Journal of Gerontological Nursing

SELF-FEEDING PERFORMANCE In Nursing Home Residents

Cheryl L Osborn, MSN, ARNP; Melody J Marshall, RN, PHD

Abstract

Supporting self-feeding in the cognitively impaired elderly poses a challenge for nurses. Feeding oneself is a complex process involving organizational, conceptual, and physical skills; these skills are diminished in, and eventually lost by, persons with dementia. Eating also has important social and psychological components. For example, less cognitively impaired individuals may consider being fed demeaning, and therefore may resist it (Henderson, 1988). Conversely, the process of being fed may in itself be reinforcing to a nursing home resident who craves social contact (Geiger, 1974). In addition, the cognitively impaired elderly exhibit a wide range of feeding difficulties including refusing food, choking, turning the head away, spitting out food, reflexively sucking or biting on the spoon, letting the mouth hang open, "squirreling" food in the cheeks, drooling, nasal regurgitation, delayed swallowing, and overstuffing of the mouth (Fabiszewski, 1988; Michaelsson, 1987; Seibens, 1986). Self-feeding efforts also may be perceived by others as problematic if they include poor table manners, slowness, or messinese.

Nurses and nursing assistants working with the cognitively impaired elderly indicate they are unable to differentiate between a lack of desire to eat and a lack of ability to eat (Norberg, 1988). Nurses' perceptions of - and feelings about - long-term care patients tend to vary according to the patients' feeding needs, with difficult-to-feed patients viewed less positively (Barnes, 1990). An ethnographic account of nursing home work from the point of view of the nursing assistant described resident mealtime in terms of "the rush to finish breakfast by 8:30" and the objectification of residents into "feeders" (Diamond, 1986).

Caregivers often find it easier and more expethent to perform tasks like feeding for the cognitively impaired than to allow them to do for themselves to the extent that they are able (Beck, 1988; Rogers, 1982). This practice can result in excess disability (Kahn, 1965) or functional disability that is greater than that warranted by actual physical impairment. Institutional practices can foster dependence or excess disability in elderly nursing home residents with dementia (Baltes, 1983; Barton, 1980; Lester, 1978), Nursing interventions can prevent or reverse excess disability in activities of daily living (ADLs), including feeding (Brody, 1971; Brody, 1974; Eaton, 1986; Hall, 1986).

Table

The most frequently displayed problem behaviors observed in the subjects were slow pace, distractibility, eating from one place only without moving on to other foods, and ineffective use of utensils. Problem behaviors are listed in Table 4.

DISCUSSION

In this study, self-feeding capability of cognitively impaired nursing home residents was significantly superior to mealtime performance among those receiving a pureed diet and in the specific feeding activity of drinking liquids. Findings imply excess disability in the drinking of liquids and among those receiving a pureed diet.

For this study, residents who required or received only verbal prompts were considered less dependent than residents who received nonverbal prompts because they were able to participate more in the feeding process. Residents who received nonverbal prompts participated more than those who received physical guiding, and those who received physical guiding participated more than those who received full assistance. A distinction between partial and full assistance (ie, partial and full dependence) is considered noteworthy because the person who is spoonfed is a passive recipient of care as opposed to an active participant. Nursing staff must distinguish between those who are totally and only partially dependent, so nursing goals and interventions can be formulated to support remaining selffeeding abilities.

There was a clear difference between the style of assistance provided by the nursing home staff and that provided by the researcher (Table 3). Nonverbal prompts used by the researcher included gesturing and demonstrating…

Supporting self-feeding in the cognitively impaired elderly poses a challenge for nurses. Feeding oneself is a complex process involving organizational, conceptual, and physical skills; these skills are diminished in, and eventually lost by, persons with dementia. Eating also has important social and psychological components. For example, less cognitively impaired individuals may consider being fed demeaning, and therefore may resist it (Henderson, 1988). Conversely, the process of being fed may in itself be reinforcing to a nursing home resident who craves social contact (Geiger, 1974). In addition, the cognitively impaired elderly exhibit a wide range of feeding difficulties including refusing food, choking, turning the head away, spitting out food, reflexively sucking or biting on the spoon, letting the mouth hang open, "squirreling" food in the cheeks, drooling, nasal regurgitation, delayed swallowing, and overstuffing of the mouth (Fabiszewski, 1988; Michaelsson, 1987; Seibens, 1986). Self-feeding efforts also may be perceived by others as problematic if they include poor table manners, slowness, or messinese.

