Post on 21-Jan-2017
Eating and nutritional problems ofEating and nutritional problems ofpeople with dementiapeople with dementia
Roger Watson PhD RN FAANProfessor of Nursing
Where the heck is Hull?
UK
Hull
What is dementia?
Various brain disorders that have, in common, loss of brain function which is progressive and, eventually, severe.
How many people have dementia?
750,000 in UK (population 50 million)
4-5 million in USA (population >300 million)
What are the types of dementia?
Alzheimer’s diseaseVascular dementiaLewy body dementiaFronto-temporalHuntington’s diseaseAIDS-relatedParkinson’s associatedCreutzfeld Jakob diseaseBrain tumourHydrocephalusAlcoholTreatable - eg malnutrition, hormones
What causes dementia?
GeneticsCo-morbidityLifestyleInfectionOld age?: 40-65 1 in 1000
65+ 1 in 5070+ 1 in 2080+ 1 in 590+ 1 in 2
At present there is no ‘cure’ for dementia
What happens to someone with dementia?
Progressive cognitive decline:loss of memorysubtle changes in personality
Behavioural change:wanderingaggressionincontinenceproblems with eating
Food and dementia
Almost inevitable disturbances to eating in dementia with decline in eating towards the terminal stages
Weight loss is also associated with dementia but this may not just be the result of eating difficulty
In fact, it has been demonstrated that weight loss can precede the onset of dementia
Ethical and legal dimensions
Because we cannot readily interpret the actions of a person with dementia we do not know what to do for the best
Questions:
How do we alleviate eating difficulty?What constitutes force feeding?When do we stop feeding a person with dementia?
Responses to difficulty with eating
Do nothingAssist with eatingForce feedEnteral/parenteral feeding
Tube feeding
Not advocated - growing research base in support
Leads to: aspirationinfectiondiscomfort/distressrestraint & sequelae
and - does NOT prolong life
Systematic review
To review, systematically, the literature on interventions to promote oral nutritional intake of older people with dementia and feeding difficulty between 1993 and 2003
Background
The area of feeding difficulty in older people with dementia and related nursing care was reviewed in 1993 and the conclusion was that there was a paucity of research into interventions that nurses could use to alleviate feeding difficulty.
Definition of terms
Feeding:
The act of moving food from a receptacle to the mouth either alone or with assistance
Eating:
Encompasses a variety of behavioural actions surrounding the process of nutritional intake
Definition of terms (contd.)
Nutrition
Something that can be achieved without either feeding or eating by artificial means
NB: this review specifically excluded artificial feeding and any ethical debates surrounding it
Methods
Databases:
MedlineCINAHLEMBASECochrane database
Dates: between 1993 to 2003
conducted: 1 December 2003
included retrievals up to 31 December 2003
Methods (contd.)
Search terms:
1. ‘feeding’, ‘eating’, ‘dementia’
Combined: ‘(feeding or eating) and (dementia)’
2. ‘mealtimes’, ‘dementia’
Combined: ‘mealtimes and dementia’
Inclusion criteria
•items on the behavioural aspects of eating and feeding in dementia
•actions specifically designed to alleviate feeding or eating difficulty
•actions aimed at encouraging older people with dementia to eat
•English
Exclusion criteria
•drug interactions with feeding
•influence of micronutrients on cognitive function
•artificial feeding
•ethics of feeding at end of life
Filtering
Papers read and categorised by Dr Sue Green (University of Southampton) and me on the basis of whether or not they were primarily about interventions to help older people with dementia to feed or not.
Therefore further excluded:
•literature reviews•assessment of feeding•surveys•professional articles•opinion pieces
Results
1. ‘(feeding or eating) and ‘dementia’
CINHAL 59Medline 73Embase 148Cochrane 57
2. ‘mealtimes and dementia’
CINHAL 9Medline 7
NB: only one of these was additional to above
Results (contd.)
First check for duplicates within and across databases and relevance to study = 67 papers
Second check for intervention studies = 13 papers
Records identified = 353
Remaining after duplicates removed and
papers screened = 13
Discarded =
340
Qualitative synthesis = 13
Meta-analysis = 0
Results (contd.)
Interventions:
• changing meal service systems (1)• staff assignment (1) • introducing nutritional assessment and changing
provision (1)• changing food texture (1)• occupational and behavioural interventions (3)• music (4)• moving dining rooms (1)• not specified (1)
Results (contd.)
