Feeding and dementia

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?

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

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


Spit out food

Turn head away



level of difficulty

The EdFED scale:applications

EdFED scale (Taiwanese data; Lin & Watson 2008)

Leave mouth open


Spit out food

Turn head away



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

email: [email protected]

@rwatson1955

mailto:[email protected]

Feeding and dementia

Health & Medicine

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