Residents with dementia require special mealtime care. They may exhibit a variety of challenging behaviors, including inability to recognize and use implements, putting hands in the food, pica (eating non-food items), a preference for sweet foods, and difficulty attending to the meal. As dementia progresses, holding or pocketing food in the mouth, turning the head away, closing the mouth, and spitting food out are common behaviors (Athlin, Norberg, Asplund, & Jansson, 1989; Durnbaugh, Haley, & Roberts, 1993, 1996; Fairburn & Hope, 1988; Hall, 1994; Michaelsson, Norberg, & Norberg, 1987; Morris, Hope, & Fairburn, 1989; Volicer et al., 1989, Watson, 1993).
These behaviors, the result of cognitive and other neurological deficits suffered by dementia patients, make them especially vulnerable to their environment and dependent on skillful, consistent care (Kane, Ouslander, & Abrass, 1994). Yet organizational factors such as the lack of adequate staffing, insufficient education of professional and paraprofessional staff and a lack of supervision at mealtime commonly result in a situation where one certified nursing assistant (CNA) is responsible for feeding 6-7 residents and assisting several others at mealtime. Given these conditions, CNAs often resort to taskoriented, mechanistic strategies instead of providing the individualized care needed by residents (Kayser-Jones, 1996, in press; Osborn & Marshall, 1992). Continuity of care is another problem. In a Swedish study, investigators found that as many as 30 different caregivers assisted a single resident at mealtime within a period of one month. They also found that the median time for feeding residents ranged from 6 to 15 minutes (Backstrom, Norberg, & Norberg, 1987). Others have reported that an "all or nothing" approach is often taken by staff: residents either are spoon-fed the entire meal or they are not assisted at all (Osborn & Marshall, 1993; Sandman, Norberg, & Adolfsson, 1988). Additionally, the cluttered, chaotic dining room environment in some nursing homes distracts and agitates demented residents (Van Ort & Phillips, 1992, 1995).
As part of an anthropological study investigating eating problems in nursing homes, data were gathered through participant observation and interviews of nursing staff, residents, family members, and physicians (about 50 in each category) in two proprietary nursing homes. A third strategy, event analysis, the primary source of data for this article, was used to gather data on 100 residents who were not eating well. Each resident was followed for a period of 6 months or longer. Subjects were predominantly female (73%) and ranged in age from 61-102 (mean 83.4 years). Seventy-five percent were severely cognitively impaired, 11% were moderately impaired, and the remainder had mild or no impairment (Kahn, Goldf arb, Pollack, & Peck, I960). Research assistants (RAs, graduate students in nursing and sociology) observed each resident weekly at all three meals, noting how, when, and what food was served, what the resident ate, and staff-resident, resident-resident, and resident-family interaction during mealtime. RAs also recorded in extensive detail the kind of help offered by the staff, the verbal and tactile communication between caregivers and residents, and the environmental context of the meal. Sixty pages of weekly notes were collected in the case presented here. Though labor intensive, this method allowed for an in-depth examination of the mealtime experience of nursing home residents over a sustained period of time.
This report provides a description and analysis of one resident's mealtime experience, a typical example of the type of eating problem seen among many of the cognitively impaired residents in the study. It describes and analyzes the effective and ineffective strategies used by staff in assisting the residents at mealtime.
Mrs. Sampson* was an 86-year-old woman who had been admitted to the nursing home with a diagnosis of Alzheimer's disease. She had been cared for at home with a 24-hour live-in caregiver for 4 years. As she became increasingly impaired and after falling several times, her family decided she would be better cared for in a nursing home.
Mrs. Sampson rarely spoke, and when she did, her speech was incomprehensible. Because she was edentulous, and for unknown reasons had not been wearing her dentures for some time, she was given a pureed diet. She also had moderate oropharyngeal dysphagia: she had difficulty moving food to the back of her mouth and her swallowing ability was slowed and diminished.
While edentulousness and dysphagia contributed to her eating problems, her main difficulty was a profound apraxia (the inability to use objects correctly). She had difficulty identifying and using the eating utensils appropriately and frequently ate with her fingers.
Unlike some residents who had poor appetites, Mrs. Sampson appeared hungry; she usually ate all of her food and frequently attempted to scrape or lick the last morsels of food from her plate or bowl. Her hunger seemed to motivate her efforts to obtain food. Although her behavior at first appeared random and meaningless, after several weeks of observation, it became clear that she was engaged in problem-solving strategies (albeit unsuccessful ones). During one meal, for example, unable to locate a spoon on her tray, she tried to use in succession a straw, the small plastic diet card, and the metal card holder to put food in her mouth. Finally, she gave up and resorted to using her fingers. Similarly, she attempted to find ways to drink her milk. It seemed she did not want to drink milk from a carton (she once pushed away a caregiver who offered it in this manner). When served milk in a cup and guided to lift it to her mouth, however, she drank all of it by herself. Apparently, she preferred to drink her milk from a cup. When a cup was not provided she poured the milk into her bowl or onto her plate. To some staff it seemed she was simply playing with her food; we came to believe that she was looking for a vessel in which to pour her milk.
