You are on page 1of 9

2.

6

hours

Continuing Education

By Chia-Chi Chang, PhD, RN, and Beverly L. Roberts, PhD, FAAN, FGSA

StrategieS for feeding PatientS with dementia
How to individualize assessment and intervention based on observed behavior.

OVERVIEW: Despite the high prevalence of dementia among elderly patients in hos­ pitals and nursing homes and the strong association between dementia and feeding difficulty, few sources adequately address effective feeding interventions. Basing their discussion on the conceptual model that grew out of a previously published systematic literature review, the authors address a wide range of assessment and intervention practices specific to various observed behaviors that may aid in feed­ ing patients with dementia. Keywords: Alzheimer’s disease, demen­ tia, feeding difficulties, malnutrition
36
AJN ▼ April 2011

I

n the United States, nearly 14% of people over the age of 71 have some form of dementia.1 People with dementia constitute roughly 25% of hospital patients ages 65 and older 2 and 47% of nursing home residents.3 And more than half of them lose some ability to feed themselves,4 which puts them at high risk for inadequate food in­ take and malnutrition. Patients who are unable to eat independently must rely on caregivers to assist them physically or with verbal prompts or cues during mealtimes. Unfortunately, caregivers may be unable to identify the various types of feeding problems that accompany dementia or unaware of the feeding prac­ tices required to address them. Certified nursing assistants (CNAs) provide nearly all feeding assistance in long­term and acute care set­ tings. Although they’re trained in basic feeding tech­ niques, CNAs may be unprepared for the challenges that arise when assisting people with dementia or fail to realize how the cognitive impairments associated with dementia may, in an institutional setting, be ex­ acerbated by physical, psychological, social, envi­ ronmental, or cultural factors.5 Although CNAs are taught the skills to deal with specific feeding difficul­ ties,6, 7 they must rely on nurses to assess particular
ajnonline.com

Vol. 111, No. 4

such as the one shown in this photo. the Feeding Behaviors Inventory.5 we evaluated three instruments commonly used to measure feeding difficulties in patients with dementia: the Edinburgh ajn@wolterskluwer. Our analysis revealed that.com Feeding Evaluation in Dementia (EdFED). problematic mealtime behaviors associated with Alzheimer’s disease in order to develop appropriate. while the EdFED was an aid in assessing feeding dif­ ficulties. chewing. open kitchen and serve residents at a large din­ ing table where they can social­ ize with staff and visitors. prepare meals in a homelike. this article focuses on tactics that formal caregivers can use in hospital or nursing home settings. 15 was de­ veloped by clinical nurses at the National Institutes of Health to help providers measure the functional abil­ ity of patients with Alzheimer’s disease to perform six general eating behaviors.5 In conducting that re­ view. and the Eating Behavior Scale (EBS). 111. swallowing. Although the strat­ egies we formulated based on that review and analysis may be used by family caregivers. This article provides an overview of the feeding dif­ ficulties associated with dementia and suggests ways that caregivers might intervene to overcome them. We developed the conceptual model for the assessment and intervention strategies presented here after com­ pleting a comprehensive systematic literature review. we used concept analysis to characterize feeding difficulties associated with dementia and to identify their antecedents (contributing factors) and conse­ quences (outcomes) (see Figure 1). situations and guide them in how to intervene. or paying attention to the task of eating). Photo by Rollin Riggs / New York Times / Redux Pictures. it didn’t address many aspects of the com­ mon feeding difficulties in dementia (such as difficulty getting food into the mouth. The Feeding Behaviors Inven­ tory13 directs clinicians to assess patients for 33 com­ mon. which was published previously. The EdFED8­12 is an 11­item assessment tool de­ signed to help clinicians determine the level of feed­ ing assistance patients need based on observed eating and feeding problems. 4 37 . the Feed­ ing Behaviors Inventory included more behaviors than the EdFED but failed to address antecedents or AJN ▼ April 2011 ▼ Vol. The EBS14. individualized nursing care plans. ASSESSING FEEDING DIFFICULTIES In our previously published review.Green House facilities. No.

