Evidence-Based Practices for the Prevention of Weight Loss in Nursing Home Residents

Definitions

Although unintentional weight loss is a well-known geriatric syndrome in frail older adults, especially nursing home residents, it may be caused by several different etiologies. Three common problems resulting in weight loss include starvation (or wasting), cachexia, and sarcopenia (Morley, Thomas, & Wilson, 2006; Roubenoff, Heymsfield, Kehayias, Cannon, & Rosenberg, 1997). All three problems may be referred to as malnutrition, which creates difficulty with accurate descriptions and treatment of the syndrome. The term malnutrition suggests that the disease is due to nutritional deficiencies and implies that adequate nutrition is the treatment (Lainscak, Filippatos, Gheorghiade, Fonarow, & Anker, 2008), yet this is not always the case.

According to Alibhai, Greenwood, and Payette (2005), unintentional weight loss is the involuntary decline in weight over time. Unintentional weight loss occurs in 27% of frail adults 65 and older (Payette, Coulombe, Boutier, & Gray-Donald, 2000). It may reflect an undiagnosed disease or disease severity. The first priority of managing unintentional weight loss with older adults is to identify and treat the underlying cause. Unintentional weight loss among this population can be associated with adverse health outcomes, increased mortality, and progressive disability if left untreated (Alibhai et al., 2005).

The direct result of calorie deprivation is known as starvation or wasting. Individuals with starvation typically lose more fat tissue than muscle tissue (Morley et al., 2006). Clinical examples of starvation may include a critical illness without adequate nutritional support, advanced AIDS, end-stage renal disease, end-stage liver disease, and marasmus (Roubenoff et al., 1997).

More than 5 million people in the United States are affected by cachexia (Morley et al., 2006). Cachexia is known for its process of weight loss, including excessive weight loss over a defined period of time, usually with pathologic muscle wasting (Lainscak et al., 2008; von Haehling, Doehner, & Anker, 2007). Common clinical examples of cachexia include critical illness with adequate nutritional support, congestive heart failure, liver disease, early renal failure, rheumatoid arthritis, HIV infection without opportunistic infection, and kwashiorkor (Roubenoff et al., 1997). Kwashiorkor is also known as protein-calorie or protein-energy malnutrition.

Sarcopenia is defined as weight loss occurring during normal aging causing a progressive decline in muscle mass and strength (Morley et al., 2006; Visvanathan, 2003). While sarcopenia is commonly found in advanced age, it may also be found with high-dose corticosteroid therapy, disuse syndromes, and weightlessness (Roubenoff et al., 1997).

Pathophysiology

As is evident in the definitions of different types of weight loss, pathophysiology appears to differ between these types of weight loss and different disease processes. Current theory regarding the pathophysiology of weight loss is presented, although research-based evidence remains unclear for most types of weight loss.

With starvation, a decline in body cell mass and a decline in weight occur together. Anorexia is common. Starvation is associated with poor dietary intake (Roubenoff et al., 1997). While there is a paucity of research literature on starvation in nursing home residents and it is possible these individuals could also have other types of weight loss, medical issues that could cause starvation might include dementia and depression. In individuals with dementia, both dependency and decreased appetite may result in an increased risk of weight loss (Knoops et al., 2005). Up to 67% of nursing home residents (Kerber, Dyck, Culp, & Buckwalter, 2005) may be depressed, and individuals with depression are more likely to experience weight loss (Blaum, Fries, & Fiatarone, 1995; Morley & Kraenzle, 1994; Morley & Silver, 1995). Starvation can be treated by increased caloric intake (Roubenoff et al., 1997).

Cachexia, defined as excessive weight loss with pathologic muscle wasting, is a major cause of increased mortality. The process of weight loss with cachexia is significant and includes a defined degree of weight loss over a defined course of time (von Haehling et al., 2007). Cachexia occurs secondary to chronic diseases, such as congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease (Lainscak et al., 2008), and cancer (Esper & Harb, 2005).

