and cognitive capacity to independently eat. 

    This model-change the context, change the care-giving, change the person has been adopted in three studies by the authors who trained caregivers in long-term care and in the community to change meals as a mechanism to promote quality of life and nutritional health ( Amella &Delegge , 2009; Amella &Laditka , 2009; Aselage , 2011).

     Furthermore, the support of the routine and the familiar was shown to be critical in older persons with cognitive impairments through the work of nurse researchers who developed the Needs-Driven Dementia-Compromised Behavior framework in the late 1990s that examined dysfunctional behavior from the areas of background (personal) and proximal (environmental) factors among people with dementia ( Algase et al., 1996).

    This work guides many interdisciplinary interventions for this compromised population today, including examination of mealtime issues ( Aselage &Amella , 2010).

Assessment of Problem

    Recommendations for assessment of nutrition among older adults vary depending on their place of residence (community, long-term care, or acute care) and their level of independence; however, a systematic review of different instruments recently supported the use of the Mini Nutritional Assessment (MNA) across sites and SCREEN II for community-dwelling older adults (Phillips, Foley, Barnard, Isenring, & Miller, 2010 ) .

     However, the MNA has only one question that even indirectly deals with meals: “How many full meals does the patient cat daily?” The individual is then asked: “Do you normally cat breakfast, lunch, and dinner?” The following definition of a full meal is given: A full meal is defined as an eating occasion when the patient “sits down” to eat and consumes more than two items/dishes ( Guigoz , Vellas , & Garry, 1997). 

    An alternative assessment instrument that has been used exclusively in the community, SCREEN II, shows strong psychometrics, but does not address contextual issues beyond "eating alone" (Keller, Goy, & Kane, 2005). 

    Assessment of the entire process of eating and mealtimes was divided into the following components by Aselage (2010) to eating behavior assessed by the Level of Eating Independence Scale (LEIS) and the Eating Behavior Scale (EBS): feeding behavior assessed by the Edinburgh Feeding in Dementia Scale ( EdFED ), Feeding Abilities Assessment (FAA), Self-Feeding Assessment Tool of Osborn and Marshall, the McGill Ingestive Skills Assessment (MISA). 

    Feeding Behavior Inventory, the Feeding Traceline Technique (FTLI), Feeding Dependency Scale (FDS), and the Aversive Feeding Inventory; and meal behavior assessed by the Meal Assistance Screening Tool (MAST) and Structured Meal Observation. 

    This critical appraisal of instruments determined that most are primarily used in research, most are setting specific with an emphasis on either long-term care or rehabilitation settings-few have been used in the community; are often lengthy and may not be practical in a clinical setting. 

    Only the EdFED , which has been used across acute and long-term care settings and in the community, has strong psychometrics, and appears to be the most practical across domains (Watson, 1994b; Watson, Green, & Legg, 2001); yet, it was designed to evaluate individuals with dementia-clearly not all older persons having difficulties with meals, but in all likelihood a significant portion. 

    The other standardized assessment instrument worth noting is the Minimum Data Set (MDS) that, as of late 2010, underwent its third complete revision MDS 3.0-to improve accuracy and reliability of assessment and reporting (Centers for Medicare & Medicaid Services (CMS), 2010). 

    The MDS is administered to all residents of nursing homes in the United States receiving federal funding, and it may be a part of the assessment information that flows between agencies during transitions-nursing home to acute care. 

    One of the foci of the MDS is determining the amount of assistance required by an individual to perform various activities, as well as health problems that may result if key factors are not addressed. The MDS dedicates only two questions in 15 sections regarding health assessment to a mealtime-like issue. 

    In the section Preference for Customary and Routine Activities, the only relevant item is “How important is it to you to have snacks available between meals?” and in the Functional Status section, “Eating includes eating, drinking (regardless of skill), or intake of nourishment by other means” (eg, tube feeding, total parenteral nutrition, intravenous fluids for hydration; CMS, 2010).

