Journal of Gerontological Nursing

The Eating Behavior Scale: A SIMPLE METHOD OF ASSESSING FUNCTIONAL ABILITY IN PATIENTS WITH ALZHEIMER'S DISEASE

Mary W Tully, BA, RN; Katherine Lambros Matrakas, MS, RN; Joanne Muir, MS, RN; Kathleen Musallam, MSN, RN

Abstract

ABSTRACT

Health care providers and family members need practical methods of assessing functional skills of individuals with Alzheimer's Disease (AD). There are neuropsychological tests that identify areas of function and dysfunction in the brain, but discrepancies have been noted between test scores and functional behaviors in activities of daily living (ADLs). The Eating Behavior Scale (EBS) was developed to measure functional ability during meals. A sample of 30 patients with probable AD were observed using the EBS during two meals on two different days. There was a strong negative correlation between meal duration and the EBS score. That is, the lower the EBS score, the longer the time required to complete the meal. Mini-Mental Status Exam (MMSE) scores were positively correlated with EBS scores. Patients with higher MMSE scores and less time since diagnosis tended to have higher EBS scores, indicating greater independence in eating.

Abstract

ABSTRACT

Health care providers and family members need practical methods of assessing functional skills of individuals with Alzheimer's Disease (AD). There are neuropsychological tests that identify areas of function and dysfunction in the brain, but discrepancies have been noted between test scores and functional behaviors in activities of daily living (ADLs). The Eating Behavior Scale (EBS) was developed to measure functional ability during meals. A sample of 30 patients with probable AD were observed using the EBS during two meals on two different days. There was a strong negative correlation between meal duration and the EBS score. That is, the lower the EBS score, the longer the time required to complete the meal. Mini-Mental Status Exam (MMSE) scores were positively correlated with EBS scores. Patients with higher MMSE scores and less time since diagnosis tended to have higher EBS scores, indicating greater independence in eating.

Alzheimer's Disease (AD) is a progressive brain disease afflicting approximately 4 million adults in the United States today (United States Department of Health and Human Services, 1994). The dementia resulting from AD is manifested by impaired memory, intellect and judgment, difficulty in communication and ability to perform activities of daily living (ADLs). By the year 2000, one in three families will be coping with AD. The functional deficits noted in AD and other dementias affect several areas of ADLs and vary with the severity of the disease. Norberg and Athlin (1989) have conducted numerous studies on eating problems of demented patients in Sweden. They report that with mild dementia, patients exhibit minor eating problems related more to social eating rules. However, 40% of institutionalized elderly demented patients were dependent upon assisted feeding.

Prior to institutionalizing a person with AD, families often provide the care at home. Much of the literature regarding feeding problems with dementia focuses on the institutionalized patient and the required assistance needed to support feeding. Some examples of assisting with feeding include the use of verbal cues, plate guards that enable a patient to scoop up food, large handled utensils, and dycem, a rubberized mat that holds a plate stationary. Assisting a patient may mean cutting up food, buttering bread, or even handing a patient the fork to get him started.

Caregivers of patients with AD frequently exhibit unrealistic expectations regarding functional abilities during ADLs such as eating. The nurses at the National Institute on Aging (NIA) patient care unit have observed family caregivers urging patients to perform tasks they are unable to do. The results are often anger on the part of the caregiver and frustration on the part of the patient because of failure to succeed. Family members caring for individuals with AD have asked nurses if the patient's behavior is deliberate, or intended as acting out against the caregivers. Studies suggest that deliberate intervention by caregivers can increase functional behavior during activity such as eating, even late in the course of the disease (Van Ort & Phillips, 1992).

The first neuropsychological dysfunction in AD is described as a loss of attention capacity, followed by loss of language and visuospatial function (Grady et al., 1988). The relationship of these early neurologic deficits to the patient's ability to perform independently in ADLs is not fully understood. An AD patient's self-report of functional abilities may be unreliable and caregiver information on functional abilities of the patient may be biased. Neuropsychological testing can identify areas of function and dysfunction (Becker, Huff, Nebes, Holland, & Boiler, 1988). However, neuropsychological testing is expensive, time-consuming, and unavailable to many patients who suffer with AD. It is often difficult for families to translate die results of these tests into useful and realistic information.

Recognizing that patients with AD will, at some point, have difficulty executing some or all ADLs, the need for a method to measure these deficits in functional ability is obvious. Deficits must be identified before any type of intervention can be started. Existing functional assessment measures are limited in their utility for patients with AD as they primarily address motor skills and tend to discount the cognitive abilities of the patient (Loewenstein et al., 1989). These tools were intended for use with institutionalized or with high functioning patients and have limited application to the moderately affected population. The development of an easy and practical instrument that can identify the deficits in cognitive skills needed to complete ADL tasks could greatly assist health professionals and family caregivers.