In cardiac cachexia, a suggested definition includes non-edematous weight loss of greater than 6% over a 6-month period (Anker et al., 2003). An acute inflammatory response caused by injury or immune system activation causes excess cytokine development. This inflammatory process plays a role in cardiac cachexia (Morley et al., 2006). The pathophysiology of cachexia involves complex mechanisms mediated by circulating catabolic factors such as tumor necrosis factor, interleukin-1, and interleukin-6 (Esper & Harb, 2005). It is suggested that the cytokines play a major role in the etiology of weight loss by activating a nuclear transcription factor, which results in decreased muscle protein synthesis and reduces a transcription factor that is involved in muscle development (Morley et al., 2006). Angiotensin-converting enzyme inhibitors (e.g., enalapril [Renitec^®, Vasotec^®]) reduce the weight loss and improve the outcomes for cardiac cachexia (Anker et al., 2003; Morley et al., 2006).

Cachexic weight loss in individuals with COPD is related to an imbalance between energy expenditures and caloric intake (Schols, 2003). Associated symptoms include muscle weakness, diaphragmatic dysfunction, respiratory failure, poor quality of life, and death (Farber & Mannix, 2000; Morley et al., 2006; Mostert, Goris, Weling-Scheepers, Wouters, & Schols, 2000; Schols, Slangen, Volovics, & Wouters, 1998). Positive outcomes of increased appetite, weight gain, stimulated ventilation, and improved body image were found with treatment of megestrol acetate (Megace^®), a cytokine antagonist (Weisberg et al., 2002).

Both starvation and cachexia occur in individuals with chronic renal failure. The cause of starvation is primarily due to poor energy intake and can be corrected with nutritional support and adequate dialysis. Systemic inflammation, enhanced proteolysis, and excessive oxidative stress occur with cachexia (Kalantar-Zadeh et al., 2005). Treatment to reduce cachexic weight loss in chronic renal failure includes dialysis, cytokine antagonists (e.g., nonsteroidal anti-inflammatory drugs, statins), erythropoietin, and nutritional support (Morley et al., 2006). Use of this treatment plan has shown increased weight, increased energy, and prolonged survival (Lundholm, Daneryd, Bosaeus, Körner, & Lindholm, 2004; Morley et al., 2006).

Cachexia is found in 50% of cancer patients and causes a high rate of mortality (Tisdale, 2009). Cancer cachexia is a complex metabolic disorder causing changes in metabolism related to interactions between the host and the tumor (MacDonald, Easson, Mazurak, Dunn, & Baracos, 2003). Although there is a multifactorial etiology for cancer cachexia, the origin probably includes a decrease in the availability of nutrients and an increase in nutritional demand, most likely related to metabolic and pathophysiological changes. As in other forms of cachexia, cytokines causing inflammation similar to infection and injury are thought to be a main mediator of this weight loss process (Esper & Harb, 2005). Other causes may include changes in gastrointestinal functional abilities, toxicities related to treatment, and psychosocial factors (Holmes, 2009). Treatment of cancer cachexia currently includes agents affecting both appetite and cachectic mediators (i.e., cytokine antagonist agents). Appetite-stimulating agents usually do not result in weight gain; however, improvement in quality of life may occur through increased appetite and mood (Tisdale, 2009).

The pathophysiology of sarcopenia has not been well discussed in the literature until recently. Sarcopenia is a multifaceted process associated with an increasingly sedentary lifestyle and poor nutrient consumption (Paddon-Jones, Short, Campbell, Volpi, & Wolfe, 2008) coupled with nervous system changes, hormonal changes, and inflammatory effects (T.E. Jones et al., 2009). Advanced sarcopenia includes physical frailty, increased risk of falling, and decreased ability to perform activities of daily living. Skeletal muscle mass begins to decrease around age 40 due to changes in physical activity and increases in fat body mass and may remain asymptomatic until a traumatic injury occurs. When injury occurs, there is an acceleration in the loss of skeletal muscle mass and a significant decline in functional abilities (Kortebein, Ferrando, Lombeida, Wolfe, & Evans, 2007). Chronic muscle loss affects an estimated 50% or more individuals older than 80 (Baumgartner et al., 1998), causing significant disability and health care expenditures (Janssen, Shepard, Katzmarzyk, & Roubenoff, 2004). Evidence-based treatment for sarcopenia includes resistance training to maintain strength and function in older adults (Hasten, Pak-Loduca, Obert, & Yarasheski, 2000; Snijders, Verdijk, & van Loon, 2009).

