Nutrition screening and counseling are key tools in health promotion for older adult women. While standard nutrition screening has been described (Nutrition Screening Initiative, 1991), less attention has been paid to strategies for counseling older adults when identified problems include meal management. Grocery stores and meal preparation can be foreboding; congregate meal sites may or may not be appropriate; and homedelivered meal programs have been described by some older adults as a "sign of weakness." Early recognition and intervention with problems of meal management and nutrition can impact older adults' quality of life from both physical and psychosocial perspectives. Meal management strategies for some clients may make the difference between living at home or in an institutional setting. This qualitative research study investigated and described older adult women's perceived challenges and strategies for meal management. Meal management is considered to include preparing meals or making alternate meal arrangements.
OLDER WOMEN'S NUTRITIONAL HEALTH AND FUNCTIONAL STATUS
It is well described that older women living by themselves constitute the greatest percentage of the older population and are the most at risk for health problems (Task Force on Older Women's Health, 1993). Results from studies of older adults' nutritional status have varied, but agreement exists that dietary deficiencies are not uncommon (Ahmed, 1992; Ryan, Crang, & Finn,1992; Wilson & Kaiser, 1995). A particular concern exists for decreased nutritional reserve capacity that comes with aging, particularly advanced age and age-dependent disease (Lipschitz, 1995). Galanos, Pieper, CornoniHuntley, Bales, and Fillenbaum (1994) found a relationship between nutritional well-being and older adults' ability to perform activities of daily living. Protein energy malnutrition was found to predict future complications in older adults' hospitalizations (Sullivan & Walls, 1994). Nutritional issues are no longer considered minor contributions to health of older adults, but factors that make major contributions to quality of life (Mason, 1997).
Disability rises steeply with age. One estimate of disability for individuals age 80 and older (based on self-report) included 30% dependent in shopping and 18% dependent in preparing meals (Guralnik & Simonsick, 1993). This would seem to be an underestimate of actual meal preparation because there are many interpretations of what older adults meant by preparing a meal (e.g., bowl of cereal versus hot lunchtime meal). There also is an important difference between the ability to prepare meals and actually doing so. Mowe and Bohmer (1996) found difficulties in shopping and cooking were common in an older adult population the last month before hospital admission. No studies were found that addressed the actual preparing of meals or making meal arrangements.
NUTRITIONAL SCREENING AND RESOURCES
Professionals do not identify and treat consistently nutrition problems of older adults (Morley, 1991). The Nutrition Screening Initiative (1991) attempted to address this deficiency through the development of screening tools to identify older adults at risk for poor nutrition. Numerous risk factors identified to detect poor nutrition included:
* Advanced age.
* Inappropriate food intake.
* Social isolation.
* Acute or chronic diseases.
* Cognitive or emotional impairment.
* Oral health problems.
* Sensory impairment.
* Chronic medication use.
Healthy People 2000, Summary Report (VSOHHS PHS, 1991) seeks to increase the number of primary care providers monitoring nutritional parameters and counseling or referring appropriate clients.
Social services for nutrition support have been described as overlooked, misunderstood, and underused resources for assisting older adults in acquiring, preparing, and eating an appropriate diet (Moyer, 1994). Core programs of food stamps, congregate meals, homedelivered meals, and other resources available to support older adults' nutrition needs have been described, but study has found these services may not be used when needed. Burt (1993) found only one third of those older adults classified as "food insecure" used the core nutritional programs. Suggested reasons for this included not knowing about, not being comfortable attending, or lacking programs in specific geographic areas. Others may not have met eligibility guidelines for specific programs, perhaps did not receive appropriate referrals, or may have been on waiting lists. A Healthy People 2000, Summary Report objective aspires to increase home food services to older adults who need these services (USDHHS PHS, 1991).
Many studies of older adults' nutritional issues have grouped individuals age 65 and older, which fails to consider the major physiological differences that can exist for the older old. Even the broader "caregiving" studies, with relevance to older adults' support needs, have been described primarily from the professional and family caregiver perspectives. Understanding issues and concerns relevant to meal management from older adults' perspectives can help better identify appropriate interventions. This study was guided by the research question, "What are older adult women's perceived challenges to meal management and their approaches for preparing meals or making alternate meal arrangements?"
Standard qualitative research procedures were used for this study. They included purposive sampling, indepth interviews, participant observation, and constant comparative data analysis.
Fifteen older adult women (age 80 and older) were recruited from a government-subsidized apartment building in a midwestern United States community. Purposive sampling strategies (Miles & Huberman, 1994) allowed opportunity to access participants with diverse orientations. Participants' ages ranged from 80 to 96 (median age = 86), with representation from the following groups: 80 to 84 (5), 85 to 89 (5), 90 and older (5). Fourteen women were White, and one woman was Black. Women had a range of chronic health problems and functional abilities, with meal activities varying from actively fixing meals to using Meals on Wheels almost exclusively. Several had paid helpers for a few hours a week. Family support ranged from those participants with consistent weekly or more often visits to those with a yearly visit from a niece or nephew. The apartment building staff consisted of a building manager, an older adult serving as the manager's assistant, and a maintenance worker.