impairments such as apraxia (the impaired ability to perform skilled or purposeful movements) and agnosia (the impaired recognition or comprehension of sensory stimuli) of­ ten emerge. 38 AJN ▼ April 2011 ▼ Vol. If the caregiver providing feeding assistance has different cultural expectations from those of the patient. coughing. clinicians have observed that patients are impatient. In addition. people with dementia resulting from vascular changes in the central nervous system often lose the ability to control and coordinate chewing and swallowing. and dental sensitivity). and executive function. which is associated with gagging.18 which can take the form of refusing food or feeding assistance. and very vocal or noisy diners. it provided no observational criteria for determining whether the behaviors were present. in the Korean culture. or hallucinations) may complicate feeding by producing somnolence or agitation. while the EBS identified important types of feeding difficulties. Older adults commonly lose some of the fine motor skills required to get food from the plate into the mouth. some of the medications prescribed to treat depression and other psychological disorders (such as aggression.20 For example. changes in func­ tional or mental status and reports of pain may signal the onset of depression. J Clin Nurs 2008. Furthermore.13 In dining rooms that are crowded and full of environ­ mental distractions such as loud background noises. agitated. and. institutional mealtime environ­ ments are very often crowded.5 CONTRIBUTING FACTORS In discussing the feeding difficulties associated with de­ mentia. Apraxia can interfere with patients’ ability to use eating utensils. No. Feeding difficulty in older adults with dementia. older adults both expect and are expected to become dependent as a part of normal aging.21 Such cultural expectations may affect not only the expression and identification of feeding difficulties but also the strategies figure 1. Environmental factors. which interferes with eating because it causes the patient to forget the task at hand or become easily distracted. both in long­term care facilities and in the com­ munity. The dining environment plays an important part in the feeding process. it’s important to first consider their anteced­ ents—the factors that contribute to these difficulties. and tend to have feeding prob­ lems. 111. may contribute to chewing difficulties. Compounding these problems.19 Cultural considerations. and the food). Dental problems (including poorly fitted dentures. 4 ajnonline. or displaying aggression. while agnosia can impair their ability to recognize food and know what should be done with it.13 Unfortunately. attention. Psychological and social issues. de­ lusions. or decayed teeth. social conversations among staff. as well as poor oral hygiene. chaotic. loose. and aspi­ ration. Physical dysfunction.16. model of feeding difficultieS Antecedents Lack of social interaction Perceptual deficits Poor motor control Cognitive impairment Psychological factors Poor dining environment Culturally inappropriate food choices Feeding Difficulties Difficulty initiating feeding tasks Difficulty maintaining attention to feeding task Difficulty getting food into the mouth Difficulty chewing food Difficulty swallowing food Consequences Inadequate food intake Weight loss Malnutrition Aspiration Pulmonary complications Adapted with permission from Chang CC. As dementia progresses.com . Roberts BL. altered smell and taste may reduce their appetite and food intake. 17 In patients with dementia. Impaired cognitive function. missing. becoming with­ drawn. The prevalence of depression in dementia is estimated to be roughly 45%. the only cognitive impairment may be a short­term memory deficit. and noisy. in addition to poor nutrition. and ineffective chewing may exacerbate dysphagia. with frequent interruptions or distractions and trays often placed out of patients’ reach.17 (17):2266-74. Dementia is associ­ ated with a progressive decline in short­ and long­term memory. it may reduce the quality of the patient’s dining experience as well as the patient’s food intake. the plate.consequences of feeding difficulties. Initially. while comorbid visual impairments may make it difficult for them to see food and utensils (particularly when there’s little contrast between the table.