A second prong of treatment for sarcopenia includes daily protein ingestion or an increase in the volume and/or quality of protein ingested (Paddon-Jones et al., 2008). The Recommended Dietary Allowance for protein may not be sufficient to maintain the metabolic and physiologic needs of older adults (Campbell, Trappe, Wolfe, & Evans, 2001; Paddon-Jones et al., 2008). Research has shown that 113 grams (4 ounces) of meat per meal contains sufficient amino acids to increase protein synthesis in both young and older adults (Symons et al., 2007). Protein needs will vary from patient to patient, but at least two servings of meat per day in addition to other protein sources (e.g., milk, cottage cheese) would be sufficient. Other treatments for sarcopenia that are being studied include pharmacological treatments with hormones, over-the-counter supplements, and a protein that regulates muscle growth (T.E. Jones et al., 2009).

The geriatric syndrome of weight loss may appear as any of the three types (i.e., starvation [wasting], cachexia, sarcopenia). In addition, an older adult may have more than one type of weight loss or may progress from one type of weight loss to two or more. This unintentional weight loss becomes significant over time. When a weight loss of 4% to 5% or more occurs within a 1-year period or a 10% or more weight loss occurs over 5 to 10 years, there is an increased risk of mortality (Alibhai et al., 2005). Each type needs to be addressed in the treatment and management of unintentional weight loss.

Etiologies

In developing countries, weight loss typically occurs due to food shortages. While nursing homes provide adequate and proper diets, the etiology of weight loss for nursing home residents is often multifactorial. Complex, individualized eating behaviors are determined by physiological, pathological, and psychological factors. These behaviors are also affected by lifelong practices and preferences (Amella, Grant, & Mulloy, 2008). Changes in these eating behaviors may occur with changes in any of the aforementioned factors, including a change in environment.

Residents’ food intake is often inadequate (Abbasi & Rudman, 1994). Changes with age, including taste, smell, and appetite, may affect food intake. Medications, such as digitalis and psychotropic agents, may cause anorexia (Morley & Silver, 1995). Gastrointestinal irritation may occur with other drugs, such as aspirin (e.g., Bayer^®), erythromycin (e.g., E-Mycin^®), and ibuprofen (e.g., Motrin^®) (Morley & Silver, 1995). Aging is associated with increased concentration of tumor necrosis factor, interleukin-1, and interleukin-6. Data suggest that a reduction in energy intake with aging is related to the increase in the satiating effect of cholecystokinin in older adults. The use of cytokine antagonism is suggested as a therapeutic option to stop weight loss (Morley et al., 2006).

In the nursing home, the prevalence of cognitive impairments among residents ranges from 39% to 75% (Magaziner et al., 2000; Magaziner, Zimmerman, Fox, & Burns, 1998; Paquay et al., 2007). Individuals with cognitive impairments often have difficulty feeding themselves (Lou, Dai, Huang, & Yu, 2007). These feeding problems are frequently related to communication issues that occur during mealtime as the caregiver has difficulty interpreting the resident’s behavior and wishes (Athlin, Norberg, & Asplund, 1990). In later stages of dementia, individuals may have difficulty identifying food and silverware and understanding their purposes (Mamhidir, Karlsson, Norberg, & Kihlgren, 2007).

However, research by Barrett-Connor, Edelstein, Corey-Blom, and Wiederholt (1996) suggests that weight loss precedes dementia. A 20-year study of 299 older community-dwelling men and women reported that weight loss is common in dementia but not necessarily a precursor. The cause-and-effect relationship of poor cognitive status as a risk factor for poor nutrition or that poor nutrition leads to cognitive impairment is unclear. Nonetheless, this study provides evidence that weight loss precedes dementia and is likely not a consequence of demented patients’ refusal of food or being unable to eat independently. Thus, weight status for all nursing home residents needs to be continuously monitored to prevent significant losses.