    As an individual ages, the likelihood of functional impairment increases. With increased frailty, loss of function follows a predictable pattern, with the ability to feed oneself the last activity of daily living (ADL) to be lost (Katz, Downs, Cash, & Grotz, 1970; Katz, Ford, Moskowitz, Jackson , & Jaffe, 1963). 

    The most recent national data on disability showed that 19.7% of all older adults (65 years old and older) are chroniccally disabled, with 3.1% of those living in the community requiring assistance with five to six ADLs (Federal Interagency Forum on Age-Related Statistics, 2006). 

    Although self-feeding must be promoted for all persons for as long as possible, techniques for promotion of independence at meals are often not used and may take too much time for caregivers resulting in increased dependence at mealtimes. 

    Interdisciplinary researchers developed individualized nutritional interventions based on regular assessment of changing status over time; the treatment group was noted to have a declining appetite, poor posture while eating, and inadequate oral care-all amenable to alterations to the process of care with improved nutritional serological markers and depression compared to the control group ( Crogan , Alvine , &Pasvogel , 2006). 

    Assessment is not a static event, especially when an older adult experiences the downward spiral of a life-limiting cognitive or physical illness.Different religious and cultural groups may have strict requirements for preparation and blessing of food before it can be consumed (Bermudez & Tucker, 2004). Therefore, assessment of these beliefs and preferences are vital. 

    Individuals who follow dietary restrictions for religious or cultural reasons may not eat when rules have not been observed ( Fjellström , 2004). In general, most cultures promote the washing of hands before meals; this may not be offered in institutional settings. Older adults who have serious chronic illness should be consulted regarding preferences for food and fluid intake. 

    They should be asked about their wishes regarding treatment with artificial nutrition and hydration if not already documented in an advance directive. If the older adult loses the capacity for decision making, the proxy for health care decisions should be consulted rather than the provider assuming responsibility for the management of nutritional care.

    Finally, for some older adults, social determinants of health may limit their ability to acquire and eat the foods they have preferred over a lifetime. For those individuals living at or near the poverty line, or those who live in rural or economically depressed neighborhoods, food insecurity and food deserts may be active concerns (Coates et al., 2006). 

    In 2008, among older adults living alone, 8.8% were categorized as food insecure and 3.8% were categorized as very low food insecure, meaning they may not be eating for a whole day and this condition was present for 3 or more months (Coates et al., 2006; Seligman, Laraia , &Kushel , 2010).

    Inability to obtain favorite foods because one lives in an area only serviced by convenience-type stores with highly processed food (food deserts), out of fear of violence, or because of poverty may result in meals that are no longer appealing or congruent with lifelong cultural preferences. For these older adults, referral to meal programs may be vital.

Interventions and Nursing Care Strategies Nutritional Health

    Assessment and management of nutritional health is covered in the Nutrition chapter in this text; therefore, the reader is referred to that discussion. However, the professional nurse is reminded that nutritional health is best assessed and managed through an interdisciplinary approach because it is a multifaceted issue. 

    Minimally, the dietitian, provider (physician, advanced practice nurse, physician assistant), dentist, speech and language pathologist, occupational therapist, and patient/caregiver should be consulted when designing a nutritional plan of care. The social worker or case manager may be key to coordinating outside resources and should be part of discharge planning for obtaining preferred, culturally appropriate, and healthy foods. 

    Strategies that produced better meal-time outcomes included “meal rounds” by a dietitian and food service supervisor working with unit staff, which allowed for early identification of residents at risk for nutritional problems and early intervention, especially those with dysphagia and those needing assistance at meals (Keller, 2006). Clearly, mealtimes are an opportunity for collaboration.

Cognitive Impairments

    Cognitive deficits impair the ability to eat and drink. Persons with severe cognitive impairments may develop refuse-like or aversive behaviors that affect their ability to be assisted at meals; this is significantly associated with mortality ( Amella , 2002; Mitchell et al., 2009). 

