Dietary and Feeding Modifications for Older Adults.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aim to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers. This article is the second of two that explain the nutritional principles nurses should consider and reinforce with caregivers. Each article includes an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Eating for Healthy Aging.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions regarding nutritional principles that nurses should reinforce with family caregivers. Most articles include an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses and Resources for Family Caregivers.

Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents.

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Eating performance in relation to intake of solid and liquid food in nursing home residents with dementia: A secondary behavioral analysis of mealtime videos.

BACKGROUND: Persons with dementia commonly experience low food intake leading to negative nutritional and functional outcomes. While multilevel personal and environmental factors that influence intake are implicated, evidence is lacking on the role of characteristics of dynamic eating performance cycles. An eating performance cycle is defined as the process of getting food from the plate or container, transporting it into the mouth, and chewing and swallowing it. OBJECTIVE: This study aimed to examine the association between intake and characteristics of eating performance cycles among nursing home residents with dementia. METHODS: A secondary analysis of 111 mealtime video clips from a nursing home communication training study was conducted. The 111 videos involved 25 residents and 29 staff (N = 42 unique staff-resident dyads) in 9 nursing homes. The Cue Utilization and Engagement in Dementia Mealtime video-coding scheme was used to code the characteristics of eating performance cycles, including eating technique (resident-completed, staff-facilitated), type of food (solid, liquid), duration of each eating performance cycle, and intake outcome (intake, no intake). The Generalized Linear Mixed Model was used to examine the interaction effects of eating technique by type of food, eating technique by duration, and type of food by duration on intake outcome. RESULTS: Totally 1122 eating performance cycles were coded from 111 video clips. The majority of the cycles (85.7%) resulted in intake. There were significant interactions for eating technique by duration, and type of food by duration. As the duration of the eating performance cycle increased, staff-facilitated cycles resulted in greater odds of intake than resident-completed cycles (OR = 17.80 vs. 2.73); and cycles involving liquid food resulted in greater odds of intake than cycles involving solid food (OR = 15.42 vs. 3.15). Though the interaction between eating technique and type of food was not significant, the odds of intake were greater for resident-completed cycles than for staff-facilitated cycles regardless of the type of food being involved in the cycle (OR = 3.60 for liquid food, OR = 10.69 for solid food). CONCLUSIONS: The findings pointed out the importance of supporting resident independence in eating performance, providing liquid food when residents struggle with solid food, and provision of longer and continuous facilitation at mealtimes to improve intake. The findings inform the development and implementation of innovative mealtime assistance and staff training to promote eating performance and intake.

Resident Vignettes for Assessing Care Quality in Nursing Homes.

OBJECTIVES: Validated process measures that correlate with patient outcomes are needed for research and quality improvement. DESIGN: Cross-sectional analysis within a cluster-randomized fall prevention study. SETTING: Nursing homes in North Carolina (n = 16). PARTICIPANTS: Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597). MEASUREMENTS: Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2) staff responses to clinical vignettes of hypothetical residents at risk for falls. Recurrent fall rates (falls/resident/year) were measured. The proportion of the total variation in falls rates explained by the scores for each method (chart abstraction or vignette) was calculated using multilevel adjusted models. RESULTS: Chart and vignette measures of comorbidity management were moderately correlated (Pearson correlation coefficient 0.43), whereas other process measure categories had low or negative correlation between the 2 methods (psychoactive medication reduction 0.13, environmental modification -0.42, and exercise/rehabilitation -0.08). Measures of environmental modification and comorbidity management explained a moderate amount of the total variation in recurrent fall fates, vignettes (7%-10% variation explained) were superior to chart abstraction (2%-6% variation explained). Vignette responses from unlicensed staff (nurse aides and rehabilitation aides) explained more variance than registered nurses, licensed practical nurses, or other licensed staff in these categories. Process measures for psychoactive medication reduction and exercise/rehabilitation did not explain any of the variation in fall outcomes. Overall, vignette process measures explained 3.9% and chart abstraction measures explained 0% of the variation in fall outcomes. CONCLUSIONS: Clinical vignettes completed by nursing home staff had greater association with resident recurrent fall rates than traditional chart abstraction process measures.

Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial.

Importance: New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. Objective: To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). Design, Setting, and Participants: Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. Interventions: CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program. Main Outcomes and Measures: Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. Results: Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. Conclusions and Relevance: An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. Trial Registration: clinicaltrials.gov Identifier: NCT00636675.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices.

OBJECTIVES: Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias. DESIGN: Randomized factorial clinical vignette survey. SETTING: Sixteen nursing homes in North Carolina. PARTICIPANTS: Nursing, rehabilitation, and social services staff (n = 433). MEASUREMENTS: Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories. RESULTS: Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1). CONCLUSION: Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia.

BACKGROUND: Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. OBJECTIVES: To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). DESIGN: A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. SETTING AND PARTICIPANTS: 30 residents living with advanced dementia in 11 U.S. NHs. MEASUREMENTS: Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. INTERVENTION: Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. RESULTS: Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). CONCLUSION: All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers.

BACKGROUND: Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. METHODS: In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. RESULTS: Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using "train the trainer" approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. CONCLUSIONS: When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. TRIAL REGISTRATION: ClinicalTrial.gov, NCT00636675.

Hartford Gerontological Nursing Leaders: From Funding Initiative to National Organization.

In 2000, the John A. Hartford Foundation established the Building Academic Geriatric Nursing Capacity Program initiative, acknowledging nursing's key role in the care of the growing population of older adults. This program has supported 249 nurse scientists with pre- and postdoctoral awards. As a result of the program's success, several Building Academic Geriatric Nursing Capacity Program awardees formed an alumni organization to continue to advance the quality care of older adults. This group of Building Academic Geriatric Nursing Capacity Program awardees joined others receiving support from the John A. Hartford Foundation nursing initiatives to grow a formal organization, the Hartford Gerontological Nursing Leaders (HGNL). The purpose of this article is to present the development, accomplishments, and challenges of the HGNL, informing other professional nursing organizations that are experiencing similar accomplishments and challenges. This article also demonstrates the power of a funding initiative to grow an organization dedicated to impact gerontological health and health care through research, practice, education, and policy.

Feasibility of a web-based dementia feeding skills training program for nursing home staff.

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

Utility of Braden Scale Nutrition Subscale Ratings as an Indicator of Dietary Intake and Weight Outcomes among Nursing Home Residents at Risk for Pressure Ulcers.

The Braden Scale for Pressure Sore Risk(©) is a screening tool to determine overall risk of pressure ulcer development and estimate severity of specific risk factors for individual residents. Nurses often use the Braden nutrition subscale to screen nursing home (NH) residents for nutritional risk, and then recommend a more comprehensive nutritional assessment as indicated. Secondary data analysis from the Turn for Ulcer ReductioN (TURN) study's investigation of U.S. and Canadian NH residents (n = 690) considered at moderate or high pressure ulcer (PrU) risk was used to evaluate the subscale's utility for identifying nutritional intake risk factors. Associations were examined between Braden Nutritional Risk subscale screening, dietary intake (mean % meal intake and by meal timing, mean number of protein servings, protein sources, % intake of supplements and snacks), weight outcomes, and new PrU incidence. Of moderate and high PrU risk residents, 61.9% and 59.2% ate a mean meal % of <75. Fewer than 18% overall ate <50% of meals or refused meals. No significant differences were observed in weight differences by nutrition subscale risk or in mean number protein servings per meal (1.4 (SD = 0.58) versus 1.3 (SD = 0.53)) for moderate versus high PrU risk residents. The nutrition subscale approximates subsequent estimated dietary intake and can provide insight into meal intake patterns for those at either moderate or high PrU risk. Findings support the Braden Scale's use as a preliminary screening method to identify focused areas for potential intervention.