Nurses and nursing assistants working with the cognitively impaired elderly indicate they are unable to differentiate between a lack of desire to eat and a lack of ability to eat (Norberg, 1988). Nurses' perceptions of - and feelings about - long-term care patients tend to vary according to the patients' feeding needs, with difficult-to-feed patients viewed less positively (Barnes, 1990). An ethnographic account of nursing home work from the point of view of the nursing assistant described resident mealtime in terms of "the rush to finish breakfast by 8:30" and the objectification of residents into "feeders" (Diamond, 1986).

Caregivers often find it easier and more expethent to perform tasks like feeding for the cognitively impaired than to allow them to do for themselves to the extent that they are able (Beck, 1988; Rogers, 1982). This practice can result in excess disability (Kahn, 1965) or functional disability that is greater than that warranted by actual physical impairment. Institutional practices can foster dependence or excess disability in elderly nursing home residents with dementia (Baltes, 1983; Barton, 1980; Lester, 1978), Nursing interventions can prevent or reverse excess disability in activities of daily living (ADLs), including feeding (Brody, 1971; Brody, 1974; Eaton, 1986; Hall, 1986).

Table

FIGURESelf-Feeding Assessment Tool

FIGURE

Self-Feeding Assessment Tool

The incidence of feeding dependency among the institutionalized elderly is high, approaching or exceeding 50%, depending on the nature of the population studied and the type of assistance required (Fabiszewski, 1988; Rogers, 1982; Sandman, 1987; Seibens, 1986). Early research showed that institutional food service and dining room routines did not foster resident independence in feeding (Diebel, 1963; Edwards, 1979). Institutional and staff support for selffeeding varied among nursing homes and had an impact on the feeding independence of the residents (Rogers, 1982).

Studies of feeding dependency and its correlates among institutionalized elderly subjects have used various, and sometimes unspecified, scales for ranking dependency (Rogers, 1982; Sandman, 1987; Seibens, 1986; Smith, 1984). While all persons who require assistance are dependent, it is useful for caregivers to distinguish between those who are totally dependent (requiring spoonfeeding) and those who are only partially dependent and can participate to some extent in the feeding process. Among the partially dependent, nursing interventions should be directed not only at meeting nutritional needs, but also at supporting remaining self-feeding capability.

Rogers and Snow (1982) also note the conceptual problem of measuring dependency in terms of assistance received. Considering the concept of excess disability, assistance received may not be the same as assistance required - ie, capability may exceed usually observed performance. The purpose of this descriptive, correlational study was to compare self-feeding capability of the cognitively impaired institutionalized elderly with their actual mealtime performance.

SETTING AND SAMPLE

The study subjects consisted of 23 residents of a 120-bed for-profit nursing home in Florida who were identified by staff as partially dependent in feeding and who scored less than 20 on the Mini-Mental State Questionnaire (Folstein, 1975), indicating probable moderate to severe cognitive impairment. Nineteen (83%) were female. Subjects ranged in age from 67 to 96 (mean age 81.7). Length of residence in the nursing home ranged from 2 to 21 months (mean 11.3), although some subjects had been previously institutionalized elsewhere.

Because of the dependent status of the subjects, full panel review was obtained for the study from the University of Florida Health Center Institutional Review Board. Informed consent was obtained from the family member identified as the responsible party on the subject's chart. Verbal consent was obtained from the subjects when possible.

INSTRUMENTS

The Mini-Mental State Questionnaire is used extensively for both clinical and research purposes as a screening tool for dementia. Kane and Kane (1981) have summarized support for reliability and validity.

Self-feeding behavior was assessed using the Self-Feeding Assessment Tool, a researcher-developed instrument (Figure) used to reveal small differences in function, to distinguish the ability to initiate action from the ability to respond to command, and to distinguish among several types of assistance. It avoids the limitations of dichotomous measures and relative terms such as maximal, moderate, and minimal.

