Commentary on Aselage MB (2010) Measuring mealtime difficulties: eating, feeding and meal behaviour in older adults with dementia Journal of Clinical Nursing 19, 621–631
Year: 2010
Type: editorial
Abstract: Tell me what you eat, and I’ll tell you who you are. Dementia, literally meaning ‘deprived of mind’, is a devastating disease that steals cognitive abilities and the ability to care for oneself. Problems with food and eating are common. In the early stages of the disease, meal planning and preparation may be compromised. As the disease progresses, shortened attention span or wandering can make mealtimes challenging. Subsequently, in late stage dementia, individuals become totally dependent on others for food and often display difficult feeding behaviours such as lip clenching, trouble swallowing, or head turning. The intense physical and emotive meaning of food illustrates why mealtime difficulties can be devastating for individuals with dementia and their caregivers (Lopez & Amella in press). At its most fundamental level, food is essential to life. Inadequate food intake leads to poor nutritional status and is a key determinate of morbidity and mortality for people with dementia (Luchsinger et al. 2008). However, food represents far more than its nutritional elements. People of all cultures break bread together as a way to create and sustain emotional bonds with one another. Cornucopia, a mythological horn containing food and drink, is a well-recognised symbol of abundance. Food represents comfort, home, love and warmth. Its absence leads to hunger, desire, emptiness and void. The act of feeding expresses love, nurturing and sustaining. Refusing food suggests rejection, fasting and starvation. Aselage (2010) conducted an integrative review to examine instruments currently available for clinical use to assess mealtime difficulties. She searched several electronic databases and found twelve observational instruments that addressed eating, feeding and meal behaviours for older adults with dementia. She found the majority of instruments did not report adequate psychometric testing or were not feasible for clinical use. One instrument, however, The Edinburgh Feeding Evaluation in Dementia (EdFED) had extensive testing for reliability and validity (Watson 1994). Therefore, Aselage recommended that the instrument be used to ‘determine the level of disability and to plan effective interventions’ (Aselage 2010, p. 629). Unfortunately, research indicates that nurses working in long-term care may be reluctant to address issues related to mealtime difficulties and dementia (Lopez et al. 2010a). Therefore, Aselage’s (2010) recommendation that nurses use a standardised instrument in clinical practice to identify those with eating and feeding problems is crucial. Recognising mealtime difficulties, however, is only the first step. As Aselage (2010) correctly asserted, The EdFED does not elucidate the cause nor does it reveal strategies that may ameliorate mealtime difficulties. Considering the complex, multifactorial nature of mealtime difficulties in dementia, further investigation is needed at the individual, environmental and organisational levels. At the individual level, a thorough health assessment, including examination of the mouth (Kayser-Jones et al. 1995) and a review of medications is needed to identify physical causes of mealtime difficulty. Moreover, one needs to understand the individual’s food preferences, rituals surrounding food and mealtime, and the meaning of mealtime and feeding for caregivers who assist with feeding (Lopez & Amella in press). It is also crucial to survey the environment to ensure that it is homelike and conducive to eating with attractive food, choice in food, attention to ethnically appropriate food choices and food available 24 hours a day (Burger et al. 2000). Feeding assistants must be skilled in feeding, provide verbal and social cues and have adequate supervision and sufficient time to provide assistants (Kayser-Jones et al. 1999, Simmons & Schnelle 2006). Finally, consideration must be given to the larger perspective of nursing home characteristics (Mitchell et al. 2003), financial incentives (Mitchell 2003) and organisational culture (Lopez et al. 2010b), which may influence how mealtime difficulties are managed and whether feeding tubes are used in advanced dementia. While nursing homes may have a financial incentive to use feeding tubes (Mitchell 2003), nursing homes that emphasise the centrality of mealtime, provide sufficient knowledgeable staff at mealtimes, include family members in care planning and value hand-feeding for its residents may be less likely to use feeding tubes (Lopez et al. 2010b). Recognising mealtime difficulties with an instrument such as The EdFED is essential. But, designing effective strategies to address this complex issue requires interdisciplinary collaboration with physicians, nurses, speech pathologist, rehabilitation specialists, dieticians, dentists, CNAs, administrative nursing home personnel and family caregivers. Nurses, however, can play a critical role on the team by gathering information at the individual, environmental and organisational level and identifying strategies to improve mealtime for individuals with dementia and their caregivers.
Source: Journal of Clinical Nursing
Author: Ruth P Lopez
Institution: MGH Institute of Health Professions
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2049274490