which recreate a homelike atmosphere by al­ lowing residents to sit with each other at the dinner ta­ ble and select food from serving bowls placed on the table. NURSING INTERVENTIONS Our clinical experience. avoiding overcrowding ajn@wolterskluwer. Culture also influences food preferences and meal­ time habits. nu­ trition. and cilantro at meals improved resident intake.com of food preparation in the dining room may also re­ duce mealtime difficulties. and Social Sciences Full Text. appropriate communication at mealtimes. there have been significant efforts to make the dining environment as homelike as possible.31.35­37 though findings have been inconsistent.27. shred­ ded cabbage. together with the conceptual model that grew out of our literature review and con­ cept analysis. tube feedings.21 caregivers may be more likely to help aging adults feed themselves. ag­ ing and concept analysis. have been found to increase resident participa­ tion.34 and it’s thought to increase con­ centration and decrease agitated behavior.caregivers use to address them. interaction be­ tween nursing personnel and patients’ family or friends may be essential for patients with dementia. both mental and physical. dementia. and mealtimes last for more than an hour.33 Research on the effects of these changes on eating behavior and caloric intake is required. serving Hispanic adults culturally familiar foods such as flour tortillas. Familiar presentations of foods common to a patient’s culture have been found to improve in­ take.26 It’s important that lighting be sufficient to contrast and illuminate food and utensils. 28 Likewise. Institutional policies that promote family involvement in feeding and social in­ teraction between patients and caregivers should be encouraged.21 By contrast. SYSTEM SOLUTIONS Some of the factors that contribute to feeding prob­ lems in patients with dementia are best managed at the system level. meals are accompanied by soft music. friends. who of­ ten have difficulty verbalizing the feeding difficulties they’re experiencing. AgeLine. 32 It’s been suggested that increasing the aroma inStitutional PolicieS that Promote family involvement in feeding and Social interaction between PatientS and caregiverS Should be encouraged. and strengthen the connection between patient and caregiver. we excluded the terms enteral feeding. eating. Similarly. where changes in social policies and environmental design can be addressed. in a study of nursing home resi­ dents. Frequent social contact with family. such as whether they prefer to eat alone or while watching television. but medical records seldom contain information about patients’ mealtime habits. and no studies have established the type of music most effective in increas­ ing food intake. we used the following keywords and phrases: feeding.22 It also might help to provide culture­ specific eating utensils. For example. facilities modeled after the Green House concept prepare meals in an open kitchen and serve them at a large dining table at which residents can socialize with staff and visitors.25 Likewise.23 In addition.22 For example. No. A Korean caregiver may provide feeding assistance to an older family member even when it isn’t needed because the culture fosters the idea that an adult child feeding a parent is simply healthy reciprocity. 4 39 . malnutrition. residents have 24­hour open access to snack foods of their choosing. Dining room music has been used in some settings to increase food intake. and children has been shown to significantly reduce de­ pression in older adults. small changes in the dining environment can support self­feeding behaviors. ta­ bles are set with flowers. Patients’ food preferences may be found in the medical record. and the frequency of praise by CNAs assisting with feed­ ing. which was conducted in PubMed.5 served as the basis for a system of assess­ ing and managing feeding difficulties in patients with dementia. in Western culture. In the literature search for that review. 111. feeding assessment. beans and tortilla chips.29 Typically. and dementia and feeding. These social contacts may be the first to recognize a patient’s feeding difficulties or to offer to provide assistance. where greater emphasis is placed on indepen­ dence. and providing adequate space for the feeder to sit down and have eye contact with the patient encour­ ages interaction between the two. the assistance they need. In some long­term care settings. The most reliable sources for this information are family members and home caregivers. the Eden Alternative strives to create a small homelike environment that enhances social interaction and supports the autonomy of resi­ dents. Family­style meals. or their food preferences.30 In Eden homes. AJN ▼ April 2011 ▼ Vol. the Cumulative Index to Nursing and Allied Health Literature (CINAHL).24 as they contribute to patient health. cheese.