As she struggled to eat without guidance or assistance, a substantial portion of food fell onto her clothing, dimimshing her nutritional intake. Already thin at 88 pounds when she entered the nursing home, Mrs. Sampson's weight continued to drop to a low of 86 pounds. To mitigate the loss, commercial supplements, which she disliked, were ordered. Yet no one suggested she be helped to consume the food being served.
A widow with three attentive and caring children, Mrs. Sampson, who had lived alone, was a proud and independent woman who had an active life (walking more than 20 blocks a day) until she became cognitively impaired. In the nursing home, this history of selfsufficiency surfaced in her desire to feed herself and in sometimes resisting the help offered by staff. When one staff member tried to feed her a bite of food, for example, she pushed him away, saying something like, "I don't like you doing that!"
During the 6 months of observation, we observed several staff members assisting Mrs. Sampson at mealtime, some ineffectively and without sensitivity to her needs, others skillfully, sensitively and effectively.
INEFFECTIVE MEALTIME STRATEGIES
Labeling Resident and Lack of Assistance and Supervision at Mealtime
Some staff members, unable to understand her behavior, labeled her "combative" or "uncooperative;" they left her to eat without any assistance or supervision. They set up her tray, covered her with a large bib (or sometimes a bath towel or pillowcase) and left her to her own devices. Once at dinner, for example, she picked up her fork and began to eat her food. Then she put down the fork, and ate the pureed food with her fingers. The RA noted that "no one stopped her from doing so."
On another occasion, Mrs. Sampson, apparently not remembering how to eat as she would have done before becoming cognitively impaired, reached for the jello dessert and emptied it onto her pureed entree. Then she put her fork into the mixture and lifting it up, proceeded to pick food from the tines of the fork and place it in her mouth. Next, she used her spoon to lift milk from the cup to her mouth. Having only minimal success in this endeavor, she tried, using the fork in the same way. Throughout this episode, though staff were in the dining room, no one redirected or assisted her.
This scene was disturbing to other residents. As Mrs. Sampson attempted to get milk from her glass using a fork, another cognitively impaired resident came to the table, sat next to her and said to the RA, "Why don't you stop her, can't you see she's trying to use a fork to get the milk?"
When she ate with her fingers, pureed food fell down her chin and onto her clothes which were sometimes protected with a bib. On one occasion, a CNA covered her with a bed sheet, expecting that when Mrs. Sampson fed herself, the food would spill not only on her blouse, but onto her lap, her legs and the floor. When a bib or bath towel were not used to protect her clothing, her attractive attire, carefully chosen by her children, was covered with food stains and not always changed after meals.
The spillage of food had another consequence. CNAs, when evaluating her nutritional intake, assumed that everything missing from the tray at the end of the meal had been consumed. Not accounting for the spillage, they erroneously recorded an inflated percentage of food eaten.
Totally Feeding the Resident and Mixing Food Together
Although Mrs. Sampson rarely got adequate help at lunch and dinner, she was assisted at breakfast. All of the residents were served breakfast while in bed. Usually, the CNAs spoon-fed Mrs. Sampson at this meal, perhaps to avoid having to change the bed linens after the meal. Interestingly, Mrs. Sampson generally did not resist being fed at breakfast, perhaps because she was especially hungry as much of the food served at lunch and dinner was not actually eaten.
When the staff fed Mrs. Sampson, they mixed the pureed food together. While she sometimes ate these peculiar concoctions, on other occasions she refused to eat. One morning, for example, a CNA poured milk on Mrs. Sampson's pureed french toast and then added the soggy toast to her oatmeal. She put a spoon into the mixture and leaving the room, told Mrs. Sampson to feed herself. When she returned, Mrs. Sampson had eaten nothing. The CNA then handed her part of a banana, which was the only thing she ate before the CNA removed the tray. Although Mrs. Sampson was unable to say why she did not eat the oatmeal-french toast mixture, perhaps the banana was the only recognizable item that seemed appealing to her.
