Journal of Gerontological Nursing

Feature Article Supplemental Data

Resident and Staff Mealtime Actions and Energy Intake of Long-Term Care Residents With Cognitive Impairment: Analysis of the Making the Most of Mealtimes Study

Kelsey Mann, MSc; Christina O. Lengyel, PhD, RD; Susan E. Slaughter, PhD, RN, GNC(C); Natalie Carrier, PhD, RN; Heather Keller, PhD, RD, FDC, FCAHS

Abstract

Long-term care (LTC) residents with cognitive impairment (CI) are at increased risk of malnutrition, often explained by mealtime actions (e.g., resident eating challenges, staff actions with eating assistance). The purpose of the current study was to examine the association between mealtime actions and energy intake of LTC residents with CI. Participants with CI (N = 353) from 32 LTC in four provinces were included. Mealtime actions were assessed using the Relational Behavioural Scale, Edinburgh Feeding Evaluation in Dementia (Ed-FED), nine additional eating challenges, and the Mealtime Relational Care Checklist. Several eating challenges (e.g., refusal to eat, turning head away) were associated with poor energy intake. Adjusting for age and sex, partial eating assistance and total Ed-FED score were associated with poor intake, whereas dysphagia risk and often receiving assistance were associated with better intake. Interventions to support eating independence and address residents' eating challenges in LTC are needed to improve their intakes. [Journal of Gerontological Nursing, 45(8), 32–42.]

Abstract

Long-term care (LTC) residents with cognitive impairment (CI) are at increased risk of malnutrition, often explained by mealtime actions (e.g., resident eating challenges, staff actions with eating assistance). The purpose of the current study was to examine the association between mealtime actions and energy intake of LTC residents with CI. Participants with CI (N = 353) from 32 LTC in four provinces were included. Mealtime actions were assessed using the Relational Behavioural Scale, Edinburgh Feeding Evaluation in Dementia (Ed-FED), nine additional eating challenges, and the Mealtime Relational Care Checklist. Several eating challenges (e.g., refusal to eat, turning head away) were associated with poor energy intake. Adjusting for age and sex, partial eating assistance and total Ed-FED score were associated with poor intake, whereas dysphagia risk and often receiving assistance were associated with better intake. Interventions to support eating independence and address residents' eating challenges in LTC are needed to improve their intakes. [Journal of Gerontological Nursing, 45(8), 32–42.]

Individuals living in long-term care (LTC) environments experience deterioration of their health and functional abilities (American Dietetic Association, 2005; Public Health Agency of Canada, 2010). The prevalence of malnutrition in LTC facilities has been shown to range from 3% to 83% often due to poor food and fluid intake (Chang & Roberts, 2011; Keller et al., 2017b; Lou, Dai, Huang, & Yu, 2007; Sitter & Lengyel, 2011; Verbrugghe et al., 2013). Malnutrition places older adults at risk for infections, delayed wound healing, pressure sores, functional limitations, morbidity, and mortality (Lou et al., 2007).

A variety of terms have been used to describe the eating and mealtime changes that happen with dementia, including: eating performance, which focuses on the specific act of getting food from the plate to the mouth (Liu, Williams, Batchelor-Murphy, Perkhounkova, & Hein, 2019); eating (Palese et al., 2018) or feeding difficulty (Watson & Deary, 1997); signs and symptoms accompanying dementia (Takada, Tanaka, Hasegawa, Sugiyama, & Yoshiike (2017); and mealtime difficulties, which include eating, feeding, and mealtime behaviors (Aselage, 2010). The authors of the current study have chosen the term mealtime actions as it is consistent with person-centered language for dementia care (Alzheimer's Society of Canada, 2017; Dupuis, Wiersma, & Loiselle, 2012) and is a term that is inclusive of resident actions (e.g., resident eating challenges, such as spitting food) and staff direct care activities with residents who require eating assistance (e.g., using a napkin to wipe mouth, providing assistance one-on-one). Terms such as behavior and difficulty, although used in the terminology of some standardized tools, are not used herein as they pathologize the actions of persons with dementia (Dupuis et al., 2012).

Cognitive impairment (CI) may impact a person's ability to eat independently and is often associated with multiple resident eating challenges (Bell, Tamura, Masaki, & Amella, 2013). Yet, relatively little is known about the prevalence of specific eating challenges and other mealtime actions that can impact food intake for individuals with CI in LTC (Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997). Eating support may be required to meet the nutritional needs of residents with eating challenges (Lin, Watson, & Wu, 2010). The level of support needed during mealtimes may include set up of the meal, opening packages, encouragement, partial assistance, and/or full eating assistance (Keller et al., 2014). If adequate amounts of monitoring and assistance are provided, this may improve nutritional intake and overall quality of life for those residents (Lin et al., 2010; Reed, Zimmerman, Sloane, Williams, & Boustani, 2005). However, existing research studies fail to exclusively focus on eating challenges and other mealtime actions in LTC residents with CI where they have been reported to be most common (Amella, 2002; Lin et al., 2010; Steele et al., 1997), use unstandardized methods of observation (Steele et al., 1997; Verbrugghe et al., 2013), and/or do not use rigorous methods to determine food intake (Engelheart & Akner, 2015; Steele et al., 1997; Verbrugghe et al., 2013).