    In a systematic review of the literature, the only intervention that was associated with increased intake in this group was high calorie supplements, although other nutritional and social interventions only showed weak association (Hanson, Ersek , Gilliam, & Carey, 2011 ) . 

    However, as this disease moves toward later stages, the individual's prior wishes should be respected regarding food and fluid and the focus is often placed on quality of life ( Amella , 2004). Watson developed a psychometrically sound instrument, the EdFED , to measure the declining ability to consume food offered related to resistance (Watson & Deary, 1997). 

    Nurses can use the principles of this instrument to determine the stage of resistive cating behavior. In the earlier stages, more active behaviors are displayed (eg, the individual pushes food away or turns his or her head away from the feeder). 

    In later stages, passive behaviors occur, as the patient does not swallow and allows food to fall from his or her mouth. In late-stage dementia, a primitive and less forceful swallow pattern may develop. The upper airway is not well protected, making the use of bottle of syringe-type feeding not only undignified but also ineffective and unsafe.

 Improve Intake

    Modifying mealtimes may result in positive nutritional outcomes one of the most notable is increasing intake of food and fluids. Interventions range from modifying a “therapeutic” diet (including favorite foods, promoting socialization, and a team approach) to planning meals. 

    Liberalization of diets is recommended by a major dietetic organization when intake of micronutrients (eg, sodium) or macronutrients (eg, fats) cannot be supported and quality of life is primary, especially in those persons with life-limiting illnesses, or who have consumed minimal nutrition (Dorner, Friedrich, &Posthauer , 2010).

    Equivocal results can be found regarding what activities promote greater intake at meals. Taylor and Barr (2006) reported that eating smaller more frequent meals increased intake of fluids; however, it did not increase food intake. 

    In a randomized crossover design, researchers found that “smaller eaters” consumed more calories and protein if breakfast and lunch meals were enhanced with higher caloric food and extra protein (Castellanos, Marra, & Johnson, 2009). Additionally, in a quasi experimental study, eating in the dining room appeared to increase total consumption of calories but did not influence intake of protein, nor did it influence weight gain (Gaskill, Isenring , Black, Hassall, & Bauer, 2009 ; Wright , Hickson, & Frost, 2006). 

    Some Acute Care for the Elderly units include a dining room in their environmental modifications in order to improve the mealtime experience, increase observation of those with eating problems, and increase food intake.

    Mealtimes can be a time to significantly increase social exchange, as was demonstrated through a bundled intervention including favorite foods, including chocolate; moderate exercise; and oral care. However, it was social engagement and functional ability that increased in the treatment group, with social engagement associated most with improvement (Beck, Damkjaer , &Sorbye , 2010). 

    Furthermore, in an observational study conducted in France that promoted caregiving staff sharing meals with nursing home residents with dementia, compared to another nursing home that did not have shared meals, weight of residents in the "treatment" facility was maintained and staffs behavior toward residents improved ( Charras &Frémonteir , 2010).

Feeding Assistance and Staff Training

    Within recent years, more emphasis is being placed on preparing staff in nursing homes to safely assist with meals; sadly, this has not occurred with equal vigor in acute care where older adults may be the most medically vulnerable and require knowledgeable staff to support meals. 

    Under experimental conditions, it has been demonstrated that feeding assistance makes a critical difference for older adults with functional impairment: When nursing home residents at risk for weight loss were assisted by trained research assistants for 24 weeks, caloric intake increased and weight improved (Simmons et al., 2008). 

    However, in the clinical world, most staff are uninformed regarding how to assist with meals and use personal beliefs and preferences to guide their delivery of meals (Lopez, Amella , Mitchell, &Strumpf , 2010). Very few elements of mealtime care are formally developed and taught: Most staff see meals as a task to be accomplished ( Amella , 1999). 

    The advent of formal paid dining assistant (DA) feeding programs in nursing homes has been supported by state survey and certification bodies to improve nutrition among residents and may include information regarding interpersonal communication in general, altering the environment and working with families. 