Design:
• not described in any detail (4)• quasi-experiment inc. time series) (5)• Quasi-experiment pre-test/post-test (2)• RCT (1)• case study (1)
Statistical analysis used in 6 studies
Results (contd.)
Sample size:
varied from two to 29 with one study not specifying one
All studies reported positive outcomes
Time of intervention varied from days to years
Results (contd.)
Outcome measures:*
• interaction and participation at meals (4)• weight or BMI (3)• agitated behaviour (2)• eating frequency (1)• food and fluid intake (2)• time spent at meals (2)• increased confidence in coping with people with
dementia (1)• none specified (1)
* - some studies used > 1 outcome measure
Successful interventions
Music at mealtimes:
Described as ‘quiet’, ‘soothing’ or ‘relaxing’
Problems:
Appreciation of music is subjective
Music also changed staff behaviour
Successful interventions (contd.)
Prompting and reinforcing behaviour
Problems:
No precise definition or differentiation of either prompting or reinforcing
Likely to be interpreted negatively by older people with dementia
Conclusion
General methodological weakness:
Small samples (type II error)Confounding variablesImpossibility of ‘blinding’ participants
‘Bottom drawer’ phenomenon
How do we know what is clinically significant?
Conclusion (contd.)
Future studies should:
Use power analysis to decide sample sizes
Agree standardised interventions across studies
Agree standardised outcome criteria
Apply more rigorous designs
Need more qualitative and observational studies
The EdFED scale:development
Edinburgh Feeding Evaluation in Dementia (EdFED) questionnaire developed:
Originally 11 item questionnaire asking about:
Level of nursing interventionProblems of people with dementia
Feeding: referring specifically to the act of moving food from a plate to the mouth
Factor analysis
Exploratory:(n=196; Watson & Deary 1994)
Confirmatory:(n=345; Watson & Deary 1997)
SupervisionPhysical Help
SpillageLeave food on plate
Refuse to eatTurn head away
Refuse to open mouthSpit out food
Leave mouth openRefuse to swallow food
SupervisionPhysical Help
SpillageLeave food on plate
Refuse to eatTurn head away
Refuse to open mouthSpit out food
Leave mouth openRefuse to swallow food
SupervisionPhysical Help
SpillageLeave food on plate
Refuse to eatTurn head away
Refuse to open mouthSpit out food
Leave mouth openRefuse to swallow food
SupervisionPhysical Help
SpillageLeave food on plate
Refuse to eatTurn head away
Refuse to open mouthSpit out food
Leave mouth openRefuse to swallow food
Mokken scaling
n=345 (Watson 1997)
Stochastic version of Guttman scaling which searches for hierarchical, unidimensional scales.
6 items related to feeding behavioural problems scaled
Louis Guttman1916-1987
Robert J Mokken1929-
EdFED scale (Edinburgh data; Watson 1996)
Leave mouth open
Refuse to swallow food
Spit out food
Turn head away
Refuse to open mouth
Refuse to eatIncreasing
level of difficulty
EdFED scale (Derbyshire data; Watson et al 2001a)
Leave mouth open
Refuse to swallow food
Spit out food
Turn head away
Refuse to open mouth
Refuse to eatIncreasing
level of difficulty
The EdFED scale:applications
EdFED scale (Taiwanese data; Lin & Watson 2008)
Leave mouth open
Refuse to swallow food
Spit out food
Turn head away
Refuse to open mouth
Refuse to eatIncreasing
level of difficulty
What is associated with low food intake in older people with dementia? (Lin et al 2010)
Low food intake (Forward stepwise logistic regression)(N=430)
p Odds ratio
Age 0.025 1.032
Feeding assistance <0.001 0.130
ADL dependence <0.001 3.185
Eating difficulty (EdFED) <0.001 20.749
Using spaced retrieval and Montessori-based activities in improving eating ability for residents with dementia (Lin et al 2010b)
Feeding and dementia: development and recent applications of the Edinburgh Feeding Evaluation in
Dementia (EdFED) scale
Summary:
•The EdFED is the only validated scale internationally
•The EdFED is stable across cultures
•The EdFED is a good measure of feeding interventions
•Feeding difficulty can be alleviated