The Making the Most of Mealtimes (M3) prevalence study demonstrated that when a resident has more eating challenges this leads to poor energy intake (Keller et al., 2017b). In addition, individuals who received eating assistance often had better energy intake compared to individuals who occasionally received assistance (Keller et al., 2017b). A clear understanding of the potential effect of mealtime actions (i.e., resident eating challenges and staff member actions when providing assistance) while considering other barriers to food intake (e.g., dysphagia) is needed, as these conditions often occur together. Further, M3 analyses to date have not focused on the group most likely to have eating challenges: individuals with significant CI. Furthermore, understanding whether specific mealtime actions do or do not support intake may lead to the development of cost-effective solutions that can be used to mitigate the effect of negative actions on food intake in LTC.

The objectives of the current study were to: (a) examine the association of mealtime actions (e.g., resident eating challenges, such as refusal to eat; staff actions at mealtimes while assisting with eating) with energy intake of LTC residents with CI; and (b) determine if physical eating assistance provided by staff (never, sometimes, often) is associated with energy intake while adjusting for other covariates (age and sex) in residents with CI.

Method

Making the Most of Mealtimes Study

The current study is a secondary data analysis of the M3 study. The M3 is a large, comprehensive, multi-site, cross-sectional study examining the determinants of food and fluid intake of older adults in LTC homes across Canada (Alberta, Manitoba, New Brunswick, and Ontario). Diverse variables based on the M3 conceptual framework of meal quality, mealtime experience, and meal access (Keller et al., 2014) were assessed with rigorous methods. The M3 objectives were to establish the prevalence of inadequate energy, protein, micronutrient, and fluid intake, as well as identify the independent and inter-related associations between multi-level determinants of energy and protein intake of residents in LTC (Keller et al., 2017b).

Twenty residents were randomly selected from 32 LTC homes (eight per province), with a total of 639 residents participating (one participant withdrew consent). The LTC sites were selected based on their diversity in regard to type of facility (profit/not for profit), size, and special characteristics (ethnicity/cultural). M3 participant inclusion criteria were: age ≥65; medically stable; residing in selected units; residence in the LTC home for at least 1 month; able to give consent or have an alternative decision maker provide consent on his/her behalf; and eat most or all meals in the LTC dining room. Exclusion criteria were: residence in the LTC home for <1 month; medically unstable; on respite admission; requires tube feeding; at the end of life; does not routinely eat in the dining room areas; and unable to speak English, French, or Cantonese. More details about the M3 protocol can be found elsewhere (Keller et al., 2017a).

Sample

The sample for the current analysis comprised residents with CI identified from the M3 using the Cognitive Performance Scale (CPS). The CPS evaluates CI by examining an individual's daily decision-making capacity, communication, and memory (Morris et al., 1994). A CPS score of 0 indicates a person experiences no difficulties, whereas a score of 6 indicates a person has very severe memory problems and is unable to make daily decisions, make themselves understood, or eat independently. For the current analysis, a person was considered to have CI if they had a score ≥3. In total, 353 (55.2%) of 639 LTC residents were included for this secondary analysis; 43.6% had moderate CI (CPS 3), 11.9% had moderate/severe CI (CPS 4), 28.3% had severe CI (CPS 5), and 16.1% had very severe CI (CPS 6).

Data Collection and Measures

Outcome Variable: Energy Intake. Food and fluid intake assessment was completed for each resident (observed and measured) for breakfast, lunch, and supper on three non-consecutive days (two weekdays and one weekend day) for a total of nine meals. Average energy intake was estimated for each participant, which was the dependent variable in the current analysis. The main plate was weighed before and after consumption of food. Beverages and side dishes were measured by estimation when weighing was not feasible, and snacks (including oral supplements) consumed between meals were estimated. Food and fluid intake were entered into ESHA Food Processer software version 10.14.1 to determine average energy intake. Potential adequacy of energy intake was calculated using kcal/kg of bodyweight, whereas absolute energy intake (kilocalories) was used for all other analyses.

