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Improving the nutritional care of nursing home residents
... Maintenance of the nutrition and hydration status of older adults residing in residential aged care facilities (RACFs) is an important contributing factor to resident well-being and quality of life (Amarantos et al., 2001;Crogan & Pasvogel, 2003;Courtney et al., 2009). Unfortunately, despite frail older persons being at particularly high risk for nutritional disorders (Lauque et al., 2000;Niedert, 2005;Sloane et al., 2008), nutrition and hydration concerns often rank low on the list of evaluation and treatment priorities in residential care (Kayser-Jones, 2000). Malnutrition, which is defined in older people as undernourishment due to insufficient dietary intake leading to weight loss and muscle wasting (Chen et al., 2001), is a common and potentially serious problem in RACFs. ...
... For example, determination of caloric intake was conducted by very few staff in both studies. While 31% indicated that they sometimes assessed the percentage of meals consumed, research has found that staff frequently overestimate the actual food intake of residents by a significant amount when doing so (Kayser-Jones, 2000;Suominem et al., 2004). Subsequently, nutritional issues may go unrecognised (Kayser-Jones, 2000;Suominen et al., 2005). ...
... While 31% indicated that they sometimes assessed the percentage of meals consumed, research has found that staff frequently overestimate the actual food intake of residents by a significant amount when doing so (Kayser-Jones, 2000;Suominem et al., 2004). Subsequently, nutritional issues may go unrecognised (Kayser-Jones, 2000;Suominen et al., 2005). ...
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.
... With the growing older population and the advent of Baby Boomers entering into the long-term care arena, there is a growing demand for change in services and products and the provision of choice. Optimal nutrition for residents in skilled nursing facilities is well documented as a necessity for optimal health of institutionalized older persons Crogan & Pasvogel, 2003;Kayser-Jones, 2000). Most nutrition-related problems in nursing homes are a consequence of undernutrition . ...
... Because residence in a nursing home is not a short-term situation, limited choice is unacceptable. A high percentage of residents will live out the remainder of their years in the facility (Kayser-Jones, 2000;Simmons, Osterwall, & Schnelle, 2001;Wendland, 2003). As Goodwin (2005) pointed out there are many indicators of quality care but nutrition, hydration, and the dining experience are critical elements of quality care from the consumer's point of view. ...
... The study noted that a supportive work environment is critical for behavior change (KAHSA, 2003). Additional research regarding long-term care employees clearly documented that high turnover and inadequate staffing contributes to lower quality of care and lower resident satisfaction Doll, 2003;Ejaz, Straker, & Swami, 2003;Feder, Komisar, & Niefeld, 2000;Kayser-Jones, 2000;Lowe, Lucas, Castle, Robinson, & Crystal, 2003). People who work in healthcare should be passionate and self-motivated. ...
The culture-change movement in skilled nursing facilities is challenging foodservices to consider their role in supporting the paradigm shift to person-centered care. Optimal nutrition for residents supports physical and emotional health of institutionalized older adults. The purpose of this study was to explore factors associated with resident dining in skilled nursing facilities that have transitioned from a traditional foodservice system to restaurant-style dining. The study investigated foodservice employee perceptions of resident satisfaction with foodservices, foodservice employee job satisfaction, and effect of the delivery system transition on employee intent to leave. The study was conducted in two phases. Phase I was a case study of one skilled nursing facility’s transition from the traditional foodservice to restaurant-style dining. Phase II consisted of a survey of residents and employees in seven skilled nursing facilities utilizing restaurant-style dining. Two questionnaires, addressing the constructs of food quality, service quality, and customization relating to resident satisfaction with foodservices, were developed and administered to residents and foodservice employees. The Phase 1 case study revealed differences in financial and unintended weight loss data from pre- to post-menu transitioning. Focus groups provided insight into resident satisfaction with food and foodservices. In both phases, residents were satisfied with restaurant-style dining. Statements regarding the ability to choose foods at meals times scored highly. Service statements such as “Being treated respectfully by employees” were rated high by the residents. Portion sizes and food quality consistency were rated lower by residents. Employee perceptions of resident satisfaction were consistent with the resident ratings of satisfaction. Foodservice employee job satisfaction was high and intent to leave was low. Job satisfaction mediated the relationship between the employee perception of resident service and their intent to leave. Overall, restaurant-style dining appears to be a positive alternative to the traditional foodservice system in skilled nursing facilities. Implications and future research are discussed. Doctor of Philosophy Doctoral Department of Hospitality Management and Dietetics Deborah D. Canter
... Multiple factors may contribute to weight loss and low BMI among nursing home residents. Decreased functional status and/or chronic psychiatric disorders may impact food intake of elderly residents in nursing homes (American Health Care Association, 1998;Kayser-Jones, 2000). Residents with these problems may not have the ability to access food and water independently, ask for additional food or water, or feed themselves. ...
... Residents with these problems may not have the ability to access food and water independently, ask for additional food or water, or feed themselves. Nutritional problems are also related to resident characteristics such as poor appetite, pressure ulcers, chronic disease, sensory loss, eating dependency, poor oral/dental health, and polypharmacy (American Diabetic Association, 1998;Kayser-Jones, 2000). Furthermore, organizational factors may influence the development of weight loss among nursing home residents. ...
... For example, licensed nurses may lack the nutritional knowledge to assess the nutritional needs of residents in nursing homes Crogan, Shultz, Adams, & Massey, 2001). Inadequate numbers of nursing assistants to help residents eat and facility food preparation and presentation practices contributed to residents' inadequate food intake Kayser-Jones, 2000). ...