aSSeSSing and managing feeding difficultieS in PatientS with dementia TYPE OF FEEDING DIFFICULTY OBSERVED BEHAVIOR Initiating Feeding AJN ▼ April 2011 Refuses food or displays aversion toward food ▼ • Pushes feeder away • Pushes food away • Turns head • Spits out food • Refuses to open mouth Vol. refer to occupational therapist for adaptive utensils • Refer for visual acuity testing to determine whether glasses are needed • Provide adequate time for patient to feed self. 46 • Use color to increase contrast between plate. then quickly release. 41 • Check that glasses are in place during mealtime33. 4 Violent reaction to feeding • Hits feeder • Throws food at feeder • Hits eating utensils as feeder attempts to assist • Verbally abuses feeder • Verbally complains about eating Refuses feeding assistance • Tells feeder that she or he doesn’t want feeding assistance Unable to see plate on table or food on plate • Has difficulty locating plate on table or food on plate Maintaining Attention Patient is distracted • Cannot start eating when instructed to do so ajnonline. offer finger foods38. 45 • Carefully try to part patient’s lips and open mouth but do not force 43 (firmly squeeze lips between thumb and forefinger. place fingers under jaw.40 MULTIDISCIPLINARY STRATEGY FEEDING STRATEGY • Try to feed patient at another time39 • Seek help from another nursing assistant39 • Offer verbal encouragement40. and food27. firmly and quickly pressing upward and then releasing) • Try to feed patient at another time39 • Introduce quiet or relaxing music to reduce agitated behavior34-37 • Determine whether verbal complaints are valid and respond accordingly • If physical ability to feed self is impaired. 50 • Remind patient of motor behaviors needed to get food from plate to mouth using a hand-overhand approach (holding patient’s hand and moving it from mouth to food and back again)33. 111. 48. 46 • Provide verbal encouragement40. 43 • Increase oral stimulation by offering ice or cold water before eating43 table 1. 47. 47.com . No. 51 • Ask patient and patient’s family and friends about food preferences and try to include familiar foods in the diet5. 50 • Sit down and make eye contact with patient while feeding33.27. 46. 43. table. 50 If physical ability to feed self is impaired.

50 • Add gentle touch to verbal encouragement33 • Try to feed patient at another time39 Patient is too drowsy to eat or is difficult to awaken • Falls asleep while eating • Is difficult to rouse. 50 • Introduce music to create an environment conducive to dining37 and to stimulate eating34 • Remove environmental distractions (for example. or rehabilitation • If assessment reveals motor difficulty. turn off the TV or move to another room)13. utensils with large handles. task modification. 4 Swallowing Food • Seat patient at a 90° angle51 • Use thickening agent in drinks46. 48. 47. 28 • Stimulate the appetite by using aromatic ingredients. 49 • Cannot sit still. 51 AJN ▼ April 2011 Ineffective chewing • Chewing fails to reduce food to a form that can be swallowed ▼ • Starts to chew but not long enough to convert food to a consistency that can be swallowed • Cut food into small pieces to speed the effects of chewing27 Vol.27. or leaves table • Discontinue or reduce dose of medications that may cause drowsiness • Provide verbal encouragement40. 47. 111. even after verbal requests and physical contact Getting Food into Mouth • Refer to physical or occupational therapy for evaluation. gets up from chair. 51 • Assist patient in swallowing by gently stroking throat. No. designed for patient’s dominant hand) • Allow patient to use hands to feed self42 Unable to move food from plate into mouth • Lacks motor ability to feed self Unable to keep food in mouth • Food dribbles out of mouth • Unable to keep mouth closed while chewing Chewing Food • Refer patient to dentist to treat dental problems or ensure dentures fit well • Cut food into small pieces or change patient’s diet from solid to soft or semiliquid food. such as onions. in food preparation or by offering foods of different colors or textures27 • Provide finger foods patient can eat while away from table27. 27. moving from base of anterior neck toward jaw43 Aphagia • Gagging and choking when try• Refer to speech and language ing to swallow therapist to assess swallowing • Aspiration • Have oral suction available at • Multiple attempts to swallow food mealtime • Put patient on aspiration precautions 41 . refer to speech and language therapist for oral movement retraining44 • Use more solid foods • Use hands to help patient close mouth • Provide utensils that compensate for poor motor ability27 (for example.ajn@wolterskluwer.com • Doesn’t continue to eat after starting • Leaves pockets of food in the area of the buccal mucosa • Provide verbal encouragement40.