Mealtime Actions. Several standardized measures were used to assess mealtime actions (e.g., resident and staff eating actions) and were based on mealtime observations completed once per day on the three days of food and fluid intake, with all three meals represented and results averaged across these three observation time points. The valid and reliable Edinburgh Feeding Evaluation in Dementia Questionnaire (Ed-FED) was used to identify resident eating challenges including level of eating assistance required (Keller et al., 2017a; Stockdell & Amella, 2008; Watson & Dreary, 1997). The Ed-FED score ranges from 10 to 30, where higher scores indicate more eating challenges. Nine additional items (i.e., Other Eating Challenges) not captured by Ed-FED but commonly observed in persons with dementia (Aselage, 2010; Palese et al., 2018; Steele et al., 1997) were also recorded (e.g., coughing at the meal, playing with food, distracted) and scaled to be consistent with the Ed-FED (Keller et al., 2017a). The Mealtime Relational Care Checklist (M-RCC), a valid (Iuglio et al., 2018) and reliable tool (Keller, Chaudhury, Pfisterer, & Slaughter, 2017), examined mealtime actions of care staff with individual residents. A subset of seven items was used in this analysis for those who required physical eating assistance (e.g., wiping mouth with napkin, providing one-on-one assistance).

The validated Relational Behavioural Scale (RBS) is a three-item measure used to investigate the quality of eating assistance for individuals requiring total eating assistance (McGilton, Sidani, Boscart, Guruge, & Brown, 2012). The scale comprises three items: (1) stays with the resident during the care episode, (2) pace of care, and (3) focus of care. Each sub-scale is rated on a 7-point semantic scale, with scores ranging from 3 to 21. The total score is derived by summing the item scores, with higher values representing more relational behaviors.

Resident Covariates. The Activities of Daily Living (ADL) scale from the InterRAI for Long Term Care Facilities, the most recent version of the Minimum Data Set, was used. The ADL hierarchy scale measured performance based on eating, locomotion, toilet use, and personal hygiene. Scores range from 0 to 6, where lower scores indicate independence and higher scores indicate greater decline (progressive loss) in ADL performance (Morris, Fries, & Morris, 1999).

The standardized Screening Tool for Acute Neuro Dysphagia (STAND) was used to determine resident's risk of dysphagia (Keller et al., 2017a; Shephard, Kovach, Hale, & Miller, 2007). STAND was not completed with residents requiring thickened fluids. For the current study, a composite dysphagia risk variable was used, as not all residents were eligible or had the cognitive capacity to complete the STAND. Dysphagia risk for M3 was defined as: (a) resident already on thickened fluids, (b) failed STAND, or (c) coughing or choking observed at meals where food intake was observed. A standardized oral assessment based on the Canadian Health Measures Survey was used to examine dentition and oral health (Statistics Canada, 2012). All oral assessments were completed by trained dental hygienists in each province.

The reliable and valid Mini Nutritional Assessment Short Form (MNA-SF) was used to assess nutritional risk (Kaiser et al., 2009). MNA-SF scores range from 0 to 14, where higher scores (12 to 14) indicate normal nutritional status, mid scores (8 to 11) show a risk of malnutrition, and lower scores (0 to 7) indicate that the resident is malnourished. The reliable and valid Patient Generated-Subjective Global Assessment (PG-SGA) was used to assess nutritional status (Keith, 2008). The PG-SGA comprises a medical history (i.e., weight loss, nutrition impact symptoms, intake, and functional capacity) and a physical examination assessing fat, muscle stores, and fluid status (Desbrow et al., 2005; Keith, 2008). Staff, family, residents, and residents' health records were used to complete this measure.

Health records were also reviewed for demographics, number of months since admission, type and total number of formal diagnoses (e.g., depression, diabetes), total number of medications, total number of vitamin/mineral supplements, diet food and fluid texture prescribed, diet prescription (e.g., high protein, renal), oral nutritional supplements prescribed, and weight history. All diagnoses were pre-existing and gathered from residents' medical charts.

Data Analysis

M3 data were analyzed using SPSS version 24.0 for Windows. Descriptive statistics (means, standard deviations, frequencies, ranges, percentages, 95% confidence intervals) were conducted and stratified by sex. Energy intake was standardized using kilocalorie per kilogram of bodyweight. A frequency distribution was used to estimate the proportion of persons with CI whose energy intake was higher or lower than the average of 30 kcal/kg bodyweight, as it is estimated that caloric requirements for older adults in LTC under moderate stress can be met at 25 to 35 kcal/kg/day (Bales & Ritchie, 2009).

Ed-FED, Other Eating Challenges, and M-RCC variables were all coded as dichotomous variables summarized across 3 days of observation, where 0 indicated that the action was not observed during the three (or less) meal observations (i.e., absent) and 1 indicated that the action occurred at least once (i.e., present). This categorization was used due to low prevalence of most items. RBS item scores were averaged from the three meals observed. Independent samples t tests were completed to assess how energy intake, the continuous dependent variable, varied with Ed-FED, Other Eating Challenges, and M-RCC items. Univariate linear regression determined the association between energy intake and RBS items. Resident covariates were similarly assessed with the outcome of average caloric intake.