In this longitudinal exploratory study, items from the minimum data set (MDS) were used to predict resident weight changes in older adults (N = 77) from three nursing homes. At the end of the study period, three variables from the last available MDS were significant predictors of weight loss: 1) leaves 25% or more of food uneaten at most meals, 2) receiving an antianxiety medication, and 3) not having the ability to feed oneself independently.
... Reflecting this, significant levels of malnutrition have been found among hospitalised patients (Garrow, 1994;McWhirter and Pennington, 1994;Eberhardie, 2002). Furthermore, malnutrition is particularly prevalent among older people (Lehmann, 1989;McWhirter and Pennington, 1994;Devlin, 2000;Greene-Burger et al., 2001) and especially among older people resident in long-term care facilities (Morely and Silver 1995;Elmstahl et al., 1997;Crogan and Shultz, 2000;Kayser-Jones, 2000;Neel, 2001;Howell, 2002). Recent estimates for the United Kingdom (UK) indicate that approximately 157,500 older people live in nursing homes and 288,750 older people live in residential homes (Royal Commission on Long Term Care, 1999). ...
... For at least a decade, much has been written about malnutrition and the perceived causes of such among older people who are resident in care homes (Nazarko, 1993, Morely andSilver, 1995;Elmstahl et al., 1997;Kamel et al., 1998;Copeman, 2000;Neel, 2001;Eberhardie, 2002;Howell, 2002). Equally, the effects of malnutrition are well documented in the literature (Booth, 1993;Mion et al., 1994;Dormenval et al., 1998;Mojon et al., 1999;Noble, 1999;Fitzpatrick, 2000;Kayser-Jones, 2000;Sheiham and Steele, 2001;Neel, 2001). ...
... These affect the alimentary system, the haemodynamic system (heart and circulation), the endocrine system, the renal system, the immune system, the central nervous system and the senses (Mion et al., 1994;Chan, 1999;Howell, 2000;Copeman, 2000). Individual factors associated with these changes, that may lead to malnutrition are: impaired speech, impaired vision and hearing, dementia, confusion, resultant poor communication, depression, sensory loss (taste and/or smell) (Davidhizar and Dunn, 1996;Copeman, 2000), poor posture and mobility, poor manual dexterity, pain, apathy (Copeman, 2000); dehydration; and dysphagia (Davidhizar and Dunn, 1996;Kayser-Jones, 2000). Furthermore, the importance of good oral health in maintaining adequate nutritional intake among older people has been emphasised (Dormenval et al., 1998;Mojon et al., 1999;Fitzpatrick, 2000;Sheiham and Steele, 2001). ...
Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged to provide high-quality care for this sector of the population, including minimum standards to ensure adequate nutrition. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples. In the interim, simple measures such as monitoring older people's weight regularly need to be implemented as a surveillance measure of nutritional status.
... I NADEQUATE FOOD INTAKE leading to malnutrition impacts up to 85% of nursing home residents (Kayser-Jones, 2000). Malnutrition, defined as insufficient dietary intake among essential nutrients, can result in compromised quality of life and can lead to chronic disability, functional decline, increased health care utilization, increased health care costs, and death (Chen, Schilling, & Lyder, 2001). ...
... Additionally, sufficient numbers of staff may not be available to provide even the most basic nutrition care. In fact, inadequate staffing has been called the most significant barrier to sufficient resident food intake (Kayser-Jones, 2000). ...
... Individual resident choice is integral to perceived quality of life in the nursing home. Unfortunately, most nursing homes offer very few opportunities for residents to choose the food they want to eat (materials) (Kayser-Jones, 2000;Perrow, 1979). In fact, some nursing home administrators believe that it is not economically possible to have a selective menu, but Kayser-Jones noted that a large amount of food was wasted at mealtime and hypothesized that if residents had more choice, waste would decrease. ...
Inadequate food intake leading to malnutrition impacts up to 85% of nursing home residents. Malnutrition can result in compromised quality of life and lead to chronic disability, functional decline, increased health care utilization and costs, and death. This article examines organizational structure (Perrow, 1979) and person-environment fit (Lawton, 1982) as factors in nutritional care of nursing home residents. The strategies used by residents to cope with organizational food and food service issues, competence, and environmental press in the nursing home can alert nurses to the need for changes in dietary services to increase food intake and quality of life.
... Protein-energy malnutrition has been reported in 25-59% of older residents in long-term care settings (McCargar et al. 1995) and in nursing homes, 30-50% of residents have substandard body weight, mid-arm circumference and serum albumin levels (Abbasi & Rudman 1994). Blood levels of both water-and fat-soluble vitamins are low (Abbasi & Rudman 1994), and an estimated 35-85% of chronically ill patients and nursing home residents are malnourished (Kayser-Jones 2000). ...
... Nurses are the closest observers of eating behaviours, as they can note what residents eat, provide assistance when necessary, and develop an awareness of how older peoples' decreased ability to understand directions and express their needs verbally poses a risk of malnutrition. However, understaffing is common and often leads to inadequate feeding and provision of mealtime assistance (Kayser-Jones 2000). ...
... There is no universal agreement about how to define under-nutrition using BMI values. In our study, we used a cut-off point of 18AE5 for BMI, resulting in an 18AE2% prevalence of under-nutrition, which is lower than that reported by Kayser-Jones (2000). The reason for this low prevalence may be the criteria we used to define malnutrition. ...