or. and swallow­ ing food. feeding difficulties. or violent reactions to feeding. nonnurse feeding assistants can be of great help during mealtimes53 by feeding residents with uncomplicated feeding needs. The search yielded 71 distinct. Although such feeding difficulties represent a sig­ nificant clinical problem. maintaining attention. 28. or speech or language therapy. therefore. A comprehensive approach to assessing and manag­ ing feeding difficulties in patients with dementia is nec­ essarily multidisciplinary. either because interventions and outcomes across studies haven’t been standardized or because intervention studies lack statistical power or fail to account for confounding factors. within each of those general areas. and literature reviews. such consistency is rare. postponing the feeding or asking another CNA to offer assistance. few sources adequately ad­ dress intervention.54 ajnonline. they’ve repeatedly been en­ dorsed by expert opinion and described as effective in observational and case studies. our goal is to help caregivers individualize assessment and interven­ tion practices in patients with dementia.com Vol. which is essential for good communi­ cation between them. chewing food. The assess­ ment and intervention strategies we subsequently de­ vised extend the general guidelines for mealtime diffi­ culties developed by Amella24 and are targeted toward feeding difficulties common in people with dementia. though verbal encouragement and a gentle touch may improve attentiveness. No.5 In Table 15. In long­term care settings. spit out the food. While turning off a TV or using more aromatic ingredients in meals may be enough to encourage the distracted patient who fails to eat or stores food.25 Unfortunately.PEG. 4 . if the patient’s reaction is violent—hitting uten­ sils or the feeder. In our literature review. or being unable to sit still) or drowsiness (with behavior 42 AJN ▼ April 2011 ▼ Although these strategies haven’t been validated in randomized clinical trials. CNAs report that they’re better able to interpret feed­ ing behaviors and identify effective feeding strategies. 13. Difficulty in initiating feeding may take the form of food refusal. It’s difficult to determine whether such practices are typical because research on the subject is so limited. Attention issues may take the form of excessive dis­ tractibility (marked by the failure to start or continue eating. storing pockets of food within the cheeks. asking the patient or family members about food pref­ erences so that familiar favorites may be incorporated into the diet. 27. trained. In presenting them. if those fail. Drowsy patients should be evaluated for a possible re­ duction or discontinuation of medications known to cause somnolence.37 The majority of feeding strategies we’ve compiled are based on de­ scriptive and cross­sectional studies or expert opinion. the patient who’s unable to remain seated during mealtime may benefit most from a meal of finger foods that can be eaten while walking. With food refusal or aversion. survey research. Feeding strategies include offering verbal encouragement. the patient may push the feeder or the food away. English­language articles. and enteral nutrition. we identified five general types of feeding difficulties involving the following tasks: initiating the feeding. 110 of whom had dementia. turn away. we referenced some sources that relied on systematic reviews and some that used experimental design. visual acuity test­ ing. Some behaviors associated with feeding difficulty suggest a need for evaluation by a physical or occupational therapist. On the other hand. ALLOCATING PERSONNEL When there’s consistency in patient care assignments. we describe several spe­ cific manifestations. 33­51 of this article. patients had a median of 16 to 20 different feeders during a four­week period. To reduce feed­ ing difficulties. health care settings should provide an adequate number of well­trained person­ nel for feeding assistance. ranging from being difficult to rouse to being unable to remain awake during mealtimes). get­ ting food into the mouth. and maintain consistency between feeders and patients. dental examination. and the multidisciplinary and feeding strategies often cited as effective in addressing these problems in patients with dementia. relevant. sit­ ting down and making eye contact with the patient.52 Hav­ ing this many feeders reduces the patient’s familiarity with the feeder. cnaS rePort that they’re better able to interPret feeding behaviorS and identify effective feeding StrategieS. In one study of 214 patients who required feeding assistance. 111. aversion to food. when there’S conSiStency in Patient care aSSignmentS. and effective management strategies. as well as the feeder’s familiarity with the patient’s food preferences. throwing food at or verbally abusing the feeder—the better approach may be to introduce quiet or relaxing music to reduce the patient’s agita­ tion and outbursts. or refuse to open the mouth. the observable behavior associ­ ated with each. in addition.