EFFECTIVE MEALTIME STRATEGIES
Encouraging Independence While Providing Supervision and Assistance
While most of the staff dealt ineffectively with Mrs. Sampson at mealtime, a few staff members exhibited skillful, sensitive, and effective care, assisting Mrs. Sampson to eat well in a conventional, dignified, and socially acceptable manner. CNA Dora, for example, recognized that Mrs. Sampson needed constant supervision and careful coaching during the meal. She knew how to help Mrs. Sampson eat independently, and she also knew when it was appropriate to spoon-feed her. In her field notes, the RA wrote:
Dora took the entree plate off the tray and put it down in front of Mrs. Sampson. Then she pulled over a chair and sat down facing her. Dora handed her the teaspoon and showed her how to place the food on the spoon. Then she sat by, observing Mrs. Sampson while allowing her to eat independently. I [the RAJ asked Dora if she stayed at the table to help as needed "Yes," she replied, "because sometimes she gets mixed up and forgets how to feed herself." Toward the end of the meal, about 20 minutes later, Dora took over because Mrs. Sampson appeared to tire of feeding herself. Mrs. Sampson consumed 100% of the meal.
Jeffrey, another CNA, respected and encouraged Mrs. Sampson's independence but understood when he needed to intervene. "I want her to feed herself. That's our goal. But, I watch her, because she starts mixing things together."
When Jeffrey intervened, he did so gently and skillfully. At one meal, Mrs. Sampson picked up the diet card on her tray. Jeffrey, knowing that she would try to use it as an eating utensil, reached to take it from her. When Mrs. Sampson pulled the card away, instead of insisting on retrieving it, he asked thoughtfully, "you need this?" The RA noted that Jeffrey was skillful at balancing Mrs. Sampson's need for independence with her need for supervision. When she stopped eating, for example, he did not take over and feed her but rather offered her a spoonful of food; thus reminding her to continue eating.
On another occasion when Mrs. Sampson repeatedly put food on her spoon and then put it back on the plate without lifting it to her mouth, Jeffrey placed his hand on hers and physically guided the spoon to her mouth, saying, "Let's do it together." After this first cuing, Mrs. Sampson put several bites of food into her mouth on her own. Then she tried to put food in her mug. Once again redirecting her, he guided her hand to her mouth.
Creating a Social Mealtime Environment and Simplifying the Process of Eating
The activities director, Jane, was also skillful at assisting Mrs. Sampson. At one meal, Jane was helping residents into the dining room. As she brought Mrs. Sampson to the table, she introduced her to her table mates. Mrs. Sampson smiled as she was introduced. Before the food came, Jane gave Mrs. Sampson water, which she eagerly drank. Offering her something to drink seemed to help Mrs. Sampson focus on eating when the food came, and moistening her throat probably facilitated swallowing. When the trays arrived, Jane set only the entree and a spoon before Mrs. Sampson. When she had finished the entree Jane removed the plate and placed the dessert and a clean spoon in front of her. Using her spoon correctly, Mrs. Sampson then ate all of her dessert.
DISCUSSION AND RECOMMENDATIONS
The Consequences of Ineffective Strategies
The ineffective strategies used by staff illustrated the "all or nothing approach;" both had deleterious consequences for Mrs. Sampson.
Labeling resident and lack of supervision. Labeling Mrs. Sampson "combative" or "uncooperative" gave staff license to ignore the underlying meaningful intention of her actions. Not understanding her behavior, some staff simply left her to eat with little or no supervision. Staff who did so compromised her nutritional intake because so much food was lost to consumption. Moreover, permitting so great a spillage of food, allowing Mrs. Sampson to mix food together, and letting her pour milk over her food showed a disregard for the aesthetics of eating that eroded her dignity and was disturbing to other residents. Furthermore, while the use of a bib is infantalizing, the use of a sheet, pillowcase, or bath towel to cover clothing is even more contrary to social convention. It is also dehumanizing. Rather than assisting her to eat with dignity, they conveyed an expectation and acceptance of spilling a large amount of food. Although maintaining independence is a worthwhile goal, this principle should not ignore the importance of preserving the dignity of the resident.
Staff who let Mrs. Sampson eat without assistance did not respond to the level of hunger exhibited by this resident. Although she ultimately gained a small amount of weight during the study (to a high of 91 pounds), she undoubtedly would have gained more had she been helped to avoid spilling food and been given larger portions of food. With this intervention, she might have even returned to her predementia weight of 107 pounds, an appropriate weight for her 5-foot frame.
Totally feeding resident and mixing food together. When staff totally spoon-fed Mrs. Sampson, they robbed her of the opportunity to exercise some independence in eating. They also failed to incorporate knowledge of Mrs. Sampson's personal history into her care, and did not acknowledge her long pattern of self-sufficiency. In mixing the food together, they showed a disregard for the aesthetics of eating, perhaps based on an assumption that aesthetics no longer matter to demented residents. Furthermore, they did not examine the effect of their behavior on her. Although we cannot say for certain, one could hypothesize that in mixing and "toying" with their food, residents like Mrs. Sampson may be imitating the behavior of the CNAs who mixed and stirred food together.