This paper is a report of a study to determine changes over a 3-month period among older people with dementia living in long-term care settings, related to: (1) changes in body mass index, and (2) health outcomes and associated factors.
Nutritional deficiencies are common problems among older people, but frequently unrecognized, both in long-term care settings and in the community.
A cross-sectional design with repeated measures of body weights and medical record reviews was adopted. The study was conducted in 2003 in two long-term care facilities for older people with dementia in Taiwan. Fifty-five residents participated in the study.
Eighteen percent of the residents were under-nourished (body mass index <18.5). There was a trend toward decreasing body mass index over the 3-month study period. Residents with low body mass index tended to need assistance at mealtimes. Nineteen residents, many receiving naso-gastric tube-feeding, experienced adverse health events during the study period. Dependency in eating was the major factor differentiating residents with normal or low body mass index values, and also in distinguishing those who experienced adverse health outcomes.
Assessment of eating ability, mode of feeding and measurement of body weight can be used by nurses in long-term care settings for early identification of the nutritional status of older people with dementia.
... Elderly people in long-term care facilities are at increased risk for malnutrition, dehydration, and weight loss (Kayser-Jones, 1998;Leydon & Dahl, 2008;Reed et al., 2005;Carrier, Ouellet, & West, 2007; American Dietetic Association [ADA], 2005). Rates of malnutrition from insufficient food intake are reportedly between 54% (Reed et al., 2005) and 85% of residents (Kayser-Jones, 2000). Dehydration from insufficient fluid intake is also cited as a innovative form of multi-method ethnography, facilitating rich data collection from different sources such as observations, document analysis and interviews, over a short period of time (Baines & Cunningham, 2013). ...
... We discovered that the low funding allotment for both food and staffing, and the standardizing regulations that direct care, limit the possibilities for high quality resident dining experiences. The existing food-related longterm care literature points to the high prevalence of malnutrition and dehydration in this population (ADA, 2005;Kayser-Jones, 2002;Leydon & Dahl, 2008;Reed et al., 2005;Carrier, Ouellet, & West, 2007), with as many as 85% of residents reported as having inadequate intake (Kayser-Jones, 2000). Also acknowledged are the links between low staffing levels (Kayser-Jones & Schell), staff attitude , lack of training (Kayser-Jones & Schell, 1997;Leydon & Dahl, 2008), and the heightened risk for malnutrition and weight loss. ...
Objective:
To explore the social organization of food provision in publicly funded and regulated long-term care facilities.
Methods:
Observations were conducted, along with 90 interviews with residents, families, and health providers in two Southern Ontario sites using rapid site-switching ethnography within a feminist political economy framework as part of an international, interdisciplinary study investigating healthy ageing.
Results:
Food is purchased within a daily $7.80/per resident allotment, limiting high quality choices, which is further problematized by privatization of food services. Funding restrictions also result in low staffing levels, creating tensions in aligning with other Ministry mandated tasks such as bathing, and documenting: competing demands often lead to rushed meals. Regulations, primarily set in response to scandals and to ensure appropriate measured nutrition, reinforce the problem. Further, regulations regarding set meal times result in lack of resident agency, which is compounded by fixed menu options and seating arrangements in one common dining room. Rather than being viewed as an important part of resident socialization, food is reduced to a medicalized task, organized within a climate of cost-containment.
Implications:
Findings warrant Ministry financial support for additional staff and for food provision. Policy changes are also required to give primacy to this population's quality of life.
... Dehydration has been shown to be associated with increasing frailty and decline in cognitive functioning (Miller, Perry, & Morley, 1998;Palmisano-Mills, 2007;Voyer, McCusker, Cole, St-Jacques, & Khomenko, 2007;Warren et al., 1994). Risk factors for dehydration in the older adult population have been identified as lack of adequate fluid intake; complications associated with medications used to treat other comorbidities, such as antihypertensive and diuretic medications; physical and cognitive impairment; and exposure to excessive heat, which can be exacerbated in the summer months (Bennett, Thomas, & Riegel, 2004;Carroll, 2002;Kayser-Jones, 2000). ...
... Older adults have a decrease in lean body mass and an increase in the percentage of body fat, which also contribute to less total body water, thus placing the individual at an increased risk of dehydration if additional stresses occur (Bossingham et al., 2005;Sheehy et al., 1999). Dysphagia has also been shown to be a risk factor for dehydration (Kayser-Jones, 2000). Other risk factors include visual problems, decreased mobility due to functional problems, acute pathology, poor access to fluids, communication problems, failure of caregivers to provide fluids, and confusion (Ferry, 2005). ...
Dehydration is a common problem among older adults and can negatively affect their health. This cross-sectional descriptive study used survey findings and focus group interviews to investigate dehydration problems among community-dwelling older adults and to identify strategies perceived to be helpful in preventing dehydration in this population. The survey sample (n = 18) and four focus groups (n = 36) included health care providers in the northeast United States from provider agencies representing emergency care, home care, primary care, and community health care. Survey findings indicated that 89% of participants identify dehydration as a problem affecting older adults, and 94% noted the need for a public campaign on dehydration awareness and reduction. Four major themes emerged: Intentional Avoidance and Caution, Lack of Awareness/Education/Understanding, Poor Access to Fluids, and Social and Environmental Influences. Strategies identified to promote hydration in community-dwelling older adults included community partnerships, community education, community engagement, and interdisciplinary approaches. This study provides useful information and detailed strategies recommended by health care providers for designing interventions to promote hydration for community-dwelling older adults.