Older adults often have dental and oral health issues, which contribute to inadequate nutrient intake. The oral health factors most associated with malnutrition in individuals who were edentulous included wearing dentures with defective bases or not wearing dentures at all. In those with teeth, the factors included the number of occluding pairs of teeth (i.e., five or fewer), the number of retained roots (i.e., four or more), and the presence of mobile teeth. These factors were found more frequently in individuals who were dependent than those who were semi-dependent (Mojon, Budtz-Jørgensen, & Rapin, 1999). In addition, the ability to eat certain foods was related to the presence, number, and distribution of natural teeth in older adults. As a result, there were lower nutrient intakes (Sheiham & Steele, 2001), significantly lower BMI and serum albumin concentrations (Mojon et al., 1999; Sheiham & Steele, 2001), and lower plasma ascorbate and retinol levels in individuals with fewer natural teeth (Sheiham & Steele, 2001). Sustained chewing ability is an important factor in maintaining or regaining nutritional status for older adults (Suzuki et al., 2005).

Dysphagia is a major health issue for nursing home residents: 25% to 60% of residents have difficulty swallowing (Kayser-Jones & Pengilly, 1999; Kumlien & Axelsson, 2002; C.M. Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997). Numerous conditions contribute to dysphagia including dementia, cerebrovascular accidents, Parkinson’s disease, neuromuscular disorders, postradiation effects, medications, or poor dentition. In one study, 55% of nursing home residents were identified to have dysphagia; however, only 22% were referred for a dysphagia evaluation (Kayser-Jones & Pengilly, 1999).

Organizational issues have also been found to affect weight loss in nursing home residents. Residents with cognitive difficulties, dysphagia, depression, and oral issues require individualized attention to ensure adequate food intake (Kayser-Jones & Schell, 1997; Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999). Residents who had at least 3 hours of certified nursing assistant (CNA) time per resident day had a 17% decreased probability of weight loss (Dyck, 2007). Total licensed and CNA staffing of 4.1 or more hours per resident day provided residents with better feeding assistance (Schnelle et al., 2004). In addition, the current Resource Utilization Group System (RUGS) likely underestimates the staff time needed to assist residents to improve their food intake (Simmons & Schnelle, 2006).

Anthropometric Assessment

Anthropometric measures are a primary feature of many general screening and assessment tools. Along with BMI, these include weight and weight change (Green & Watson, 2006). Research on the weight status of adults typically uses BMI as a measure (Sergi et al., 2005). BMI is calculated by dividing the weight of individuals in kilograms by the square root of their height (kg/m²) (Crouch & Meuier, 2005). The simple calculation of BMI renders itself as a useful screening tool to indicate nutritional status. BMI is a good predictor of morbidity and mortality among older adults (Miller et al., 2009). Additional anthropometric measurements could add supplementary information to nutrition assessment; however, BMI itself stands as a predictive measure of nutrition status (Whitlock et al., 2009).

Although measuring the ideal weight for older adults presents some controversy in the literature, most authorities in the field consider a BMI between 24 and 27 as a satisfactory weight for those 65 and older (Wellman, 1994). Older adults with a BMI between 22 and 30 for women and 23 and 30 for men have the lowest mortality rate and best functional ability (Martin, Kayser-Jones, Stotts, Porter, & Froehlicher, 2007). An indicator of major nutrition risk for older adults is a BMI between 19 to 23. Additionally, a BMI of 20 or less increases one’s risk for malnutrition, morbidity, and mortality (Crouch & Meurier, 2005). Interpretation of BMI with older adults should be more liberal than with younger adults. Older adults shrink over time, so their measured body height often is underestimated. Also, BMI is not related to the presence of diseases (Mathey, Siebelink, de Graaf, & Van Staveren, 2001). Nutrition risk is increased with unintentional weight loss, which is defined as a loss of 10 pounds (4.6 kg) in 6 months, 5% per month, or 1% to 2% per week (Wellman, 1994).