A value of p < 0.01 was used to determine statistical significance due to multiple tests being completed. A value of p ≤ 0.2 cut point for bivariate associations with resident covariates was used to determine which variables were candidates to include in the initial full regression model to determine if physical eating assistance (i.e., often, sometimes, or never) predicted energy intake (Hosmer & Lemeshow, 2000). Total scores for Ed-FED, M-RCC, and Other Eating Challenges scales (i.e., not individual eating challenge items) were also included in these regression models. Only resident-level variables were considered in this analysis. A backwards stepwise selection technique was performed to remove variables from the model and determine a final parsimonious model. Dummy variables were created for two categorical variables (i.e., CPS score and eating assistance) that had more than two levels.

Ethics

Ethics approval was received from the Research Ethics Boards at the Universities of Waterloo, Alberta, Manitoba, Moncton, and Toronto. As necessary, ethics approval was also obtained from LTC homes with individual review committees. Informed consent was obtained from all participants or their alternative decision makers.

Results

Participant Characteristics

Participant characteristics are summarized in Table A (available in the online version of this article). Of the 353 participants, 70.5% (n = 249) were female and 29.5% (n = 104) were male with ages ranging from 62 to 107 years (mean age = 87, SD = 7.9 years). Average energy intake was 1,546 kcal (SD = 411 kcal), and approximately 70% of residents did not meet the suggested 30 kcal/kg of bodyweight recommendation; the average was 25 kcal/kg (SD = 8 kcal/kg). According to the MNA-SF, more than one half of residents (52.4%) were at risk of becoming malnourished and the PG-SGA showed that 54.5% of residents were malnourished. Based on the CPS, men had moderate cognitive impairment (53.8%) and were less severely impaired than women (39.4%). In addition, 28.3% of residents had severe cognitive decline (CPS = 5). Sixty-eight percent of residents' oral health status was rated by hygienists as likely to affect their food intake, and this was more common in women (65.6%) than men (34.4%).

Characteristics of residents with cognitive impairment (N = 353) Characteristics of residents with cognitive impairment (N = 353) Characteristics of residents with cognitive impairment (N = 353) Characteristics of residents with cognitive impairment (N = 353)

Table A:

Characteristics of residents with cognitive impairment (N = 353)

Mealtime Actions Associated With Energy Intake

Based on the Ed-FED scoring, 61% of residents never required physical eating assistance, 18.1% required eating assistance sometimes, and 20.9% required eating assistance often. The average Ed-FED score for resident eating challenges was 13.4 (SD = 2.5). Common items from the Ed-FED and Other Eating Challenges list included: requiring supervision (n = 197), spilling food (n = 235), leaving food on plate (n = 288), and requiring verbal prompting to eat (n = 219). The seven M-RCC staff actions were completed for only those residents requiring physical eating assistance. Common actions included stopping being assisted (n = 97) and not being told what one was eating (n = 89). Bivariate associations between these mealtime actions and energy intake are provided in Table 1 and Table 2, respectively. Residents who required close supervision had lower intake compared to residents who did not require this care during meals (mean = 1,489 kcal [SD= 403] vs. mean = 1,648 kcal [SD = 372]; t (347) = 3.77, p < 0.001). Similarly, when physical eating assistance was observed, lower energy intakes were found compared to residents who did not require assistance (mean = 1,460 kcal [SD = 410] vs. mean = 1,647 kcal [SD = 364]; t (347) = 4.51, p < 0.001). When residents ate all food provided, they had a higher energy intake (mean = 1,808 kcal [SD = 349]) compared to when leaving food on the plate (mean = 1,505 kcal [SD = 387]; t (347) = 5.64, p < 0.001), and those who did not refuse to eat had higher energy intake (mean = 1,614 kcal [SD = 380]) compared to residents who refused to eat (mean = 1,427 kcal [SD = 408]; t (347) = 4.13, p < 0.001). Three significant associations were found for Other Eating Challenges and energy intake; all were in anticipated directions. Lower intakes were noted for residents who received close supervision compared to those who had no supervision (t [347] = 3.54, p < 0.001); residents receiving verbal prompting compared to those with no prompting (t [347] = 2.74, p = 0.007); and residents who lacked energy to eat compared to those who did not have this challenge (t [347] = 2.80, p = 0.005). For the M-RCC, no significant associations were found. In addition, no significant association was seen for RBS item scores and energy intake (i.e., staff mealtime actions for those who require physical eating assistance).