... Nursing home residents with PCM have an increased risk for death or chronic disability (Callahan et al., 1998;Keller, 1995). In a study reported by Kayser-Jones (2000), nursing home residents who did not receive or consume adequate amounts of food were more susceptible to urinary tract infections, pneumonia, pressure ulcers, and confusion. ...
... If residents at risk for malnutrition are identified on admission, individualized interventions to prevent or reverse PCM could be immediately implemented, reducing the subsequent morbidity and mortality from poor food intake. Malnutrition has been described as a common, serious, frequently undetected, yet avoidable problem in nursing homes (Kayser-Jones, 2000). Early intervention and treatment could dramatically improve the quality of care and quality of life for elders in nursing homes. ...
The purpose of this study was to describe the prevalence of protein-calorie malnutrition (PCM) among newly admitted elderly nursing home residents and identify the most significant predictors of PCM using Minimum Data Set (MDS) variables. Using a cross-sectional design, the authors studied 306 nursing home residents. Malnutrition risk factors found on the MDS were measured for each resident. Overall, 118 (38.6%) residents met the Nutrition Screening Initiative Guidelines for PCM. MDS variables found to be significant predictors were weight loss, leaves 25% or more offood uneaten at most meals, psychiatric/mood diagnoses, deteriorated ability to participate in activities of daily living. and older age. Three additional variables (antidepressant use, diuretic use, therapeutic diet) were found to be protective-residents with these variables were more likely to have a normal body mass index. MDS data provide an opportunity for early identification of residents who are at riskfor PCM and accompanying morbidity.
... Nursing home residents with PCM have an increased risk for death or chronic disability (Callahan et al., 1998;Keller, 1995). In a study reported by Kayser-Jones (2000), nursing home residents who did not receive or consume adequate amounts of food were more susceptible to urinary tract infections, pneumonia, pressure ulcers, and confusion. ...
... If residents at risk for malnutrition are identified on admission, individualized interventions to prevent or reverse PCM could be immediately implemented, reducing the subsequent morbidity and mortality from poor food intake. Malnutrition has been described as a common, serious, frequently undetected, yet avoidable problem in nursing homes (Kayser-Jones, 2000). Early intervention and treatment could dramatically improve the quality of care and quality of life for elders in nursing homes. ...
This article describes the prevalence of protein/calorie malnutrition among newly admitted elderly nursing home residents and identifies the most significant predictors using Minimum Data Set (MDS) variables. This random selection, cross-sectional study included 266 residents, 65 and older, from three nursing homes. Malnutrition risk factors, indicators, and prevalence variables in the MDS were measured for each resident on admission to the nursing home. MDS data provide an opportunity for early identification of residents at risk for malnutrition and accompanying morbidity. Treating residents who are malnourished or at high risk for weight loss on admission could dramatically improve their quality of life.
... U NDERNUTRITION is a common, multidimensional, frequently undetected problem for approximately 2 of every 5 nursing home residents, negatively influencing their health and quality of life (1)(2)(3). Undernutrition can be defined as any insufficient dietary intake of essential nutrients and may result from risk factors such as chronic illness; polypharmacy; dietary restrictions; mechanical problems resulting from ill-fitting dentures or loss of teeth; normal changes of aging in taste, smell, and satiation; lack of choice and control in relation to food; loss; dependency; loneliness; and depression (4)(5)(6)(7)(8). ...
... However, little is known about why residents fail to eat. It has been suggested that the quality of care, including staffing and provision of foods that residents enjoy, may affect their consumption (3,6). The FoodEx-LTC can help differentiate those residents at risk for undernutrition because of poor food quality or lack of attention to their food preferences, and it can facilitate prompt alteration of dietary services. ...
Background. Undernutrition occurs in approximately 2 of every 5 nursing home residents, negatively influencing their health and quality of life. The purposes of this study were to collect data about institutional meal preparation and food service practices that promote or retard adequate nutritional intake and to evaluate residents' food and food service satisfaction. Methods. The FoodEx-LTC, a simple, 44-item, 5-subscale questionnaire that measures food and food service satisfaction, was administered to 61 residents. Serum albumin and body mass index gauged the nutritional status of each resident. SPSS for Windows, version 10, was used for analyses. Results. Overall, 89% of residents were satisfied or somewhat satisfied with the food service. Of those who ate in the dining room, 44% had to wait to go back to their rooms, presenting a quality of life issue. Fifty-two percent received food they hated, 56% often received the same food, and 59% received food always cooked the same way. Most residents (75%) felt comfortable refusing food they did not like, but 65% did not complain. Most (79%) wanted to choose what to eat, but only 54% believed that choosing when to eat was important. Conclusions. The FoodEx-LTC, used to monitor nutrition care in nursing homes, incorporates residents' views into service delivery and responds to the Health Care Finance Administration's Nutritional and Hydration Awareness Campaign, part of the federal Nursing Home Initiative. Using the FoodEx-LTC to identify residents' perspectives may promote resident satisfaction and dietary intake through adaptation of nursing home food and food service practices.
... Although others have suggested that "higher-level management" is responsible for identifying and assigning roles (14)(15)(16)(17), the dietitians who participated in our study indicated that most of the roles they took on were self-labelled and selfappointed, emerging and evolving through their tenure at a facility. Previous research suggests that many nutrition-related tasks are not easily itemized or assigned (18,19), and that the dietitian's time and presence in facilities provide costeffective benefits (20,21). This may, in part, explain why our participants preferred to discuss their work in terms of roles rather than tasks. ...