With performance assessments, there are advantages for both clinical use and research, for example: simplistic methodology, ability to replicate findings, and a sensitivity to focus on a patient's actual ability rather than his presumed ability. This article describes the development and evaluation of a practical functional assessment tool for the activity of eating that could be easily used by caregivers of patients with AD. The EBS is an easy-to-use observational tool that does not place an additional burden on the patient. Accurate assessment of the impact of interventions can be made by using such a standardized tool.

DEVELOPMENT OF THE EATING BEHAVIOR SCALE

The Eating Behavior Scale (EBS) (Figure) was developed by clinical nurses at the National Institutes of Health. The purpose of the instrument is to measure AD patients' functional ability during eating. The EBS incorporates the cognitive components of functional abilities into the measurement instrument, providing a greater depth of information for assessment purposes. Where other functional assessment measures identify only motor skills associated with deficits, the EBS identifies the patient's ability to perform the task of eating, and to eat safely. In addition, the EBS identifies differing levels of intervention needed, such as physical assistance, verbal prompts or need to be fed. The EBS is a six-item observational checklist that yields a score derived from subtask scores. The observed behaviors in the EBS include the following:

a) Initiation: Can the patient start eating on his own without prompts?

b) Maintain attention: Is the patient easily distracted from the task or can he maintain focus?

c) Locate all foods: Can the patient find all of the food on the plate or does he eat what is only on one side?

d) Correct Usage: Does the patient use the right utensil and use it correctly?

e) Safety: Is the patient able to eat without choking?

f) Termination: Does the patient realize that he has eaten all his food and that the meal is completed?

Each of the sub-tasks has a range of scoring from 0-3 with total independence=3, needing verbal prompts=2, needing physical assistance=l, and total assistance^). The sub-task scores are added: the higher the total score the more independent the patient is in the activity of eating. A total score of 18 shows independence in eating.

Table

FIGURENational Institutes of Health Warren G. Magnuson Clinical Center Nursing DepartmentEating Behavior Scale (EBS)

FIGURE

National Institutes of Health Warren G. Magnuson Clinical Center Nursing Department

Eating Behavior Scale (EBS)

This version of the EBS grew out of previous work by Petrucci and colleagues (1989), who conducted a pilot study in which all behaviors exhibited during eating test meals were observed and recorded. Patterns of behavioral deficits were related to attention, initiation, communication, problem-solving, coordination, visuospatial abilities, taste, appetite, and weaknesses. Demented patients often experience problems in relationship to the environment which may impact upon their eating ability. Examples include recognizing food, knowing it is mealtime, or interpreting hunger signals. Patients may not know how to begin eating a meal and they may leave the table before finishing the meal. This first measurement instrument was deemed too long and cumbersome for practical use. Further work by Muir, Musallam, Tully, and Young (1991) refined, the behavioral deficit observations into a checklist. This checklist was refined and then further abbreviated to the current easy-to-use format. The purpose of this study was to further evaluate the psychometric properties of the EBS, which included correlating direct observations of dementia eating behavior, as measured by the EBS, with the results of the neuropsychological tests.

METHODS

The protocol was reviewed and approved by the National Institute on Aging (NIA) Institute Review Board at the National Institutes of Health. Prior to participating in the study, all patients or the holder of their durable power of attorney signed informed consents.

Sample

A convenience sample of 30 subjects, 16 males and 14 females, was selected from the geriatric inpatient unit of the NIA. These subjects were concurrently participating in a longitudinal study of dementia. This longitudinal study required careful screening for three significant reasons: 1) the health selection criteria reduced the influence of secondary disease on brain function; 2) the evaluation and extensive neuropsychological testing was unusually comprehensive; and 3) a special effort was made to recruit patients with mild dementia to allow study of the full course of the disease.

Table

TABLE 1Sample Demographics

TABLE 1

Sample Demographics

The sample (Table 1) ranged in age from 51 years to 87 years old with a mean of 69.4 years. These persons had been given a diagnosis of probable Alzheimer's disease according to the DSM-III criteria (American Psychiatric Association, 1987). Diagnoses ranged from 1 year to as long as 14 years in duration with a mean of 36 months. One subject had only 8 years of formal education and, on the other end of the spectrum, one subject had 19 years of formal education. The mean was 14.5 years of education. Of the 30 subjects, 15 were in the mild stage of dementia, 8 were in the moderate stage and 7 were classified as severely demented. The stages were determined by MMSE score as follows: 010=severe, ll-20=moderate, and 21-28=mild. Participants were accepted into the NIA dementia studies only if they were without any confounding illnesses and conditions.