Participants were interviewed twice in their homes using a semistructured interview guide generated from a literature review, Kane's (1985) model of functional assessment, and professional experiences. Broad questions were used to initiate the interviews, with sample items including: "What is a typical mealtime like for you?" and "What is it like for you to get groceries?" As appropriate for the constant comparative method, new questions were generated as themes emerged. Participant observation included observing the home setting and making simple estimates of participants* functional abilities. Basic nutritional status data were collected using the Nutritional Screening Instrument, Level I (Nutritional Screening Initiative, 1992).
Data collection and analysis were ongoing which is consistent with the constant comparative method (Glaser & Strauss, 1966). Codes were organized into major categories, and tentative links were identified (Wilson, 1989). Reliability and validity for this qualitative study were supported by methods summarized by Miles and Huberman (1994) including confirmability (audit trail); dependability (coding checks with research assistant, colleague review); credibility (triangulation among methods, informant checks, and feedback to participants); and transferability (characteristics of sample and setting fully described).
RESULTS AND DISCUSSION
The organizing framework, Meal Management Transitions, emerged from the data to clarify a range of older women's experiences with meal management. Some type of meal management transition was described by all women. The sample quotes in Table 1 demonstrate the extent of these transitions.
Schumacher and Meleis (1994) described transitions as consisting of process, direction, and change in fundamental life patterns. Transitions can be chronic and gradual as is likely seen with health problems such as arthritis or chronic lung disease. Transitions also can be acute and rapid such as those necessitated by hip fracture or stroke. Numerous factors influence transitions including: expectations about transitions; personal meanings of transitions; knowledge and skill levels; planning or lack of planning for transitions; environmental factors; and emotional and physical well-being. Study participants implied similar issues in their meal management transitions.
Five broad categories of transitions were evident in the older women's meal management. These included:
* Shopping plans.
* Cooking strategies.
* Helper status.
* Appetite issues.
* Mealtime companionship.
Incorporated throughout the women's discussions were their practical resources to assist in meal management transitions. Discussion of these categories follows.
A range of strategies for obtaining groceries, including the transportation component and actual shopping process, was described in this category. Some women continued to enjoy grocery shopping, which almost could be considered "recreational shopping." Others saw shopping as a task that needed to be accomplished, while several had not been to the grocery store for more than 1 year. Representative comments included:
* It's fun to grocery shop, to see what they have got new [sic]. I take a friend; we go for lunch, then get groceries, then stop for ice cream.
* I always go to the grocery store myself. So far I'm able to drive but I'm not supposed to lift or bend down.
* My working girl, I send her to the store with my list. [This participant had not been to the grocery store in more than 12 months.]
SAMPLE TRANSITIONS DESCRIBED BY STUDY PARTICIPANTS
Participants' practical advice relevant to grocery shopping included: avoid shopping when there is ice and snow outside; purchase heavy items when a helper is with you; map out the store to minimize walking; shop where there are benches to rest; ask others to purchase a few items for you; and if necessary, use the "grocery van." Strategies for using the grocery van, a community-based service offering rides to the grocery store one afternoon per week, were also shared. These strategies included shop quickly and have two grocery lists in case you run out of time (e.g., one list for necessities, one list for luxury items). Some participants found using the grocery van too exhausting and would instead pay helpers to buy groceries for them. Those using a helper to purchase groceries kept detailed grocery lists, which included the sizes of items because helpers often bought items that were too big, or saved labels and jars to demonstrate desired grocery items.
Few studies in the literature discuss older women's grocery shopping strategies. The various processes described by these women indicate numerous factors are considered in planning and obtaining groceries. The simple yes or no or 4point response options often used on functional assessment tools to address grocery shopping ability do not capture the complexity and major strategies involved. Health providers and family members can be alert to the complexity of this task and be proactive in suggesting strategies to make shopping easier.
Various approaches to fixing meals were described in this category. Some women still cooked because they enjoyed it, it kept them busy, and they liked to share. Others wanted to cook but had to make modifications because of pain or weakness. For others cooking was very difficult and done only when Meals on Wheels did not deliver. Their approaches to cooking are exemplified in the following statements:
* My family likes desserts, so I get to bake.
* Standing hurts, so I fix the least I can. I think ahead to a meal that will be the least hassle.
* There is one little burner I use in the front [of the stove]. That takes care of my needs. I'm not too scared of it.