In this study, we sought insight into the clinical practice experiences of dietitians working independently (i.e., as the only dietitian in a facility) in long-term care (LTC). We hoped to learn about their work roles and identify specific factors that facilitate their success.
Grounded theory methods were used. Data were collected through 11 semi-structured interviews. Verbatim transcripts were analyzed using a constant comparative method, which included coding, memo writing, and ongoing discussion between the two researchers.
When speaking about their roles, participants identified both specific tasks they had to complete and broader roles they fulfilled. Many of these roles focused on relationships with co-workers and building effective multidisciplinary teams. Effective teamwork was linked with dietitians' personal feelings of success in providing resident-focused nutritional care in the LTC setting.
The LTC dietitians' various roles were generally self-appointed, and they focused more on the purpose of their work than on tasks. A primary focus of these roles was the multidisciplinary team and the promotion of effective teamwork, especially, but not exclusively, as it applies to the provision of nutritional care. Successful teamwork was linked to dietitians' reports of personal success in their work.
... Although few have directly discussed the notion of mealtimes being the highlight of nursing home life, a number of studies have shown the importance of mealtimes in nursing homes (Gastmans, 1998;Kayser-Jones, 2000;Nijs, de Graaf, Kok, & van Staveren, 2005). In addition to this, it can also be observed that the Chinese cultural emphasis on meals contributes further to the importance of mealtimes in the present nursing home. ...
This study has explored the culture of nursing home life as experienced by elderly nursing home residents in Taiwan in order to understand, describe and interpret their care needs. In December 2006, the elderly represented 10% of the total population of Taiwan, and this proportion is predicted to increase steadily. In turn, this increase suggested that Taiwan would see ever greater numbers of elderly people with chronic illnesses and physical and mental disabilities. To care for these people, nursing homes have expanded rapidly throughout Taiwan. However, the quality of care provided in these nursing homes has become an urgent matter of concern. Though meeting the residents' care needs is essential for the provision of the best quality care, a review of the available literature shows that the care needs of the elderly residents within the nursing home context are poorly understood, both in Taiwan and internationally. To address this gap in present understanding, a focused ethnographic approach, using participant observation, in-depth interviews and a review of documents, was undertaken between July 2005 and February 2006. The key participants were sixteen elderly residents who were 65 years old and over, had no cognitive impairment and had lived in the nursing home selected for the present study for at least six months. Eight nurses, six nursing assistants, one private nursing assistant, one orderly, one physician's assistant and four family members were also interviewed, with questions put to them being based on the data generated from the observation and in-depth interviews with the elderly residents. All interviews were recorded on a digital recorder and transcribed verbatim. Following this, the data gathered from the in-depth interviews, the participant observation and the review of documents was sorted and indexed using the qualitative software program, NVivo7. A five-step analytic process, based on concepts discussed in previous literature, was used to trace the emerging themes. Nine major care needs were identified by the elderly residents. These included basic functional care needs, emotional support care needs, economic care needs, psychological care needs, environmental care needs, social support care needs, professional care needs, religious care needs and preparation for death care needs. Three themes of nursing home culture were generated; these were collective life, care rituals and embedded beliefs. The findings of the study indicate that the structure and culture of the nursing home contribute to several care needs remaining unmet. In addition, the results reveal that it is necessary to satisfy economic care needs before other care needs can be resolved. These findings fill an important gap in nursing knowledge regarding the delivery of better quality care in nursing homes. They also provide relevant information to nursing practice, nursing education and Taiwanese long-term care policy-making, and provide a sound basis for future residential care research.
... Although little literature has directly discussed the notion of mealtimes being the highlight of nursing home life, several studies have shown the importance of mealtimes in nursing homes (Kayser-Jones 2000, Nijs et al. 2005. Additionally, the Chinese cultural emphasis on meals contributes further to the importance of mealtimes. ...
To explore and understand the culture of nursing home life for older residents in Taiwan.
The environment, the care providers and the residents all influence how the nursing home operates and performs. The literature has shown that there has been a move from understanding nursing home culture to changing it. However, there is no literature illustrating nursing home culture in Taiwan. It is appropriate to understand the phenomenon before making any changes.
Ethnographic methodology was used to understand this phenomenon.
Three methods, participant observation, in-depth interviews and examination of related documents, were used to collect information from July 2005-February 2006. All the data were recorded in either field notes or verbatim transcripts and were analysed concurrently.
Three themes have been generated including collective life, care rituals and embedded beliefs. 'Living in a public area', 'mealtime is the highlight', 'every day is the same', and 'the ceiling is my best mate' are used to explain the collective life. Under care rituals, there are 'the perception of inadequate staffing in spite of legal requirements being met' and 'task-oriented care'. The embedded beliefs can be described by the notions of 'patients and hospitalisation' and 'compromise'.
A tedious, monotonous, idle and lonely life is experienced by the residents, and insufficient staffing is obvious, despite the legal staffing requirements being met. This is exacerbated by the provision of care that is task-oriented rather than individual driven. The residents, whether consciously or not, consider themselves to be the patients of a hospital. They easily compromise to maintain harmony and balance in the nursing home life.
The findings contribute to the understanding of Taiwanese nursing home culture and filling the gaps in nursing knowledge for the purpose of improving care of residents.