The Consequences of Effective Strategies
Encouraging independence while providing supervision. The most skillful and effective CNAs appeared to grasp the underlying intent of Mrs. Sampson's behavior and were able to assist her in ways that allowed her to eat neatly and in a socially acceptable manner without compromising her independence. They gave her just the right amount of assistance, individualizing care to her particular needs. They approached her in a non-threatening manner, provided constant cuing and guidance, and gently redirected her when she became confused about how to use her implements or how to get food to her mouth. Moreover, they seemed to operate from an underlying assumption that they could gain Mrs. Sampson's cooperation, as evidenced by Jeffrey's comment, "let's do it together." For him, mealtime was a collaborative effort.
Creating a social mealtime environment and simplifying the process of eating. Jane's thoughtful gesture of introducing Mrs. Sampson to her table mates, as social convention dictates, emphasized the social context of the meal and established Mrs. Sampson's presence and worth as a member of the dining room community. By responding with a smile, Mrs. Sampson showed acknowledgment of Jane's action. A heightened awareness of the social context may have helped Mrs. Sampson maintain socially appropriate behavior throughout the meal.
Simplifying the process of eating was another important strategy used by Jane and others. Providing Mrs. Sampson with one course at a time and a single appropriate eating utensil helped her to focus on eating appropriately.
Establishing a pleasant dining environment in which cognitively impaired residents can be helped to eat an adequate amount of delicious food in a socially appropriate manner should be the goal of every nursing home. To do so requires knowledgeable nursing leadership that communicates a philosophy of compassionate and individualized care that supports and enhances the effective mealtime strategies observed in this case.
Ideally, gerontological clinical nurse specialists (GCNSs) or gerontological nurse practitioners (GNPs) should assist CNAs in interpreting the meaning of a cognitively impaired resident's behavior. In Mrs. Sampson's case, a GCNS or GNP might have explained to the CNAs that Mrs. Sampson was usually hungry, and would eat well, given appropriate assistance. The GCNS or GNP could also suggest that perhaps Mrs. Sampson was trying to eat in the way to which she was accustomed, pointing out, for example, that Mrs. Sampson seemed to prefer drinking milk from a cup rather man a carton (the generational preference of many elders) and making certain mat a cup was on her tray. Helping staff to understand mat labeling a resident "combative" or "uncooperative" can hinder attempts to uncover the meaning of behavior and inhibit creative approaches to care is also important.
As Hall (1994) emphasized, and as seen in this case, creating a pleasant social mealtime context can positively affect behavior. Staff can help establish this environment by introducing table mates and sitting down with residents whom they assist. In all instances, staff should model normal, socially acceptable eating behavior and refrain from practices such as mixing food together and using bibs or towels to cover clothing. While we cannot say how much the mixing of food affected Mrs. Sampson, mamtaining quality of lire is an important nursing goal, and food should be presented to the resident in the most pleasing possible manner so as to enhance enjoyment of eating, one of the few pleasures left for cognitively impaired residents.
The personal history of residents is important to discern. Those with a keen sense of independence like Mrs. Sampson did best with a skilled CNA who could sense when and how to intervene. This may mean that the CNA sits by as an observer, as Dora did, ready to assist when the resident needs help. Supervisory staff must recognize and support this nursing intervention and not assume that the CNA is passively doing nothing when observing a resident like Mrs. Sampson (Holzapfel et al., 19%; Kolodny & Malek, 1991).
As seen in this case, carefully nuanced assistance, provided in a gentle non-threatening way that supported both the dignity and independence of the resident was most effective in gaining Mrs. Sampson's willing cooperation. Such an approach is important not only at mealtime but in all aspects of care (Kayser-Jones, Bird, Redf ord, Schell, & Einhorn, 1996).
AsBonnel(1995)has suggested, simplifying the meal for cognitively impaired residents by providing one course at a time and by giving only implements that the person can actually use (such as a spoon and/ or fork) can reduce distractions and help the resident focus on the meal.
Finally, avoiding the use of bibs (if necessary, replacing them with a large cloth napkin securely attached to clothing, for example with clips), taking care not to spill food on clothing (a taboo in our society), and supporting socially appropriate mealtime behavior will help maintain the dignity of cognitively impaired residents.
Nursing homes should strive to provide meals as attractively as possible, reflecting mealtime as it would be in one's home. To do less is to dehumanize and stigmatize cognitively impaired elderly people.
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