Mealtime Actions Associated with Energy Intake in Residents with Cognitive Impairment (N = 349) Mealtime Actions Associated with Energy Intake in Residents with Cognitive Impairment (N = 349) Mealtime Actions Associated with Energy Intake in Residents with Cognitive Impairment (N = 349)

Table 1:

Mealtime Actions Associated with Energy Intake in Residents with Cognitive Impairment (N = 349)

Relational Behaviour Scale (RBS) Items Associated with Energy Intake for Residents Requiring Total Eating Assistance (N = 93)

Table 2:

Relational Behaviour Scale (RBS) Items Associated with Energy Intake for Residents Requiring Total Eating Assistance (N = 93)

Physical Eating Assistance Predicts Energy Intake

Factors associated with increased energy intake in the final adjusted model (Table 3) were: male sex, dysphagia risk (p = 0.03), total number of vitamin/mineral supplements (p = 0.001), total MNA-SF score (i.e., well nourished; p = 0.002), higher CPS score (i.e., more cognitive impairment) (p = 0.007), and receiving physical eating assistance often at meals (p = 0.052). Factors negatively associated with energy intake included: age, requiring eating assistance sometimes, and total Ed-FED score. This final model accounted for 27% of the variability for energy intake.

Multivariate Analysis of Resident-Level Factors Associated with Energy Intake in Residents with Cognitive Impairment (N = 353)

Table 3:

Multivariate Analysis of Resident-Level Factors Associated with Energy Intake in Residents with Cognitive Impairment (N = 353)

Discussion

The current study describes the prevalence of diverse resident-level eating challenges experienced by persons with CI living in LTC and mealtime actions when assisting and determined if physical eating assistance predicted energy intake when adjusting for other covariates. Energy intake was generally low for residents with CI, with an average energy intake of 25 kcal/kg of bodyweight. Older adults residing in LTC are considered to be sedentary and under moderate stress; therefore, an average consumption of 25 to 35 kcal/kg of bodyweight is recommended (Bales & Ritchie, 2009). Considering this information, an acceptable energy intake was set to 30 kcal/kg for the current study. Overall, 73.3% of residents were below this recommendation, suggesting that continued inadequate intake could lead to malnutrition, which was common (55%) in this M3 subset. Common resident eating challenges included the need for assistance, whether it be supervision, verbal prompting, or physical assistance.

Among residents with CI, 59.8% were at risk of dysphagia. This finding is similar to the prevalence rate of 52.7% found by Park et al. (2013). Dysphagia risk was found to be a significant predictor of higher energy intake in regression analyses. During mealtimes, eating assistants often target vulnerable residents, such as those who are malnourished and/or have dysphagia, and dysphagia often coincides with requiring full physical eating assistance (Manning et al., 2012). Further, enhancements to modified texture food or use of supplements in individuals with dysphagia risk would also increase intake (Vucea et al., 2017; Vucea, Keller, Morrison, Duizer, et al., 2018; Vucea, Keller, Morrison, Duncan, et al., 2018).

More resident eating challenges (higher Ed-FED scores) were associated with lower intake in residents with CI. There is a well-described association between eating challenges and CI (Berkhout, Cools, & Van Houwelingen, 1998; Blaum, Fries, & Fiatarone, 1995; Lin et al., 2010; Steele et al., 1997). Eating challenges typically progress as the severity of CI increases (Liu, Cheon, & Thomas, 2014; Steele et al., 1997). In the current study, several resident-level eating challenges were associated with lower energy intake in bivariate analyses: residents who left food on their plate, refused to eat, turned head away while being assisted, and lacked energy to eat. Factors such as refusing to eat may be due to the way the food looks or smells or cultural preferences, but also quality of eating assistance (Chang & Roberts, 2008). When assisting a person with CI, it is fundamental to match the level of assistance to the needs and capabilities of that resident (Sloane, Ivey, Helton, Barrick, & Cerna, 2008). Fast paced or rushed assistance can lead to food refusal. The current analysis reinforces the need to create individualized care plans specific to eating challenges experienced. Requiring or receiving close supervision while eating was associated with lower energy intakes compared to those where supervision was not observed. Supervision was less common than verbal prompting, which suggests that supervision is a step toward requiring physical eating assistance and potential interventions may be required at this stage to further support intake.