... The results from the 3-day supplement charts highlighted inadequate documentation by care staff in recording residents' daily supplement intake. Lack of, or inappropriate recording of these details may give the false impression that residents' nutrition status is being addressed, when in fact the problem is only likely to worsen if supplements are administered incorrectly or not consumed [25]. Many residents may dislike the taste and texture of nutritional supplements [23]. ...
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.
... The nursing home environment contributes to feeding difficulty and poor nutritional outcomes (Chang et al., 2006; Van Ort & Phillips, 1992 ). Investigators have characterized some dining environments as chaotic (Clay, 2001) with features that interfere with communication between a caregiver and a resident with dementia (Amella, 1999) and with feeding residents (Backstrom, Norberg, & Borberg, 1987). A quiet, relaxed dining atmosphere increases food intake and decreases agitation (Amella, 1998; Kayser-Jones, 2000). Culturally appropriate food and mealtime procedures might also improve food intake (Sidenvall, 1999). ...
To investigate factors related to feeding difficulty that is shown in the interaction between nursing assistants and elderly residents with dementia.
Forty-eight residents and 31 nursing assistants were observed during meal times in a congregate dining room of a Taiwanese nursing home specializing in dementia care. Residents' eating behaviors, the dining environment, interactions between the nursing assistant and the residents, and feeding strategies used by nursing assistants were observed. Nutritional data for residents were collected from medical charts. The EdFED Scale #2 and interviews of nursing assistants provided information about feeding difficulty. Interviews also provided data on strategies used to address feeding difficulties.
The most frequent feeding difficulty was refusal to eat (37.5%). The strategies used by nursing assistants were limited. Nursing assistants stated they needed more training to address feeding difficulty in residents with dementia.
Future research should be focused on the interface between the residents and nursing assistants who must identify various feeding difficulties and select appropriate interventions.
Results might provide information that can be used to develop effective interventions and promote high-quality mealtime care in patients with dementia.
... It is also suggested that physiological factors related to dementia, such as hypermetabolism, can contribute to malnutrition (Keller et al., 2003). Studies involving general nursing home populations have found that factors such as medications, number of illnesses and requiring help with eating were associated with weight loss and malnutrition (Woo et al., 2005;Reed et al., 2005;Westergren et al., 2002;Kayser-Jones, 2000;Keller, 1993). Others have suggested that institutional characteristics, including foodservice factors such as monotonous meals, the appearance of certain foods, unfamiliar foods, cultural preferences, and dining atmosphere, can affect residents' food intake (Carrier et al., 2007;Whalqvist & Savige, 2000;Griep et al., 2000;Marcus & Berry, 1998;Lilley & Gaudet-Leblanc, 1992). ...
Several long-term care studies have shown that residents with dementia-related disorders are more prone to weight loss and malnutrition. Very few studies have investigated institutional characteristics, such as foodservice factors, and their possible link to malnutrition in this population. The objective of this study was to identify whether foodservice factors influence risk of malnutrition in cognitively impaired elderly nursing home residents.
Cognitively impaired residents meeting inclusion criteria and living within each of 38 participating nursing homes were randomly sampled. The final sample of 263 residents was screened for risk of malnutrition, and a questionnaire on participants' dining experiences was completed by primary caregivers. Additional data came from participants' medical charts, and a written questionnaire was completed by each institution's foodservice manager. Logistic regressions were used to examine relationships between risk of malnutrition and foodservice characteristics.
Close to 70% of participants were at risk of malnutrition. Foodservice factors, including tray food delivery systems, timing of menu selection, difficulty manipulating dishes, lids and food packages, as well as therapeutic diets were all significantly associated with risk of malnutrition.
Our findings suggest that many nursing homes could modify certain aspects of foodservices that may affect risk of malnutrition among cognitively impaired residents.
This chapter discusses dietary limitations associated with prevalent chronic diseases; medications affecting appetite and nutrient use in the body; and highlights topics related to diversity and aging. Adequate nutrition plays a vital role in health maintenance and disease prevention at every age and can highly benefit the lives of older adults. Nutrition status is fundamental to the quality of life in the aging person as it is closely associated with functionality and the ability to remain independent. Maintenance of a healthy body weight in the face of aging, with the prevention of both underweight and obesity, can reduce the symptoms of chronic health conditions and have a protective effect against mortality. However, physiological and social changes that naturally occur with aging may lead to reduced appetite and food intake, body weight changes, malnutrition, and a compromised immune system. Early identification of nutrition deficiencies and timely intervention can improve length and quality of life. In order to identify any nutritional risks in the elderly, nutrition assessment is crucial. The Modified MyPyramid for Older Adults is a useful guide to assess the well older person's diet and highlights age specific nutrition needs. Additionally, there are four commonly used tools to evaluate the nutrition status in the elderly that includes anthropometric, biomedical, clinical, dietary and economic data (ABCDEs), the Mini Nutritional Assessment, Council on Nutrition Appetite Questionnaire (CNAQ) and Simplified CNAQ (SNAQ), and Geriatric Nutritional Risk Index (GNRI).
Dementia: From Diagnosis to Management - A Functional Approach is a comprehensive description of a functional and behavioral approach to assessing and treating persons with dementia. While very practical, the information is embedded in a scientific context of the causes, neuropsychological manifestations, and complications of dementia. The management of the impairments of dementia is centered on its functional consequences and impact on daily living. The chapters describe behavioral interventions and environmental strategies that aim to improve daily activities and quality of life from a proactive communication and memory basis. Specific suggestions are provided to enhance family involvement and staff relationships, interdisciplinary cooperation, reimbursement, and documentation across various home and institutional settings.