investigators need to develop instruments by which they can assess all types of feeding difficul­ ties.ahcancal. social. protein consumption can be ob­ tained and tracked.thereby leaving CNAs free to assist those with com­ plex feeding needs. and speech therapists. 2. June 2009 update. Social interaction among people with dementia. based on estimates of meal por­ tions eaten. Washington. 2009. and pulmonary complications are adverse outcomes associated with feeding difficulties. CNAs. with close attention paid to their efficacy and appropriateness for each patient and provider.26 In addition to calorie counts. taking into account calories consumed and body weight or body mass index.6 Outcomes data were limited. Taiwan. Alzheimer’s Association. all food should be weighed and consumption recorded.5 Malnu­ trition should be assessed at least monthly. and cultural factors that can contribute to. patients’ family members. researchers need to conduct more experimental studies.edu. Neuro­ epidemiology 2007. demographics.23(4):16­20. et al. The authors of this article have disclosed no sig­ nificant ties. J Gerontol Nurs 1997.5(2):123­33. 3. atti­ tude toward. Effects of a feeding skills training pro­ gramme on nursing assistants and dementia patients. To ensure the safety of residents. 5. Further research is needed to evaluate whether CNA training in feeding assessment and intervention reduces feeding difficulties in patients with dementia. To be successful. American Health Care Association. 7. Alzheimers Dement 2010. and then move on to gauging outcomes. Feeding difficulty in older adults with dementia. Chang CC. In addition to promoting fluid and nutritional intake. or prevent these difficulties.37 In order to generate targeted interventions for this patient population. and employing various types of caregivers. possibly. psychological. Chia­Chi Chang is an associate professor in the School of Geriat­ ric Nursing and Care Management in the College of Nursing at Taipei Medical University in Taipei. assessment and intervention strategies must account for the cog­ nitive. physical. 111. Such strategies require a mul­ tidisciplinary approach that includes nurses. Chang CC. The strategies presented here should be carefully adapted to the health care settings in which feeding assistance is provided and used.com/ce. Alzheimers Care Q 2004. cchang@tmu. and memory study. environmental.6(2):158­94. Nursing personnel may find it helpful to work with families to identify patient feeding preferences. For an accurate intake record. Noting a progressive decline in caloric intake can allow for intervention before significant weight loss has occurred.29(1­2):125­32. J Clin Nurs 2005. Although findings from long­term care stud­ ies may be applicable to other settings. however. CNAs further ben­ efit from consistency in patient assignments. 2010 Alzheimer’s disease facts and figures. t For 74 additional continuing nursing educa­ tion articles on geriatric topics. LeClerc CM. No. but remain on hand to serve in a supervisory role and manage the more challenging feeding cases. Feeding difficulties faced by patients with dementia are common. Plassman BL. Roberts BL. Roberts is the Annabel Davis Jenks Endowed Professor for Teaching and Research in Clinical Nursing Excellence at the University of Flor­ ida College of Nursing in Gainesville. malnutrition. Lin LC. physical. One small study evaluated the effects of a CNA feed­ ing skills program on participants’ knowledge of. as well as to interpret the meaning of the patients’ body language and verbal expressions. go to www. DC. Because patients with dementia are often unable to communicate their needs. as­ piration.tw. http://publish. In particular.pdf. by the small size of the sam­ ple. any existing differences must be articulated. To sup­ port such interventions. REFERENCES 1. A feeding abilities assessment for persons with dementia. occupational. nursingcenter. This manuscript was supported by a grant from the National Health Research Institutes (NHRI­ EX99­9921PC). financial or otherwise. nonnurse feeding as­ sistants. in a variety of settings. multifactorial. to any company that might have an interest in the publication of this educational activity. it’s critical that CNAs not be assigned to provide other types of nursing care during mealtimes. 4 43 .com members may be the first to identify feeding difficul­ ties or to initiate interventions to address these diffi­ culties. MONITORING OUTCOMES Inadequate food intake. there’s a pau­ city of research in settings other than long­term care facilities. 6. Beverly L. AJN ▼ April 2011 ▼ Vol. which enables them to become familiar with the needs of specific patients and respond accordingly. and. et al. Randomized clinical trials are needed to assess the benefit of educational programs on feeding difficulties for nursing assistants and nonnurse feeding assistants. Prevalence of dementia in the United States: the aging. apart from their contributing factors. OSCAR data report: nurs­ ing facility patient characteristics report. and most have methodologic limitations.55 SUGGESTIONS FOR FUTURE RESEARCH Few studies have evaluated the efficacy of interven­ tions to address feeding difficulties in patients with de­ mentia. and behavior when dealing with feeding difficulties in patients with dementia. Kelley MF. A registered dietitian usually calculates calorie counts over a period of at least three days.14(10):1185­92. early intervention may enhance the dining ex­ perience of patients with dementia by increasing the pleasure they associate with food.17(17):2266­74. J Clin Nurs 2008. and threaten both fluid and nutritional intake.org/research_ data/oscar_data/NursingFacilityPatientCharacteristics/ HISTORICAL_HSNF_OSCAR%20Data%20Report_ 2009Q2. reduce. including those with large sample sizes. weight loss. such as fluid and nutri­ tional status and pulmonary complications. Contact author: Chia­Chi Chang. family ajn@wolterskluwer. 4.