As noted in this regression analysis and elsewhere (Keller et al., 2017b), frequently receiving physical eating assistance was found to overcome the eating challenges that are associated with CI. In contrast, occasionally offering eating assistance was not sufficient to overcome eating challenges; lower energy intake was found in the group of residents who sometimes received eating assistance. It appears that residents who occasionally require assistance during mealtimes are likely on the cusp of losing their ability to eat independently. They may not seem as though they need as much attention as those requiring total eating assistance, but they still need to be supported during mealtimes. Lin et al. (2010) found that residents with moderate dependency could eat independently with appropriate staff support, but were not given any eating assistance and were commonly ignored by staff, resulting in lower food intake. Early signs of declining ability to eat independently need to be recognized and greater priority should be placed on early detection and intervention of eating challenges (Steele et al., 1997). Physical capability highly influences ability to perform eating tasks independently (Liu et al., 2016). Therefore, routinely screening residents' physical capabilities and providing assistance based on individualized care plans may help improve eating performance and increase intake. Staff mealtime actions for residents who required eating assistance (i.e., M-RCC and RBS) were not associated with energy intake in bivariate analyses, suggesting that the relationship-centered practices that staff engaged in were not as important as providing total eating assistance.

Limitations

Several limitations need to be considered when interpreting the current findings. The LTC homes included in the M3 study were purposively selected; therefore, the results of this study may not be representative of all Canadian LTC homes. There were some missing data, but the majority of measures were completed on approximately all residents. Eating assistance at meals was observed at only three meals using the Ed-FED and some resident-level eating challenges were uncommon; thus, prevalence estimates should be used with caution. The current study excluded residents with mild CI (CPS score <3); therefore, residents who may have experienced early mealtime difficulties were excluded.

Conclusion

The current findings illustrate that mealtime actions and specific resident eating challenges and physical eating assistance are important predictors of food intake in residents with CI. The provision of eating assistance in persons with advanced CI is an area requiring further exploration, especially considering that residents who received only partial assistance had lower energy intakes. Interventions to support eating independence and address resident eating challenges are needed to promote adequate food intake for persons with CI in LTC.

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Mealtime Actions Associated with Energy Intake in Residents with Cognitive Impairment (N = 349)

Measure Categoryb Total Energy Intake (Mean, SD) (kcal) t df p Value
Ed-FEDa
  Does the resident require close supervision while feeding/eating? Noc 152 1,648 (372) 3.77 347 <0.001
Yesd 197 1,489 (403)
  Does the resident require physical help while feeding? No 183 1,647 (364) 4.51 347 <0.001
Yes 166 1,460 (410)
  Is there spillage while feeding/eating? No 114 1,560 (446) 0.06 347 0.955
Yes 235 1,557 (373)
  Does the resident tend to leave food on the plate at the end of the meal? No 61 1,808 (349) 5.64 347 <0.001
Yes 288 1,505 (387)
  Does the resident ever refuse to eat? No 244 1,614 (380) 4.13 347 <0.001
Yes 105 1,427 (408)
  Does the resident spit out his/her food? No 325 1,566 (399) 1.34 347 0.180
Yes 24 1,453 (360)
  Is there spillage of food out of the mouth? No 231 1,554 (386) −0.30 347 0.766
Yes 118 1,567 (420)
  Does the resident turn his/her head away while being fed? No 297 1,576 (394) 2.05 347 0.041
Yes 52 1,454 (404)
  Does the resident refuse to open his mouth? No 277 1,575 (394) 1.58 347 0.116
Yes 72 1,493 (407)
  Does the resident refuse to swallow? No 333 1,560 (393) 0.38 347 0.702
Yes 16 1,521 (494)
Other Eating Challenges
  Does the resident receive close supervision with feeding/eating? No 156 1,640 (366) 3.54 347 <0.001
Yes 193 1,492 (410)
  Does the resident receive verbal prompting to eat? No 130 1,633 (387) 2.74 347 0.007
Yes 219 1,514 (398)
  Does the resident use adaptive utensils to eat? No 282 1,545 (403) −1.25 347 0.21
Yes 67 1,612 (369)
  Does the resident appear distracted? No 254 1,569 (403) 0.82 347 0.42
Yes 95 1,530 (383)
  Does the resident treat the food in an unusual way? No 283 1,554 (397) −0.42 347 0.67
Yes 66 1,577 (400)
  Does the resident lack energy to eat? No 214 1,605 (379) 2.80 347 0.005
Yes 135 1,484 (416)
  Does the resident appear to have chewing problems? No 296 1,550 (405) −0.85 347 0.40
Yes 53 1,601 (354)
  Does the resident cough during the meal? No 204 1,543 (387) −0.82 347 0.42
Yes 145 1,579 (412)
  Does the resident choke during the meal? No 334 1,556 (398) −0.50 347 0.62
Yes 15 1,608 (394)
Mealtime Relational Care Checklist–Eating Assistancee
  Waited for assistance with food in front of them No 105 1,475 (406) −0.56 153 0.57
Yes 50 1,517 (463)
  Had an apron or washcloth used to wipe their mouth No 85 1,478 (428) −0.63 153 0.53
Yes 70 1,521 (424)
  Stopped being assisted, staff left No 65 1,488 (407) 0.05 156 0.96
Yes 93 1,485 (436)
  Was assisted at the same time as other residents No 93 1,450 (425) −1.26 156 0.21
Yes 65 1,537 (417)
  Was rushed when assisted to eat No 122 1,452 (420) −1.96 155 0.052
Yes 35 1,609 (419)
  Was not told what they were eating when assisted No 71 1,457 (462) −0.85 156 0.40
Yes 87 1,515 (389)
  Assisted by staff using unsafe practices No 100 1,424 (445) −2.50 155 0.01
Yes 57 1,597 (368)