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.
Inadequate food intake leading to malnutrition impacts up to 85% of nursing home residents. Malnutrition can result in compromised quality of life and lead to chronic disability, functional decline, increased health care utilization and costs, and death. This article examines organizational structure (Perrow, 1979) and person-environment fit (Lawton, 1982) as factors in nutritional care of nursing home residents. The strategies used by residents to cope with organizational food and food service issues, competence, and environmental press in the nursing home can alert nurses to the need for changes in dietary services to increase food intake and quality of life.
Objectives: Purpose
To explore the extent of food security among older people, particularly those with cognitive impairments residing in Canadian long-term care homes (LTCHs) through a focused review of literature.
Method
Databases including Medline, Nursing and Health Sciences (SAGE), Psych Info, Social Sciences Abstract, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and HealthSTAR were searched for peer-reviewed articles related to food experiences of older individuals in industrialized countries including Canada. Only articles that were published in English between1997–2012 were included.
Results
Sixty two studies met the inclusion criteria. Of those 17 focused on older adults in LTCHs. The review found that food security has rarely been examined among older persons living in LTCHs, and has never been examined within the context of cognitive impairment. While a few studies have focused on residents’ satisfaction with foods that are provided to them in LTCHs, none have explored the extent of food security in this population. Furthermore, food satisfaction surveys in the LTCH are limited to the assessment of foods that are served to residents, and do not capture residents’ food accessibility beyond the food dispensing routines of the organization. Thus, food quality, food preferences, and the traditional meanings and rituals associated with food consumption are not purposefully evaluated. In addition, LTCHs are not required to monitor residents’ food satisfaction using a consistent, regular, and standardized approach and there is no regulation in the LTCH Act that requires LTCHs to assess their residents’ food security.
Conclusions
The findings highlight the need for: 1) expansion of food security research to non-community-based settings including LTCHs; 2) re-conceptualization of food security and modification of measurement tools to assess the extent and determinants of food security among older adults in LTCHs; 3) mandatory monitoring of food security via standardized and regular surveys tailored to meet the unique preferences and needs of the older population, particularly those with dementia; and 4) education of healthcare professionals regarding food security and its assessment in LTCHs.
This study assessed whether individuals with dementia who observe aquariums increase the amount of food they consume and maintain body weight. The sample included 70 residents in dementia units within 3 extended care facilities in 2 states. The intervention included the introduction of an aquarium into each common dining area. A total increase of 196.9 g of daily food intake (25.0%) was noted from baseline to the end of the 10-week study. Resident body weight increased an average of 2.2 pounds during the study. Eight of 70 residents experienced a weight loss (x¯=1.89 lbs). People with advanced dementia responded to aquariums in their environment documenting that attraction to the natural environment is so innate that it survives dementia.
Vitamin C is an important nutrient, and its labile nature means that prepared vegetables containing sufficient amounts of vitamin C are likely to be rich in other important nutrients as well. Samples of prepared green beans and carrots were obtained from eldercare facilities and their vitamin C content was determined. The results indicated a lack of consistency in the Vitamin C content, and the value for many samples was less than expected. Vitamin C content was maximized through the use of steaming followed by hot-holding for less than 20 minutes. Suggestions for improving relevant public database information are provided.
Factors that influence the menu planning process in Ontario long-term care (LTC) homes were studied, as were key informants' perspectives on how this process could be improved to promote resident-centred menus. Key informants were interviewed by telephone to obtain qualitative data through standardized open-ended questions. The key informants (n=35) were randomly selected nutrition managers of Ontario LTC homes. Selected registered dietitians from the Ontario Long-Term Care Action Group also participated (n=5). Descriptive thematic analysis was completed on data provided. Three over arching themes emerged from the data as drivers in the menu planning process: resource limitations, Ontario Ministry of Health and Long-Term Care standards, and the accommodation of diverse and evolving preferences. Challenges involving resources include insufficient food labour and raw food funding, the workload involved with altering menus, and providing food items for special diets or preferences. In terms of ministry standards, participants reported barriers to complying with rotation and portion standards. Other common obstacles within LTC homes include accommodating personal preferences, cultural preferences, and therapeutic diets. Ontario LTC homes face numerous challenges in the planning of menus for residents, regardless of a home's size, location, or profit status. Suggestions are aimed at improving the menu planning process and providing high-quality, palatable, and culturally appropriate food in these homes so that menus are resident-centred.
To determine differences in the physical and psychological factors and feeding difficulty between people who are well-nourished and malnourished and to determine the predictors of risk of malnutrition and malnutrition in Taiwanese residents with dementia.
Malnutrition is a common problem among nursing home residents but frequently is unrecognised. Nutritional status of older people is associated with cognitive impairment and patients with dementia have high risk for malnutrition because of difficulties in eating.
A cross-sectional design was used to determine predictors of risk of malnutrition and malnutrition.
Subjects were recruited from five Taiwanese long-term care facilities. Data were collected using Mini Nutritional Assessment Screening Form, body mass index, Short Portable Mental Status Questionnaire, Barthel index, Edinburgh Feeding Evaluation in Dementia scale and eating time.