Practical advice from participants focused on strategies to make cooking easier, such as fixing extra food and freezing packets to reheat. Frozen vegetables were a popular item because they did not need to be cut up, they did not spoil, and a can did not have to be opened. Microwave ovens were a convenience for many but were described as a "poor substitute for cooking" by others. One woman described concurrent use of microwave, broiler, and oven to speed meal preparations.
A functional environment for meal preparation was described as important. One participant creatively filled a small space with a narrow ironing board as a handy place to sit and prepare food.
Others discarded extra tools to avoid clutter and displayed commonly used cooking equipment. Safety issues also were addressed by the women with particular concerns regarding low-lying electrical outlets and low cupboards. One participant noted, "getting down is easy, getting up is not."
Consistent with the literature, environmental characteristics influenced functional ability (Dunn, Brown, & McGuigan, 1994; Lawton, 1983). Assisting older adults to individualize their kitchens with attention to safety and function for their preferred cooking style is an initial approach to supporting older women's cooking abilities.
Considerations regarding food appeal and actual food intake were included in this category. Many women described their eating patterns as changing with advancing age. The most typical responses regarding appetites involved a change from previous meal enjoyment to an "it is necessary to eat" approach. The tendency to have a very light meal or snack later in the day was described by many participants. Responses ranged from continuing to enjoy meals to complete lack of interest in eating. Eating, for the most frail women, was a chore. Representative comments suggesting the range of appetite issues were:
* I'm lucky to have my appetite.
* Well, I don't get hungry, but when the clock says it is time to eat, I eat.
* I'm not much of a breakfast eater...but I have to take a pill in the morning and I have to have some food so the pill will agree with me.
Practical advice for those with appetite problems included using reminder cues such as eating with a certain television program, keeping favorite prepackaged foods handy, and making oneself eat. While several commented on using Meals on Wheels as their primary source of food each day (one woman left the tray on a counter and ate snacks from it throughout the day), it is noted that in most cases homedelivered meals are designed to be only a percentage of required daily nutritional intake.
While food preferences and eating behaviors have been described as part of one's social identity and self-identity through life (Hendricks, Calasanti, & Turner, 1988), eating patterns tend to change with advanced age (Davis, Murphy, & Neuhaus, 1988). A physiological anorexia of aging has been described by Morley and Morley (1996). While some participants made adequate food choices related to convenience and pleasure, others had obvious deficits in caloric and nutritional intake. Appropriate assessment for additional factors, such as medications affecting appetite or dental problems that may influence nutritional intake, is warranted (Nutrition Screening Initiative, 1991). Particularly for those at risk, the importance of families and health care providers asking more detailed questions than simply "Are you eating?" is clear.
Activities described within this category varied from providing help with meal preparations to receiving help with meal preparations. Some women described enjoying the opportunity to help others, while some described becoming tired of their previous helper role. Several participants commented on apartment neighbors' needs for help but felt the neighbors' problems were too difficult. The most frail participants described their need to obtain help and the strategies they used. Sample comments within this category included:
* I pick up groceries for others when I go out.
* I'm the one on this floor who usually fixes the chili for the soup lunch, but it is somebody else's turn [regarding tiring easily].
* I used to worry about calling my sister for help but now I have figured out she is in the height of her glory when she is helping [regarding receiving help].
While some still enjoyed helping and its accompanying benefits, the more intense discussion was from those who needed to seek help and their frustrations with helpers. Participants' frustrations with helpers included:
* When 70-year-old children were sick or went on long vacations.
* When 65-year-old paid helpers retired.
* When children were too busy to help or moved out of town.
* When neighbors who had previously assisted them became old and frail themselves.
* When paid helpers did not always do things the way the women liked.
Participants described that even when they have helpers there still are many issues regarding the helpers' effectiveness.
The difficulty and frustration of transition to a "helpee" role was obvious. Many women were without close family (e.g., "my family is a nephew who lives 3 hours away"). The building manager noted, "It's the ones without families that we really need to worry about." Worry about being a burden on friends and family was common. One participant said, "If you ask them to get some groceries for you, don't load them down too much." Practical strategies for finding help included: be nice to others; avoid being a burden; only call family when help really is needed; and ask friends for ideas regarding getting paid help.
An issue which is not well addressed in the literature is the process of adjusting to the helpee role or learning how to obtain help when it is needed. Conn, Taylor, and Messina (1995) described the lack of study of this transition for both dependent older adults and caregivers. Uhlenberg (1996) noted access to care includes not only objective factors such as having someone to call on and resources to do so but also knowledge of how to access care or even knowing care sources are available. Educating older adults and families regarding "helper resources" within a community as well as assessing the effectiveness of these resources can be important nursing roles.