Relational Behaviour Scale (RBS) Items Associated with Energy Intake for Residents Requiring Total Eating Assistance (N = 93)

RBS Itema R2 F Ratio df Unstandardized B p Value
Stays with resident during the care episode 0.052 5.07 1, 92 78.91 0.09
Altering the pace of care 0.007 0.66 1, 92 30.23 0.79
Focus of care 0.002 0.184 1, 92 −12.25 0.67

Multivariate Analysis of Resident-Level Factors Associated with Energy Intake in Residents with Cognitive Impairment (N = 353)

Predictor Unstandardized B SE p Value
Age −13.35 2.42 <0.001
Sexa 152.12 41.63 <0.001
Dysphagia riskb 84.08 38.71 0.031
No. of vitamins/minerals 53.33 16.40 0.001
Total MNA-SF scorec 26.75 8.44 0.002
Total Ed-FED scored −40.04 12.49 0.001
Cognitive impairmente 0.007
  Moderate Ref
  Moderate/severe 55.94 64.17
  Severe 130.54 48.52
  Very severe 146.31 71.60
Eating assistance required at meals 0.05
  Never/rarelyf Ref
  Sometimes −116.18 59.49
  Often 76.60 80.95

Characteristics of residents with cognitive impairment (N = 353)

Variables Overall % (N) Male % (n) Female % (n)
Age (years) (353) (104) (249)
  Mean ± SD 87.0 ± 7.9 84.8 ± 7.3 87.8 ± 7.9
  Range 62–107 65–102 62–107
  CIa 71.6; 102.3 70.6; 99.1 72.3; 103.4

Months since admission (353) (104) (249)
  Mean (months) ± SD 31.4 ± 29.6 25.2 ± 23.8 34.0 ± 31.4
  Median 23.0 21.5 25
  Range 1–170 1–139 1–170

Prescribed Liquid Consistency (353) (104) (249)
  Regular, Thin Liquids 83.9 (296) 76.9 (80) 87.8 (216)
  Thickened 16.1 (57) 23.1 (24) 13.3 (33)

Diet Type (353) (104) (249)
  Regular 41.1 (145) 39.4 (41) 41.8 (104)
  Soft 12.2 (43) 11.5 (12) 12.4 (31)
  Minced/Moist 28.0 (99) 33.7 (35) 225.7 (64)
  Pureed 17.8(63) 15.4 (16) 18.9 (47)
  Liquidized 0.8 (3) 0 (0) 1.2 (3)

Diet Prescriptionc (353) (104) (249)
  None 63.7 (225) 55.8 (58) 67.1 (167)
  No Added Salt 2.8 (10) 1.9 (2) 3.2 (8)
  Diabetic 13.9 (49) 20.2 (21) 11.2 (28)
  Renal 0.0 (0) 0.0 (0) 0 (0)
  High Energy 9.1 (32) 9.6 (10) 8.8 (22)
  High protein 9.3 (33) 10.6 (11) 8.8 (22)
  Other 17.3 (61) 20.2 (21) 16.1 (40)

Oral Nutritional Supplements Use (ONS) (353) (104) (249)
38.2 (135) 34.6 (36) 39.8 (99)

Dysphagia Risk (353) (104) (249)
59.8 (211) 71.2 (74) 55.0 (137)

Medical Diagnosesb,c
  Asthma 4.0 (14) 4.8 (5) 3.6 (9)
  Dementia (including AD) 83.9 (296) 81.7 (85) 39.8 (99)
  Congestive Heart Failure 8.2 (29) 8.7 (9) 8.1 (20)
  COPD/Emphysema 11.0 (39) 16.3 (17) 8.8 (22)
  Cancer 13.6 (48) 18.3 (19) 11.7 (29)
  Cardiovascular 71.1 (251) 75.0 (78) 69.5 (173)
  Diabetes 18.7 (66) 24.0 (25) 16.5 (41)
  Endocrine 22.1 (78) 17.3 (18) 24.1 (60)
  Depression 31.0 (109) 31.1 (32) 30.9 (77)
  Mental Health (not depression) 15.3 (54) 11.5 (12) 16.9 (42)
  Gastrointestinal disease 32.3 (114) 31.7 (33) 32.5 (81)
  Liver 0.8 (3) 0.0 (0) 1.2 (3)
  Macular Degeneration/Glaucoma 23.2 (82) 18.3 (19) 25.3 (63)
  Osteoarthritis 36.0 (127) 28.8 (30) 39.0 (97)
  Osteoporosis 30.3 (107) 8.7 (9) 39.4 (98)
  Parkinson's 7.4 (26) 13.5 (14) 4.8 (12)
  Neurological (not Parkinson's disease) 4.2 (15) 6.7 (7) 3.2 (8)
  Renal 13.9 (49) 17.3 (18) 12.4 (31)
  Rheumatoid arthritis 4.0 (14) 2.9 (3) 4.4 (11)
  Stroke 21.2 (75) 31.7 (33) 16.9 (42)