Nutritional Assessment

A comprehensive nutritional assessment can help nursing staff at long-term care facilities establish plans for feeding assistance and education to achieve adequate nutritional intake. During the nutritional assessment, data collected should include age, height, weight, BMI, recent weight loss, appetite, dietary intake, eating preferences, ability and/or difficulty chewing and swallowing, drug-nutrient interactions, and gut function (Ali, 2007). Through the comprehensive nutritional assessment and/or nutrition screening tools, the causative factors of any problem can be identified. Awareness of the nutrition risk should prompt appropriate therapy to prevent weight loss and subsequent malnutrition for the resident (Martin et al., 2007).

A wide variety of socioeconomic, psychological, and biological factors influence the nutritional status of older adults, which results in a large number of risk factors for malnutrition (Green & Watson, 2006). The wide range of risk factors is reflected in the varied pool of screening and assessment tools for long-term care residents. A systematic approach often used with screening tools is to assign a score to each category of the variables related to malnutrition and total the score to represent the risk of malnutrition; however, risk factors tend to influence nutritional status in varying degrees. After a review of 44 nutrition screening and assessment tools, J.M. Jones (2002) concluded that this approach prejudges the effect of each variable. The alternative approach is to weigh each variable’s effect on the risk of malnutrition using multivariate analysis to determine the risk factors that are the best predictors of malnutrition.

In J.M. Jones’ (2002) review of nutritional screening and assessment tools, only two tools were developed using the multivariate technique. One tool was the Nutrition Screening Equation (Elmore et al., 1994), which is completed on admission, and the other was the Nutrition Risk Assessment Tool (Ward et al., 1998). The Nutrition Risk Assessment Tool is designed to be used when reassessing patients regularly. Neither of these may be as widely used in practice as other screening and assessment tools due to issues of training and administration time for clinical staff. Green and Watson (2006) argued that it may be more useful to consider using a general screening or assessment tool with the older adult population for use within an interdisciplinary team. This would decrease the amount of training and clinical practice time used to complete the screening. General tools with nutritional components do exist and have been suggested to be valid.

The Mini Nutritional Assessment (MNA^®) is an extensively tested instrument that fulfills many criteria for both screening and diagnostic measures. It was developed for older adults and validated in a large representative sample. It works to identify individuals at nutritional risk and provide information for intervention planning, and no laboratory data are required (Garry & Vellas, 1999). The tool is complex, using anthropometric measures and subjective judgments, but is an accurate assessment tool for nutritional problems. The MNA takes approximately 10 to 15 minutes to administer, whereas geriatric assessments typically take less than 5 minutes. However, researchers sought to maintain the validity and usefulness of the original MNA as they developed the short-form version (MNA-SF) (Rubenstein, Harker, Salvà, Guigoz, & Vellas, 2001).

The MNA-SF has six questions instead of 18 and eliminates the subjective items while preserving the accuracy of the original MNA. The time for administration of the MNA-SF is approximately 3 minutes. Research found the MNA-SF to have high diagnostic accuracy relative to clinical nutritional status and high correlation with the full MNA (Rubenstein et al., 2001). Rubenstein et al. (2001) recommend using a two-step screening process with the MNA-SF. First, the MNA-SF should be administered to residents. For those identified as “at risk” by the MNA-SF, the full MNA should be administered to confirm the diagnosis and plan for the needed interventions.

The Council on Nutrition Appetite Questionnaire (CNAQ) includes 8 items scored on a 5-point Likert scale. Its 4-question derivative, the Simplified Nutritional Appetite Questionnaire (SNAQ), is a validated appetite assessment tool that predicts weight loss in nursing home residents (M.M. Wilson, 2007). A cross-sectional measurement study of the CNAQ and SNAQ found both to be adequate assessments of weight loss in nursing homes, but the 4-item SNAQ was clinically more efficient (M.-M.G. Wilson et al., 2005).