The Self-Feeding Assessment Tool allows for separate scoring of the ability to feed oneself solid and semisolid food and to drink liquid. These distinctions are drawn from the KleinBell ADL Scale (Klein, 1982), and reflect the observation that partially dependent individuals can manage some types of foods more easily than others. Self-feeding behavior is described in terms of the type of assistance required from others to complete the feeding task and is ranked along an ordinal five-point scale adapted from Tappen and Hogan's Miami Refined ADL Scale (1987). The five levels or types of assistance are unassisted, verbal prompt, nonverbal prompt, physical guiding, and full assistance.

Table

TABLE 1Differences Between Self-Feeding Capability and Mealtime Performante on Initial and Follow-Up Assessments by Food types

TABLE 1

Differences Between Self-Feeding Capability and Mealtime Performante on Initial and Follow-Up Assessments by Food types

Primary validity concerns in ADL measures are content and construct. Law and Letts (1989) consider responsiveness to change the essential evidence for validity required for ADL measures as evaluation tools. The Self-Feeding Assessment Tool corresponds closely to the content of the more detailed standard ADL scales. Face validity was supported by experts in both geriatric nursing and occupational therapy. This research did not examine change in function over time, although the tool did reveal a range of dependency among subjects, as well as differences in function in the same subject under two conditions.

Interrater reliability with use of a videotaped simulation shown to three geriatric nurse raters was 100%.

PROCEDURE

The study involved observations of subjects' self-feeding behavior during two meals. Each subject was assessed individually at one meal for capability and at another meal for performance. Assessment of mealtime performance involved observation of subject behavior and subjectstaff interaction. Because some subjects could feed themselves part of a meal but required assistance to finish, or the type of assistance changed during the meal, each subject was scored twice: once on their behavior at the beginning of the meal, and once on their behavior at the point that the level of assistance changed or at the end of the meal.

Table

TABLE 2Differentes Between Self-Feeding Capability and Mealtime Performante by Diet

TABLE 2

Differentes Between Self-Feeding Capability and Mealtime Performante by Diet

Table

TABLE 3Levels of Mealtime Assistante Provided to Cognitively Impaired Nursing Home Residents Under Two Conditions

TABLE 3

Levels of Mealtime Assistante Provided to Cognitively Impaired Nursing Home Residents Under Two Conditions

Self-feeding capability was assessed with the researcher assisting each subject individually in a way structured to maximize the subject's participation in the feeding process. For example, if the subject did not attempt to eat unassisted, verbal prompts were offered. If verbal prompts were unsuccessful, first nonverbal prompts, then physical guiding, and then full assistance were offered in turn. Each type of intervention was attempted three times before proceeding to the next. Subjects were considered capable of performing a behavior if they repeated that behavior three times with the same level of intervention. Again, each subject received an initial and a follow-up assessment during the meal.

All observations took place during the noon meal in the subject's usual eating location. Subjects were alternately assessed for either capability or performance first. Problem behaviors exhibited by the subjects were also noted.

Initial and follow-up scores were obtained for each category of feeding task (solid food with utensil, solid food without utensil, semisolid food, and liquid) under each condition (Table 1).

FINDINGS

Analysis of the difference between self-feeding capability and mealtime performance was performed using the Wilcoxon matched-pairs signedranks test. Subjects who received solid foods were scored on all four items of the assessment instrument, while subjects on a pureed diet were assessed only on semisolid foods and liquids.

When capability and performance scores were compared separately for each item on the assessment instrument, self -feeding capability was superior to mealtime performance in drinking liquids in the initial assessment (at the teginning of the meal) (p = 0.0283). That is, in the specific task of drinking from a cup, subjects demonstrated they were capable of doing more than their usual performance indicated. With supportive assistance, a "hidden" capability was revealed. Staff behavior was found to promote excess disability in the specific task of drinking from a cup.

Excess disability was also shown in those receiving a pureed diet. When subjects were divided into regular/mechanical soft diet and pureed diet groups so that total capability and performance scores could be compared, capability was significantly superior to total performance in the pureed diet group (p = 0.0156)(Table 2).

Data were also analyzed with regard to frequency with which the various types of assistance were provided by the researcher and the nursing staff. This data is summarized in Table 3. When assisted by the researcher, all five levels of assistance were successfully used. Most frequently used was "unassisted." The next most frequently used was physical guiding, then verbal and nonverbal prompts. The researcher used full assistance least often; but when attended by staff, subjects were overwhelmingly either unassisted or fully assisted. (Also note changes in assistance over course of the meal.)