Diagnosis Total (353) (104) (249)
  Mean ± SD 5.3 ± 2.0 5.3 ± 2.1 5.2 ± 1.9
  Median 5.0 5.0 5.0
  Range 1 – 12 1 – 12 1 – 11

Medications Total (353) (104) (249)
  Mean ± SD 8.0 ± 3.4 8.6 ± 3.4 7.7 ± 3.3
  Median 8.0 8.5 7.0
  Range 0 – 18 1 – 17 0 – 18

Vitamin Total (353) (104) (249)
  Mean ± SD 1.3 ± 1.2 1.3 ± 1.1 1.3 ±1.2
  Median 1.0 1.0 1.0
  Range 0 – 6 0 – 5 0 – 6

MNA-SF Category (353) (104) (249)
  Malnourished 16.1 (57) 9.6 (10) 18.9 (47)
  At Risk of Malnutrition 52.4 (185) 56.7 (59) 50.6 (126)
  Normal Nutrition Status 31.4 (111) 33.7 (35) 30.5 (76)

Total MNA-SF Score (353) (104) (249)
  Mean ± SD 9.7 ± 2.5 9.94 ± 2.5 9.63 ± 2.5
  Range 0 – 13 0 – 13 2 – 13

PG-SGA Category (n = 352) (352) (104) (248)
  Well-nourished 45.5 (160) 49.0 (51) 44.0 (109)
  Moderate malnutrition 46.3 (163) 41.3 (43) 48.4 (120)
  Severe Malnutrition 8.2 (29) 9.6 (10) 7.7 (19)

CPS Scored (353) (104) (249)
  Moderate (3) 43.6 (154) 53.8 (56) 39.4 (98)
  Moderate/Severe (4) 11.9 (42) 13.5 (14) 11.2 (28)
  Severe (5) 28.3 (100) 22.1 (23) 30.9 (77)
  Very Severe (6) 16.1 (57) 10.6 (11) 18.5 (46)

Oral Status Likely Affects Food Intake (n=297) (297) (95) (202)
68.0 (202) 34.4 (55) 65.6 (105)

Ed-FED Scoree (349) (104) (245)
  Mean ± SD 13.4 ± 2.5 13.0 ± 2.5 13.5 ± 2.5
  Median 12.7 12.3 13.0

Eating Assistance at Mealsf (349) (104) (245)
  Never 61.0 (213) 65.4 (68) 59.2 (145)
  Sometimes 18.1 (63) 17.3 (18) 18.4 (45)
  Often 20.9 (73) 17.3 (18) 22.4 (55)

Energy (kcal) Intake per Kilogram of Bodyweight (348) (102) (246)
  Mean ± SD 25 ± 8 24 ± 7 26 ± 9
  Median 24 22 24
  Range 2 – 90 9 – 45 2 – 91
  CI 9; 42 10; 38 9; 43

Average Energy Intake (kcal) (353) (104) (249)
  Mean ± SD 1546 ± 411 1702 ± 425 1482 ± 387
  Median 1544 1746 1482
  Range 131 – 2788 606 – 2783 673 – 2259
  CI 742; 2351 870; 2534 722; 2241
Authors

Ms. Mann is Research Coordinator, and Dr. Lengyel is Associate Professor, Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Manitoba; Dr. Slaughter is Associate Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta; Dr. Carrier is Dean, School of Food Science, Nutrition and Family Studies, Faculty of Health Sciences and Community Services, Université de Moncton, Moncton, New Brunswick; and Dr. Keller is Professor, Schlegel University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Canadian Institutes for Health Research provided peer-reviewed funding for this study.

The authors thank the residents who participated in the Making the Most of Mealtimes Study (M3).

Address correspondence to Christina O. Lengyel, PhD, RD, Associate Professor, Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, 405 Human Ecology Building, 35 Chancellors Circle, R3T 2N2, Winnipeg, Manitoba, Canada; e-mail: Christina. Lengyel@umanitoba.ca.

Received: November 21, 2018
Accepted: June 18, 2019

10.3928/00989134-20190709-04

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