All nursing homes in the United States providing care to older adults with Medicare and/or Medicaid insurance coverage are required to use the Minimum Data Set (MDS) (U.S. Department of Health and Human Services, Health Care Financing Administration, 1989). The MDS is part of the Resident Assessment Instrument and provides a screening assessment at admission, quarterly, annually, and with any significant change of condition. A standardized nutritional assessment is included as part of the MDS and could be used as a tool to identify residents at high risk for nutritional problems. When a nutritional problem is identified, the interdisciplinary team can intervene to slow, prevent, or reverse the malnutrition. Assessment items on the MDS that have been found to be predictive of malnutrition include living alone prior to admission, psychiatric diagnosis, lost or missing teeth, difference in functional status from morning to evening, weight loss in the past 30 days, use of antidepressant and/or diuretic agents (Crogan & Corbett, 2002; Crogan & Pasvogel, 2003), end of life, male gender, planned weight change, 25% or more food uneaten at most meals, depression, swallowing problems, renal disorders, and diabetes mellitus (Dyck, 2007). Both Crogan’s and Dyck’s work show a significant relationship between malnutrition, functional status, and psychosocial well-being in nursing home residents.

Nursing home quality indicators (QIs) based on MDS data can be used on an individual resident or facility level. At the resident level, QIs represent either the presence or absence of a condition in a resident (Karon & Zimmerman, 1996). The definition of weight loss is a 5% or more weight loss in the past 30 days or 10% or more weight loss in the past 6 months (Brown, 2003). At the facility level, the QI is the aggregation of all resident scores for a QI at one facility. The prevalence of weight loss between nursing homes is shown by the QI on weight loss. QIs with a lower number are indicative of better quality of care and can provide useful feedback for nursing homes (Rantz et al., 1996).

Clinical nutrition status is more than Section K of the MDS, as nutrition is integrated throughout the overall process (Richardson, 2002). More than 60 MDS items can act as guidelines or triggers for nutrition and fluid status of residents. This type of assessment views the resident’s total picture and assists in the development of a precise and complete care plan.

Further assessment with physiological testing may also be completed. While there is a paucity of research on routine laboratory testing in the nursing home population, early research indicated that a modest panel of annual laboratory tests could benefit patients without excessive screening costs (Levinstein, Ouslander, Rubenstein, & Forsythe, 1987). Laboratory tests recommended as part of an annual physical examination and their rationales are listed in Table 1. In addition, upper gastrointestinal studies that may be useful in determining etiology of actual symptoms are noted in Table 2.

Table 1: Recommended Laboratory Tests as Part of an Annual Physical Examination

Table 2: Possible Upper Gastrointestinal Tests

Adequate Nutritional Intake

Supplements. The intake of nutritional supplements is a primary intervention when managing weight loss in the long-term care environment (Gosney, 2003). Varieties of supplements are available and provide residents with additional calories and protein. Supplements come as liquid drinks, powdered form to be added to food, and even as desserts. Nutritional supplements are meant to be added to meals or provided between meals for additional nutrient intake.

However, there is a lack of consensus about whether these supplements are effective in maintaining or improving nutritional status of long-term care residents. A systematic review of oral nutritional supplementation of older adults included 55 trials involving 9,187 participants. There was little evidence to suggest that longer-term supplementation was effective. Participants were often replacing their typical food with the supplement and not consuming the additional calories they needed to gain or maintain weight (Milne, Avenell, & Potter, 2006).

Another cause for the low consumption rate of supplements is that nutritional supplements are not consistently provided per a general order in the long-term care setting. A specific nutritional supplement order may increase the type of supplement offered to the resident at the designated times. It is important to have clear orders that work with the nursing staff’s schedule to ensure the supplements reach the particular residents at the necessary time of day (Whiteman, Ward, Simmons, Sarkisian, & Moore, 2008). Staff spend little time promoting supplements in the nursing home environment. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents (Simmons & Patel, 2006).