The extensive screening process included a complete history and physical exam, blood tests, and other tests to rule out diabetes, hypertension, heart or blood vessel disease, history of alcoholism, head trauma, exposure to toxins and infectious agents capable of causing dementia, endocrine diseases, and connective tissue disease. Family history was considered significant if potential familial dementias, Down Syndrome and other neurological conditions such as Parkinson's disease were identified. Subjects without evidence of significant chronic disease or substance abuse who met the standard clinical criteria for diagnosis of dementia of the Alzheimer's disease type, either possible or probable, were accepted for the study according to the DSM-?? criteria.

Procedures

Mealtime Observations: Nurses who conducted the observations of the patients followed a standardized protocol which included precise definitions and directions for rating each of the six items included on the EBS tool. Meals were presented to the patients on the tray as delivered by the nutrition department. The tray covers were removed and the utensils were removed from the plastic wrap by the staff. Eating observations took place at the dining table in the day room with observers present at the meal. Subjects were observed by two nurse researchers during mealtimes for the purpose of obtaining interrater reliability assessments.

Neuropsychological Testing: Patients participating in this study also underwent a battery of standardized neuropsychological tests that measured cognitive functioning. Since dementia affects widespread areas of the brain, it is necessary to use a variety of tests to provide a composite score of cognitive functioning. This testing, which was conducted by the Laboratory of Neurosciences (LNS) of the NIA, consisted of 8-10 hours which was conducted in increments of one hour or less. Although a wide range of neuropsychological tests were administered, the tests discussed in this article are limited to the Mini Mental Status Exam (MMSE), the Mattis Dementia Scale (MDS) and the Raven's Colored Progressive Matrices.

The MMSE is a short 5-10 minute test used to detect major cognitive alterations. There are 30 items in this test which has been found to be particularly useful with more impaired subjects (Folstein, Folstein, & McHugh, 1975).

The MDS is a screening tool used to measure cognitive status in adults. It assesses the progression of behavioral, cognitive, and neuropathological decline. In the early stages of the disease, the test takes 15-20 minutes to administer. In the late stages, the test can take 45 minutes or longer (LaRue, 1992). The MDS is divided into five sub-tests; attention, initiation, construction, conceptualization, and memory. The sub-scales relate to eating as follows: Attention: the ability to focus on the task of eating, Initiation: the ability to start the meal, Construction: the ability to use utensils, Conceptualization: the ability to recognize that this was a meal and through abstract thinking, know the difference between a table and utensils, and Memory: the ability to know one has eaten a meal. A profile of cognitive strengths and weaknesses can be determined by comparing the five sections of the test in the MDS. The total score allows the tester to determine a global cognitive performance score. This particular test is especially helpful at the low end of the performance range. Scores of less than 130 (out of a total of 140) are considered mildly demented. It is useful in longitudinal studies of progressive dementing disorders and is considered the best measure of its kind (Mesulan, 1985).

The Raven Colored Progressive Matrices is a test of reasoning in patients who have trouble with verbal output; in other words, it does not require verbal responses, and is effective for testing patients with aphasia.

RESULTS OF THE RELIABILITY AND VAUDITY OF THE EBS

Reliability

Twenty-one paired observations were available for assessing interrater reliability. On those occasions, two nurses observed the same meal and independently rated the patient using the EBS tool. Percent agreement was computed for each item and exceeded 90% for all items. The average level of agreement was 95.9% (Table 2).

Table

TABLE 2Percent Agreement of Baters by EBS Tasks

TABLE 2

Percent Agreement of Baters by EBS Tasks

Validity

The content validity of the EBS was assessed by computing the index of content validity (CVI=LO). The ratings of two content experts were also used to compute the percent agreement (P0) which represents the consistency of the judges' rating of the relevancy of the items (P0=LOO). For the purposes of validity assessment, the total EBS score was also correlated with several patient characteristics. The EBS score correlated negatively with the length of the mealtime (r=-.66, p<.001) indicating that the longer the mealtime, the lower the EBS score. The EBS score also correlated with the shorter duration of illness since diagnosis (r=.468, p<.01). Patients with shorter duration of illness had higher EBS scores, thus indicating more independent eating behaviors. The EBS scores were unrelated to patient age (r=-.243, p=.106), education (r=- .190, p=.171), and gender (r=.050, p=.401).

The significant correlations identified between the EBS scores and the neuropsychological tests are reported in Table 3. The significant correlations between the EBS and the neuropsychological test results support the validity of this measurement tool.