Significant correlations between level of cognitive impairment and self-feeding behavior as well as length of residence and self-feeding behavior were found among subjects eating a regular/mechanical soft diet (n = 13). Correlations between these variables were not significant in subjects who ate a pureed diet. Using the Spearman Rank Correlation Coefficient, subjects receiving a regular/ mechanical soft diet who were less cognitively impaired had both higher self-feeding capability (rs = -0.6222, p = 0.0232) and higher total mealtime performance (rs = -0.5594, p = 0.0468). Those who had been in the nursing home the longest had the lowest mealtime performance (rs = -0.57465, p = 0.0400).

Table

TABLE 4Mealtime Problem Behaviors

TABLE 4

Mealtime Problem Behaviors

The most frequently displayed problem behaviors observed in the subjects were slow pace, distractibility, eating from one place only without moving on to other foods, and ineffective use of utensils. Problem behaviors are listed in Table 4.

DISCUSSION

In this study, self-feeding capability of cognitively impaired nursing home residents was significantly superior to mealtime performance among those receiving a pureed diet and in the specific feeding activity of drinking liquids. Findings imply excess disability in the drinking of liquids and among those receiving a pureed diet.

For this study, residents who required or received only verbal prompts were considered less dependent than residents who received nonverbal prompts because they were able to participate more in the feeding process. Residents who received nonverbal prompts participated more than those who received physical guiding, and those who received physical guiding participated more than those who received full assistance. A distinction between partial and full assistance (ie, partial and full dependence) is considered noteworthy because the person who is spoonfed is a passive recipient of care as opposed to an active participant. Nursing staff must distinguish between those who are totally and only partially dependent, so nursing goals and interventions can be formulated to support remaining selffeeding abilities.

There was a clear difference between the style of assistance provided by the nursing home staff and that provided by the researcher (Table 3). Nonverbal prompts used by the researcher included gesturing and demonstrating as well as moving food or utensils to make them more accessible or recognizable. For example, some subjects started drinking milk on their own only after they watched it being poured from the carton into a cup. Physical guidance ranged from a gentle nudge on the elbow to initiate movement to continuous hands-on assistance in keeping the spoon in the subject's hand and directing movements. Physical guidance tended to go more slowly than spoonfeeding, perhaps because it allowed the subject increased control over the speed of eating. With supportive assistance provided by the researcher, every subject displayed some measure of self-feeding capability, even if it was only to hold a cup while the researcher controlled the movement between table and mouth.

When nursing home staff provided assistance, it was almost always full assistance to which the subject was a passive recipient. Staff sometimes gave orienting information while they were setting up a meal tray and used verbal prompts while spoonfeeding, but they did not give verbal prompts or encouragement as a way of assisting residents who could otherwise feed themselves. Staff routine in and out of the dining room supported this all-ornothing style of assistance. After trays were passed out, each nursing assistant sat down to feed a resident. When all the "feeders" had been fed, the staff moved on to those who had been set up for independent eating, but who were judged to need followup assistance.

Follow-up assistance almost always took the form of feeding the resident the remainder of the meal. This routine dictates that staff are approaching partially dependent residents during the last part of the mealtime when feeling the most pressure from time constraints. This routine also does not provide for those who need only occasional or intermittent assistance or encouragement to continue. For residents who ate in their rooms, follow-up assistance was provided as the trays were being collected at the end of the meal.

The nursing assistants tended to use the same level of assistance throughout the meal, while the researcher often found the level of assistance that was needed changed during the course of the meal. This also reflects the all-or-nothing approach of the nursing home staff. Subjects usually received more assistance at the end of the meal than at the beginning.

Only four subjects (18%) received the same level of assistance under capability and performance conditions. Seven subjects (30%) received a higher overall level of assistance from the researcher than from the nursing home staff. For 12 subjects (52%) there was a lower overall level of assistance from the researcher than from the staff. If the researcher's level of assistance is considered optimal, the staff "overassisted" in some instances and "underassisted" in others. Providing more than optimal assistance implies the generation of excess disability. Providing less than optimal assistance has implications relating to consumption and nutrition. These findings, though, may simply reflect day-to-day variability in the subject's behavior.