Food Fortification. Fortification of foods may be the most suitable way to increase the micronutrient intake of long-term care residents (Dunne & Dahl, 2007). Fortifying foods allows residents to consume more nutrients without having to increase the volume of food eaten. Although current research is minimal, fortification of foods appears to be capable of improving blood vitamin levels of older adults. Acceptance of the fortified food increases if the food tastes the same as the original food item (Dhonukshe-Rutten et al., 2005).

Aging is associated with an increase in taste and smell thresholds, which may decrease food consumption and likely contribute to negative changes in eating behavior. A study was conducted to determine if the addition of flavor enhancers to cooked meals for nursing home residents promoted food consumption. Four flavor powders (chicken, beef bouillon, turkey, and lemon butter [for fish]) enhanced the meals. The nature of the protein component of the meal determined the flavor enhancer that was used. Results of the intervention showed both an increase in dietary intake at meals and an increase in body weight after consumption of the flavor-enhanced meals during the 16-week study. Adding flavor enhancers to meals is a simple yet effective way to improve dietary intake and body weight in the nursing home population (Mathey et al., 2001).

Feeding Assistance

Improvements in the quality and adequacy of feeding assistance for mealtimes and snacks have been shown to improve long-term care residents’ daily caloric intake and promote weight gain. Consistent verbal prompting and social interactions with residents during meals occur in nursing homes with less resident weight loss (Simmons et al., 2003). Use of verbal prompting and social interactions to assist residents to eat better are learned skills. Often, nursing staff who provide the most care to residents undergo the least training. In many long-term care facilities, the caregivers assigned to provide feeding assistance lack feeding skills, are unable to identify resident feeding problems, and provide inadequate assistance (Simmons, Lim, & Schnelle, 2002). Feeding skills training programs have shown that nursing assistants can develop greater knowledge about feeding and more positive behaviors toward feeding patients (Chang, Wykle, & Madigan, 2006). With this increased knowledge, resident outcomes should be improved.

Faced with realities of increased time necessary for mealtime feeding assistance, many long-term care facilities welcome volunteers or family members to assist at mealtimes. The participation of volunteers has yielded positive nutritional and social outcomes for residents (Robinson et al., 2002). The role of volunteer-recipient relationships emerged as dominant in facilitating optimal mealtime assistance. Over time, the experiences and attitudes of the mealtime assistants evolved as a relationship developed between the volunteers and the residents. This evidence suggests that social relationships can enhance mealtime experiences for residents in long-term care facilities (J. Steele, Rivera, Bernick, & Mortensen, 2007). Unfortunately, feeding assistance requires much time from the nursing staff. Alternative staffing models may need to be implemented to increase the time spent on feeding assistance care (Simmons, 2007).

Wandering Residents

Nursing home residents with dementia are at increased risk for nutritional problems because of their decline in functional abilities critical to maintaining adequate nutrition and hydration, such as feeding themselves and communicating their needs effectively (Beattie & Algase, 2002). Wandering residents have high activity levels and often less time at the table, which can lead to weight loss (Beattie, Algase, & Song, 2004). Beattie and Algase (2002) suggested that residents who leave the table receive positive interpersonal social engagement with staff as they try to persuade the wanderer to sit back down and eat; such engagement may actually promote leaving the table at mealtime. As such, the authors created an intervention using the communication abilities of the residents to attempt to keep residents at the table.

Heron’s six-category intervention was used to structure verbal elements of the conversation during mealtime (Beattie & Algase, 2002). The three categories of prescriptive, informative, and supportive that were used in the intervention worked to increase table time for wandering residents. In the prescriptive category, the nurse would make suggestions and recommend behavior to the resident (e.g., “Hold your glass tightly when you lift it up.”). Using informative verbiage, the nurse gave the resident new knowledge or information (e.g., “This is your glass of milk.”). The supportive intervention category affirms the worth of and is supportive of the resident (e.g., “It’s great that you’ve drunk all your milk!”) (Beattie & Algase, 2002). Structured communication intervention with behavioral reinforcement can keep wandering residents at the table longer (Beattie et al., 2004).