47.4(3):148­55. and body weight of nursing home residents: cluster randomised controlled trial. 20. Evidence­based geriatric nursing protocols for best prac­ tice. 34(12):8­15. Van Ort S.edenalt.aspx?id=148. 29. 32. J Gerontol Nurs 1994. et al. Relaxing music at mealtime in nursing homes: effects on agitated patients with dementia. Geriatr Nurs 1998. et al. et al. A simple method of assessing functional ability in patients with Alzheimer’s disease.19(5):269­74.org/default.10:87. Young Y. McDaniel JH. 2703­4.20(2):36­40. Feeding assistance needs of long­ stay nursing home residents and staff time to provide care. J Gerontol Nurs 2008. 39. Norberg A. Using family­style meals to increase par­ ticipation and communication in persons with dementia. 193­226. Br J Nurs 2001. http://gateway. Ragneskog H. J Psychiatr Ment Health Nurs 1994. Am J Nurs 2008. Nutr Clin Care 2001. A review of the literature. et al. A preliminary evaluation of the paid feed­ ing assistant regulation: impact on feeding assistance care process quality in nursing homes. Nutritional management of individuals with Alzheimer’s disease and other progressive dementias. J Gerontol Nurs 2002. Jacobsson C. et al. 18. Bäckström A. Watson R. Fernandez M. J Gerontol Nurs 1997. 49. Int J Palliat Nurs 2001. Nijs KA. et al. Caregiver turnover and caregivers’ assess­ ments of duration and difficulty of assisted feeding and amount of food received by the patient.30(2): 319­28. 27. 21.13(5):249­53. Amella EJ. 48. Marland GR. 53. et al.26(1/2):25­37. Geriatr Nurs 1996. Challenges in feeding a patient. et al. BMJ 2006. Am Fam Physician 1997. VA. et al. Hutlock T. Hall GR. 51. J Nutr Health Aging 1998. 28. 33. 31. Lange­Alberts ME. J Adv Nurs 1999. J Adv Nurs 1994. Altus DE. Improving the nutritional status of people with dementia. Watson R.. 42. Meal procedures in institutions for elderly peo­ ple: a theoretical interpretation. J Adv Nurs 2006.23(7):9­15. Am J Alzheimers Dis Other Demen 2001. et al. Interaction between patients with se­ vere dementia and their caregivers during feeding in a task­ assignment versus a patient­assignment care system. 26. Nurs­ ing Homes 2004. 23. J Adv Nurs 1999. Watson R. Kverno KS. Ford G. Kayser­Jones J. 41. Kindell J. Outcomes of individualized interventions in patients with severe eating difficulties.5(3):262­82.1(1): 45­6. Crogan NL. Deary IJ. Behavioural symptoms in patients with Alzheimer’s disease and their association with cognitive im­ pairment. Nursing Homes 2000. 9. 17. Watson R. Stockdell R. 3rd ed.. et al. 4 . Feeding nursing home residents with Alzheimer’s disease. n.org/ how­we­serve/spreading­the­word. 40. Milton Keynes.29(3):608­14.57(1): M52­M56. Assessing problem feeding behaviors in mid­stage Alzheimer’s disease. nurs­ ing intervention and indicators of feeding difficulty. Assessment and management of eating and feed­ ing difficulties for older people: a NICHE protocol. Barratt J. Cultural perspectives in feeding dif­ ficulty in Taiwanese elderly with dementia. 38. Arlington. 2002.16(5):297­302. Int J Nurs Stud 1987. physical performance. http://www.332(7551):1180­4. n.gov/MeetingAbstracts/ ma?f=102274154. J Gerontol Nurs 1994. In: Kaplan M. et al. Chronic dementia. Lundquist RS. Social interaction and depression among older adults [meeting abstract].40(3):235­40. Durnbaugh T. 16. Ragneskog H.10(17):1104­14. No. J Psychosoc Nurs Ment Health Serv 1996. Hicks­Moore SL. Measurement of feeding difficulty in patients with dementia. Measuring feeding difficulty in patients with dementia: developing a scale. 