Eighty-three subjects participated. According to the Mini Nutritional Assessment Screening Form cut-point scores, 75 (90·4%) residents with dementia had risk of malnutrition. However, using the World Health Organization (WHO) body mass index cut-point of <18·5, the prevalence rate of malnutrition was 19%. Using logistic regression, gender (odds ratio: 38·627, 95% CI: 1·927-774·407) and eating time (odds ratio: 0·814, 95% CI: 0·689-0·962) were significant predictors of risk of malnutrition. However, only gender (odds ratio: 6·12, 95% CI: 1·05-35·662) was a significant predictor of malnutrition using the WHO body mass index cut-point.
The prevalence of the risk for malnutrition was high in residents with dementia in Taiwanese nursing homes. Feeding difficulty, activities of daily living dependence, cognitive impairment, number of medications and age increased with malnutrition while shorter eating times were associated with poorer nutrition. However, when the factors were considered together, only being female and eating time were significant risk factors for malnutrition. Being female was the only significant factor of malnutrition.
Monthly monitoring of weight and assessment with Mini Nutritional Assessment Screening Form are essential to early identification of emerging malnutrition and implementation of interventions. Providing nutritional supplements and energy and protein-dense food may be needed for good nutrition and more time for eating or feeding assistance may delay malnutrition or even improve nutritional status.
Overview:
Despite the high prevalence of dementia among elderly patients in hospitals 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 feeding patients with dementia.
To use the evolutionary method of concept analysis to identify attributes, antecedents and consequences of mealtime difficulties providing direction for assessment and management in older adults with dementia.
Mealtimes encompass more than the physical act of feeding a person with dementia. Social and contextual considerations are vital considerations to improving nutritional intake. While feeding difficulties in dementia have been analysed in the literature, this paper proposes a broader scope of mealtime considerations to alleviate nutritional deficiencies often associated with dementia.
Evolutionary method of concept analysis.
In 2008, literature searches using keywords (meal, history, sociology, mealtime, culture, habit, dementia, dementia) were done in CINAHL, Academic Search Premiere, MasterFILE, Americal Life and History, Communication and Mass Media Complete, EJS, Health Source Plus-Academic, PsychARTICLES and PsychINFO, ScienceDirect, Sociological Abstracts and Google. Year limits were from 1988-2008. A total of 659 abstracts were reviewed, Google, books and textbooks with relevant content.
Fourty-eight sources were used in the final analysis of mealtime difficulties in older adults with dementia. A model of mealtime difficulties delineates attributes, antecedents and consequences.
Mealtime difficulties in dementia emerged as a concept with supporting evidence-based practice guidelines in 2003. Most research has been conducted in institutional settings, but community research is growing as the shifting demographics of ageing demand attention for this setting. Interventions vary in effectiveness for alleviating sequelae of mealtime difficulties in older adults with dementia.
The conceptual model of mealtime difficulties provides a broader scope of mealtime difficulties in dementia that considers environmental, social, cultural and contextual implications with nutritional intake. The model can be used to guide future research to alleviate mealtime difficulties in older adults with dementia.
To use concept analysis to identify characteristics of feeding difficulty and its antecedents and consequences that provide direction for assessment and management.
Feeding difficulty is often recognised as a common problem for older adults and is associated with weight loss, poor nutrition and risk for aspiration pneumonia. The cognitive impairment found in persons with dementia impairs the ability of these adults to complete motor and perceptual tasks required for eating and often prevent the older adult from accepting help with feeding from caregivers.
Systematic review.
In 2006, literature searches using keywords (feeding, eating, nutrition, malnutrition, feeding assessment, dementia, ageing and concept analysis, dementia and feeding and excluding enteral feeding, tube feedings, PEG and enteral nutrition) were done in Medline, CINHAL, AGELINE and Social Science Full Text. Seventy relevant articles in English were found. After a review of the relevant articles, concept analysis was used to develop a definition of feeding difficulty, its defining characteristics and to delineate feeding difficulty from its antecedents and consequences.
Feeding difficulties arise at the interface between the caregiver strategies to assist the older adult with getting food into the mouth and chewing and swallowing food. A model of feeding difficulty delineates the antecedents and consequences of feeding difficulties.
The conceptual model of feeding difficulties provides a strong and clear organising structure for research that can be used to developed evidence based guidelines for practice.
The conceptual model provides directions for assessment of feeding difficulties and their antecedents. The model can be used to identify interventions that address antecedents of feeding difficulty (risk factors) and different types of feeding difficulties.
Undernutrition can be a significant deterrent to healthy aging and can nega tively affect health outcomes in older adults. Researchers have identified the prevalence of undernutrition in older adults and the need for intervention yet the incidence remains high. The purpose of this article is twofold: to emphasize the need for nutritional assessment across the continuum of care a experienced by older adults, and to identify possible barriers to effective treatment. The assessment of nutritional status and the implementation of effective nutritional interventions are essential to the health of older adults.
Malnutrition has been a well-known risk factor of disease in elderly population, however, the welfare and quality of life can be reached for the elder with the implementation of information technology among a rapidly aging society. In this study, by integrating the food composition nutrient database into an electronic healthy diet and nutrition assessment system (eHDNAS) to establish an informative and healthy dinning environment for the elderly. It does not only provide the elderly with more enjoyable and flexible pre-order meal services but also enable self-management of diet control. At the same time, nutritionist, nurse or the caregiver of a nursing home can do nutrition assessment for the elderly by the electronic diet records. In the future, eHDNAS is expected to play an important role in nutrition-caring plan.
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