    However, a careful review of an 8-hour New York State program revealed that very little time is allocated for focus on these elements (New York State Department of Health, 2007). Simmons has been working to develop and refine an interdisciplinary-informed DA training program (Simmons &Schnelle , 2006), and recently with an interdisciplinary team tested a 12-month implementation with follow-up, finding that trained DA staff were just as effective as certified nursing assistants (CNAs) at recognizing problems and assisting with meals (Bertrand et al., 2010). 

    However this program also had a focus on safety and the task of feeding. When CNAs were trained in feeding skills, and the residents they assisted using those improved strategies were then evaluated using the EdFED , the residents receiving the new strategies had better eating behavior and were given more time to eat (Chang & Lin, 2005). In acute care, no training material could be found for direct care workers regarding the alteration of environment, personalized strategies, or methods to encourage eating.

    In addition to lack of training regarding facilitation of meals and promotion of meal-time independence, mealtimes may be poorly staffed, especially in acute care settings because personnel are often taking meal breaks at the same time as patients (Crabtree, Miller, &Stange , 2005; Xia & McCutcheon, 2006). 

    However, when hospital nurses in the United Kingdom decided to redesign meals on medical wards and address nutritional needs of patients by taking breaks at other than mealtimes, patients actually consumed more food (Dickinson, Welch, & Ager, 2008). When surveyed, CNAs and licensed nurses identified lack of time and training, as well as "working short staffed." as being related to residents not receiving enough food ( Crogan , Shultz, Adams, & Massey, 2001). 

    Mealtimes are one of the most time-consuming activities of daily living and, unfortunately, not reimbursed at the required levels. It has been reported that nursing home residents with low intake required 35-40 minutes of staff assistance despite their level of dependency (Simmons &Schnelle , 2006); the amount of time taken to support meals among acutely and critically ill older adults in hospital is not known.

Environment and Interaction

    Because of the strong social and cultural components of eating, where one dines is sometimes as important as what one eats. Nurses should simply ask themselves, “Would I want to eat my next meal where this person is eating?” If the answer is no, then steps should be taken to improve the dining environment. Small changes in the dining environment may make large improvements in a patient's capacity and motivation to eat or be fed. 

    Unfortunately in institutions, the mealtime experience is often not focused on individual needs ( Sydner &Fjellström , 2005). Several patient-centered factors have been identified as critical to older adults: Each mealtime was seen as a unique process, and patients are central to the process through their actions not only at meals but also during the time surrounding meals, such as socializing while waiting (Evans, Crogan , & Shultz, 2005; Gibbs-Ward & Keller, 2005; Wikby &Fägerskiöld , 2004). 

    External factors such as decreased noise. increased lighting, and playing of relaxing music at meals positively influenced appetite (Hicks-Moore, 2005; McDaniel, Hunt, Hackes , & Pope, 2001). Using contrasting colors (foreground/background) in tableware and tablecloth, and placing dishes in similar positions may help persons with low vision be more independent ( Ellexson , 2004). 

    Proper positioning using the appropriate, supportive chair (instead of eating in bed or sitting on the bedside) or promotes good eating posture ( Rappl & Jones, 2000). Encouraging the family to eat with the patient can be beneficial; this has been shown effective in nursing homes to increase body weight and fine motor function in a randomized control trial (Altus, Engelman, & Mathews, 2002; Nijs, de Graaf, Kok , & van Staveren , 2006). 

    Meals caten in small groups-much like family dining are considered an ideal method; however, this intervention had more affect on staff's perception of meals and willingness to spend time in the process of attending to meals ( Kofod &Birkemose , 2004). Successful completion of the meal is dependent on who assists or feeds the patient and the interpersonal process that the person uses to interact with the patient (Altus et al., 2002; Amella . 2002).

    Caregivers who are able to let the patient set the tempo of the meal and allow others to make choices will be more effective in increasing intake. These studies point to a need to patient-centered approaches that individualize mealtimes for patients and that the responsibility for ensuring this occurs rests with a sensitive and well-trained staff.