34.ncbdc. TX. Berrut G. Improving the nutritional care of nursing home residents. The Eating Behavior Scale: a simple method of assessing functional ability in patients with Alzheimer’s disease. 37.34(5):35­9. Food refusal and dysphagia in older people with dementia: ethical and practical issues.nih. 45. J Ger­ ontol Nurs 2005. 46. 1998. p. Influence of dinner music on food in­ take and symptoms common in dementia. et al. Volicer L. Phillips L.19(5):850­5. editors. et al. Athlin E. The “feeding assistant rule”: pros and cons. The Eden alternative and convivium. Wimberley. Clin Nurs Res 1997. Hellen CR. Building a scientific base for nutri­ tion care of Hispanic nursing home residents.54(6):919­24. Clin Nurs Res 1996. 2008. 111. 11. Morris J. Gerontologist 2007. Simmons SF. Measuring feeding difficulty in patients with dementia: multivariate analysis of feeding problems.20(3): 154­72.10(1):11­7. 30.20(2):283­7. Simmons SF. 2002. Hoffman SB.8. Sidenvall B.20(4):21­30. 13. McGillivray T. 6(1):25­44.d. 25. 337­51. 36. 55. MD. Eating­mealtime: challenges and interven­ tions. Amella EJ. Academy for Health Ser­ vices Research and Health Policy Meeting.d. Following the path to mastery: the art of creating a caring community. J Gerontol A Biol Sci Med Sci 2002.3(4):215­27. Geriatr Nurs 1992. UK: Speechmark Publishing Ltd. 6(3):275­90. Shott S. Tully MW.7(10):465­71. 54. Access to participation: occupational ther­ apy and low vision. Elder care in Korea: the future is now. New York: Springer Publishing Company. Effect of family style mealtimes on quality of life. Comorbid disease in geriatric patients: dementia and depression. Estimation of calorie and protein intake in aged patients: validation of a method based on meal por­ tions consumed. Feeding difficulties in long­stay patients at nursing homes. 50. Prevalence and treatment of neuropsychi­ atric symptoms in advanced dementia. 15. Wasson K. Nurs Clin North Am 2004.55(8): 2687­94.53(1):42­4. 22. Ageing Int 2000.108(8):46­54. Feeding and dementia: a systematic literature review. Amella EJ. Mealtime difficulties. et al. Schnelle JF. Coyne ML. Green SM. Ellexson MT. 12. The Green House concept.39(3):607­23. 24. J Adv Nurs 1994. BMC Neurol 2010. Eden Alternative.com 44 AJN ▼ April 2011 ▼ Vol. 14. Improving eating behaviors in de­ mentia using behavioral strategies. Biernacki C. Hoskins L. Measuring feeding difficulty in patients with de­ mentia: replication and validation of the EdFED Scale #1. edi­ tors. Behaviors in de­ mentia: best practice for successful management. Geriatr Nurs 2006. J Adv Nurs 1994. et al. 52. 43.17(2): 63­7.49(10):56­9.nlm. Yeon KC. Baltimore. et al. Impact of dining room environment on nutritional intake of Alzheimer’s residents: a case study. Chang CC. Dinner music for demented patients: analysis of video­recorded observations. Putting feeding back into the hands of patients. Scand J Caring Sci 1996.19(2): 257­63.html. 19.2(2):119­21. European Nurse 1998. The Eating Behavior Scale. Roberts BL. 44. J Nurs Scholarsh 2008. http://www. Fan MY.47(2): 184­92. p. 10. Baltimore. Evans BC. Feeding and swallowing disorders in dementia. J Am Geriatr Soc 2006. Amella EJ. Watson R.31(12):26­32. NCB Capital Impact. Clin Nurs Res 1997. Feeding and hydration issues for older adults with dementia. Nutritional intake. 35. 113­14.. Top Geriatr Rehabil 2004. Use of touch and verbal cuing. et al. ajnonline.54(1):86­93.28(9):47­53. MD: Health Professions Press.27(5):273­9.24(1): 69­76. Tully MW. Assisting demented patients with feeding: problems in a ward environment. The Edinburgh Feeding Evaluation in Dementia Scale: determining how much help people with dementia need at mealtime. In: Capezuti E.