DISCUSSION

Eating is a complex behavior that requires attention, initiation, conceptualization, visuospatial abilities, and planning. The complex deficits identified through the neuropsychological testing support the observations of mealtime difficulties in this sample of probable Alzheimer's using the EBS. The scores of the EBS and the subtests on the MDS were strongly correlated. Functional deficits in eating observed during mealtime were related to the areas of neuropsychological dysfunction identified in the battery of neuropsychological testing. This is consistent with the complex task of eating. Furthermore, problems in the neuropsychological tests were consistent with the observations and functional impairment exhibited during eating. Impairments in attention, construction, conceptualization and memory may adversely impact the patient's functional abilities to complete the task of eating.

Table

TABLE 3Correlation Coefficients Between EBS Scores and Neuropsychological Measures

TABLE 3

Correlation Coefficients Between EBS Scores and Neuropsychological Measures

One role of nursing is to assist patients to function at their maximum capacity, or to achieve maximum health potential in spite of their disability. In chronic illnesses like AD, nurses assist patients and their families to maintain or preserve optimal functional abilities. It has been the experience of these authors that families and caregivers of patients with AD exhibit frustration with the individual not being able to accomplish some "simple" tasks, like eating. It is believed that with the use of this tool, families will have a better understanding of the patient's strong points and areas where assistance is needed. This will allow the patients to maximize their strengths and receive help where needed. Use of the EBS can provide the family and caregiver with a realistic objective appraisal of the patient's current functional status. Appropriate interventions can then be implemented.

Communication is often cited as the primary problem related to feeding people with dementia. The person with dementia has difficulty interpreting the environmental cues and the feeder may have difficulty in interpreting behaviors as responses to the interaction. Education of the caregiver is essential to the desired outcome, which is to preserve the independence of persons with mild to moderate AD.

The environment plays an important role with confused and disoriented people. The organization, seating arrangement, decor, lighting, and unit management all have a positive effect on eating behavior. By decreasing the stimuli, making sure the room has adequate lighting, and having the patient sit in the same seat each meal, the mealtime may be less stressful for the Alzheimer's patient. Early in the disease process, patients usually exhibit only minor eating problems, thus their nutritional status is not usually compromised. However, the severely demented patient has many problems, such as forgetting to eat and difficulty differentiating food from non-food items. If interventions are used, the chronic weight loss of patients may be decreased. Patients should also be allowed food choices (Watson, 1989). Studies show that with these adjustments and a calm, homelike environment, the dietary intake of patients is increased. Nursing is in a pivotal position to have a key role in influencing the environment (Norberg & Athlin, 1989).

The EBS encompasses both cognitive and motor deficits and abilities apparent during eating. Thus, the EBS fills a gap between the motor skills-only measures, like Loewenstein and colleagues (1989), and the extensive neuropsychological testing. The EBS can provide caregivers a way of objectively evaluating the patient's capabilities at any given time. Future research directions could include measuring functional assessment in the other domains of ADLs such as bathing, dressing, and toileting. An easy-touse instrument could offer care providers a practical method by which to identify tasks and assess levels of assistance needed to maximize the individual's functional abilities and to maintain his highest level of independence.

CONCLUSION

The EBS is a quick, simple, and inexpensive measure of functional assessment. The relationship of the EBS and neuropsychological tests lend support to the validity of the EBS tool. Health care providers may be able to use the tool in settings where neuropsychological testing is not feasible. Findings from this study demonstrated that patients with mild cognitive impairments have less difficulty eating and conversely, those with significant impairment have greater difficulty managing the complex sequencing involved in the task of eating.

IMPLICATIONS

The EBS can be easily used by nurses to assess the functional abilities of patients during the activity of eating. Nurses can utilize the EBS scores to assist caregivers in objectively identifying functional eating skills that may require assistance. The accurate assessment of functional abilities and deficits related to eating may significantly impact upon caregiving strategies for patients with Alzheimer's disease. Because the EBS tool is simple, needing only paper, pencil and observation, it can be used at home by a home health aide, a family caregiver, in nursing homes, group homes, assisted living situations and in day care settings.

REFERENCES

  • American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (Third Edition, Revised). Washington, D.C.: American Psychiatric Association.
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  • United States Department of Health and Human Services. (1994). Alzheimer's disease and related dementias: Legal issues in care and treatment. A report to congress of the advisory panel on AD. Washington, D.C.: Author.
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  • Watson, R. (1989). Making a meal of it. Nursing Elder, 1(3), 14.

FIGURE

National Institutes of Health Warren G. Magnuson Clinical Center Nursing Department

Eating Behavior Scale (EBS)

TABLE 1

Sample Demographics

TABLE 2

Percent Agreement of Baters by EBS Tasks

TABLE 3

Correlation Coefficients Between EBS Scores and Neuropsychological Measures

10.3928/0098-9134-19970701-08

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