Companionship issues (including companionship frequency) and social outings associated with mealtimes were included in this category. The majority of participants had mealtime company fewer than two times per month. While some continued to enjoy social outings and companionship, others felt the discomfort and hassles experienced with outings were not worth the effort. Participant activities ranged from regular mealtime outings to rarely venturing past their apartment doors (e.g., for a rare doctor visit). Sample items included:
* The kids usually come by and take me out on Sundays. We go to church and then get a big breakfast and then I'm through for the day. I'm going to go as long as I can.
* It is so hard for me to go and get in to the car and go down there to a restaurant and have to get out. It is hard on my daughter too.
* I used to go to the potluck dinners (in the building), but there is too much confusion, and then to try to eat yet.
A surprising finding was the lack of meal sharing and mealtime companionship with apartment neighbors on a regular basis. "We don't do it that way here [share meals], people want their space," was a representative response. One participant commented that a neighbor "drives me buggy" by coming to visit all the time. Rather than seeing close neighbors as a chance for frequent companionship, participants seemed to have concerns about losing their privacy and having neighbors become too dependent.
Participants' practical tips for outings included: "take pain pills prior to the trip" and "inquire about stairs." For those who desired more outings, some women scheduled doctor's appointments around mealtimes to encourage family helpers to eat with them. Those who wanted more company but were not able to entertain, recommended inviting family or friends to "snack" parties, rather than meals. One older woman had a paid helper who fixed and ate breakfast with her after the helper completed her night shift work at a hospital.
Findings were consistent with the Davis et al. (1988) study of older women in which participants' numbers of meals away from home declined with increasing age. Findings also were consistent with Porter's (1994) qualitative study and discussion of geographic restrictions women placed on themselves when they became increasingly frail. There is agreement in the literature on the relationship between social companionship and improved eating behaviors (Nutrition Screening Initiative, 1992).
Preparing meals and making alternate meal arrangements are complex activities and can be difficult with increasing frailty. This creates problems older adults likely are not anxious to share or families are not anxious to see. Study data support that meal management transitions are important topics to consider when assessing older adults' nutritional health and function. The categories of Shopping Plans, Cooking Strategies, Appetite Issues, Helper Status, and Mealtime Companionship provide beginning direction for nurses to assist families and older adults to cope with meal management transitions.
Families may be able to assist older adults by watching for beginning problems in meal management. Health care providers in primary care clinics, discharge planning, and home care settings also are logical people to screen for meal management problems. Asking and helping families address basic questions related to function, such as "What interferes with or prevents a quality mealtime ?" and "What can be done to make mealtime better?" are beginning steps. The concept of anticipatory coping, defined as acknowledging and planning for changes, has been described as a concept to consider for older adults (Moneyham & Scott, 1995). It may be that just as anticipatory coping guidelines have been developed to guide young families in coping with predictable family stresses, guidelines for assisting families in assessing and monitoring older adults' meal management status could be developed. A list of topics generated from study participants' comments and practical considerations is suggested to begin discussions with families and older adults (Table 2).
SUGGESTED CONSIDERATIONS FOR FAMILIES AND OLDER ADULTS WITH MEAL MANAGEMENT CONCERNS
Health care workers can provide families and older adults with educational materials about community resources including congregate meals, commodities programs, grocery vans, Meals on Wheels, and other meal management resources such as those compiled by the Nutrition Screening Initiative (1992). Addressing adequate monitoring mechanisms for those older adults with limited family support also is important. Wilson and Kaiser (1995) noted that improving the nutritional status of older adult women goes beyond client-physician interactions to include public awareness, health education programs, and attention to older women's functional Hmitations with more programs to assist with these obstacles.
Education of health care professionals and assistants concerning meal management screening and intervention opportunities also should be beneficial. A brief review of health care providers' texts suggests functional interventions for promoting meal management often are not addressed. While these texts document the importance of good nutrition for frail older adults, they often neglect the functional issues important for adequate meal management. Further research pertinent to meal management is needed including questions such as "How do families know when it is time to assist with meal management?" and "What are the best strategies for assisting with meal management?" Rappaport and Peters (1988) noted, as with most issues concerning older adults, nutrition and meal management need further study from a biopsychosocial framework.
Poor nutrition has been described as a modifiable risk factor. Lipschitz (1995) noted the main approach to nutritional intervention is to identify and treat the underlying cause that leads to a nutritional problem. Meal management problems, as possible causes of poor nutrition, need further attention and provide opportunities for intervention. Successful meal management strategies are critical for older women to live independently and maintain nutritional status. Identifying appropriate meal management interventions can impact older women's health and quality of life.
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SAMPLE TRANSITIONS DESCRIBED BY STUDY PARTICIPANTS
SUGGESTED CONSIDERATIONS FOR FAMILIES AND OLDER ADULTS WITH MEAL MANAGEMENT CONCERNS