A wide range of problem behaviors was noted. Several subjects fed themselves, but very slowly. Some repeatedly stopped eating to watch and listen to events in the dining room. Others spent time rearranging food and utensils. Slow pace can be considered a problem from the perspective of the institution, and may in itself prompt assistance. Subjects who ate from the plate but did not move on to the dessert or drink may have been cognitively impaired to the extent that they could perform a simple repetitive activity, but could not initiate a change from one activity to another. Or they simply may not have been able to see as far as the top of the meal tray, may have been unable to reach that far, or could not recognize a milk carton with a straw as something to drink from. Fidgeting may have been related to such causes as agitation, agnosia, apraxia, easy distractibility, or simply poor appetite or dissatisfaction with the menu.

If nurses respond to problem mealtime behaviors such as those Usted before by simply taking over the task of feeding, then they meet the person's nutritional needs at the cost of an unnecessary loss of functional independence. This may rob cognitively impaired individuals of one of their few remaining opportunities for adult mastery.

Intervening to maximize independence is not equivalent to giving the least possible amount of assistance. Providing assistance that supports self-care to partially dependent individuals is not "less" than full assistance in terms of either time or effort. Indeed, it may take more time and effort and cannot be performed without some thought given to the reasons for behaviors that interfere with self-feeding.

Nursing home staffs should be familiar with feeding techniques that support resident participation in the feeding process even when independence is no longer possible. Staff assignments during mealtimes can be made with the recognition that residents' levels of dependence may change over the course of a meal, and that some residents may require only intermittent or occasional assistance. Assignment of a single staff person to assist a group of partially dependent residents in need of mostly verbal and occasional or intermittent hands-on assistance is suggested. Nursing assistants may need the supervision of a professional nurse at mealtime to help them with problem solving when faced with problematic patient behaviors and to assure that their interventions support remaining self-feeding skills.

FUTURE RESEARCH

There is little empirically based descriptive research about the behavior of patients with dementia and few empirically based interventions for supporting self -care (Duffy, 1989). Though the ability to generalize findings from this study is limited by the size and selection of the sample and by the data gathering tool, the findings do indicate profitable areas for further investigation.

It is suggested that the complex behavior of feeding oneself requires an assessment instrument that takes into account the ability to initiate behavior and manage different types of food, as well as changes in behavior over the course of a meal and the need for intermittent or occasional assistance. Repeated observations would identify variability in behavior from meal to meal and day to day.

A multitude of cognitive, physical, psychosocial, and environmental factors have an impact on feeding behavior (Sandman, 1987; Seibens, 1986). Self-feeding behavior among subjects of this study may have been significantly affected by the quality of interpersonal relationships between subjects and caregivers (Norberg, 1989). The research of Norberg and colleagues (Michaelsson, 1987; Norberg, 1988; Norberg, 1989) substantiates the value of qualitative findings concerning caregiver knowledge, attitudes, beliefs, and concerns in regard to the feeding process.

A pureed diet was ordered for 10 of the subjects (43%). It is not known if this proportion is typical. Is variety of food consistency sometimes restricted in order to promote selffeeding or faster feeding? Is it possible that some subjects could have tolerated a more varied food consistency if self-feeding skills received more support?

This study did not examine how food consumption or mealtime duration were affected under the two conditions. Nutrition is a major concern of professionals caring for persons with dementia, since weight loss and malnutrition are common in this population (Rudman, 1989). The resource constraints of an institution may put the goals of promoting independence and optimizing nutritional intake in opposition. Which types of supportive interventions are most effective and least demanding of time and staff? Would interventions designed to support independence in feeding be considered appropriate if consumption levels were negatively affected?

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FIGURE

Self-Feeding Assessment Tool

TABLE 1

Differences Between Self-Feeding Capability and Mealtime Performante on Initial and Follow-Up Assessments by Food types

TABLE 2

Differentes Between Self-Feeding Capability and Mealtime Performante by Diet

TABLE 3

Levels of Mealtime Assistante Provided to Cognitively Impaired Nursing Home Residents Under Two Conditions

TABLE 4

Mealtime Problem Behaviors

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