Interventions to address mealtime support needs in dementia: A scoping review.

The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.

Mealtime nonverbal behaviors in nursing home staff and residents with dementia: Behavioral analyses of videotaped observations.

This study characterized mealtime nonverbal behaviors of nursing home staff and residents with dementia and examined the relationships between individual characteristics and nonverbal behaviors. Videotaped observations (N=110) involving 25 residents and 29 staff (42 unique staff-resident dyads) in 9 nursing homes were coded using the refined Cue Utilization and Engagement in Dementia Mealtime Video-Coding Scheme. Wilcoxon rank-sum test or Kruskal-Wallis test were used for continuous characteristics, and Fisher's exact test for categorical characteristics. Residents primarily exhibited challenging behaviors including resistive behaviors (35.7%), chewing/swallowing difficulties (33.5%), and functional impairments (9.9%), followed by positive/neutral behaviors (20.9%). Staff primarily used person-centered behavioral strategies, including modifications of: 1) resident abilities (41.9%), 2) care approaches (35.1%), and 3) dining environment (13.6%), followed by task-centered behaviors (9.3%). Residents challenging behaviors were correlated with staff person-centered behavioral strategies. Dyadic nonverbal behaviors were correlated with multiple individual characteristics. Understanding dyadic nonverbal interactions facilitates use of person-centered, multilevel, behavioral strategies to optimize mealtime outcomes.

A Call to the CMS: Mandate Adequate Professional Nurse Staffing in Nursing Homes.

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article.

Development and Psychometric Testing of the Mealtime Engagement Scale in Direct Care Providers of Nursing Home Residents With Dementia.

BACKGROUND AND OBJECTIVES: Mealtime engagement is defined as verbal and nonverbal assistance provided by caregivers to guide and motivate care recipients in eating. Quality mealtime engagement is critical to improve mealtime difficulties and intake among older adults with dementia requiring eating assistance. Few tools are feasible and valid to measure mealtime engagement. This study developed and tested the Mealtime Engagement Scale (MES). RESEARCH DESIGN AND METHODS: Items were developed based on literature review and expert review and finalized based on content validity and corrected item-total correlation. A secondary analysis of 87 videotaped observations capturing 18 nursing home staff providing mealtime care to residents with dementia was conducted. Internal consistency, interrater reliability, and intrarater reliability were assessed. Concurrent and convergent validity were examined through correlation (rs) with the Relational Behavior Scale (RBS) and the Mealtime Relational Care Checklist (M-RCC), respectively. RESULTS: The 18-item MES was developed with adequate content validity (Scale-content validity index [CVI] = 1.00; Scale-CVI/Average = 0.962-0.987). Each item is scored from 0 (never) to 3 (always). The total scale score ranges from 0 to 54. Higher scores indicate greater mealtime engagement. The MES had very good internal consistency (Cronbach's α = 0.837), outstanding interrater reliability (interclass correlation = 0.920), outstanding intrarater reliability (interclass correlation = 0.956), adequate concurrent validity based on strong correlation with the RBS (rs = 0.821, p < .001), and fair convergent validity based on weak correlation with the M-RCC (rs = 0.219, p = .042). DISCUSSION AND IMPLICATIONS: Findings provide preliminary psychometric evidence of MES to measure mealtime engagement. Future testing is needed among more and diverse samples in different care settings to accumulate psychometric evidence.

Mealtime verbal interactions among nursing home staff and residents with dementia: A secondary behavioural analysis of videotaped observations.

AIMS: To characterize dyadic mealtime verbal interactions and examine the associations with staff and resident characteristics. DESIGN: A secondary analysis of 110 videotaped mealtime observations collected from a dementia communication trial during 2011-2014. METHODS: Videos involved 25 residents with dementia and 29 staff in nine nursing homes. Verbal behaviours (utterances) were coded during 2018-2019 using the Cue Utilization and Engagement in Dementia mealtime video-coding scheme, addressing eight positive behaviours and four negative behaviours. Bivariate analyses and multivariate regression models were used. RESULTS: Staff spoke three times more frequently (76.5%) than residents (23.5%). Nearly all staff utterances were positive (99.2%); 85.1% of residents' utterances were positive and 14.9% negative. Staff positive utterances were correlated with their negative utterances and resident positive and negative utterances. Staff negative utterances were correlated with resident negative utterances. Resident positive and negative utterances were correlated. Resident positive utterances were significantly associated with staff care-giving length in the current nursing home (OR = 1.430, 95% CI = 1.008, 2.027). Resident negative utterances were significantly associated with resident gender (female versus male, OR = 11.892, 95% CI = 1.237, 114.289) and staff years worked as a caregiver (OR = 0.838, 95% CI = 0.710, 0.989). Staff positive and negative utterances were not associated significantly with any participant characteristics. CONCLUSIONS: Staff engage residents using primarily positive verbal strategies. Staff-resident mealtime verbal interactions were dynamic, interactive, and complex and related to multiple individual characteristics. IMPACT: Positive dyadic mealtime interactions are critical to engage residents in eating. Little work has characterized dyadic mealtime interactions, limiting the development of effective interventions. Findings showed staff-resident mealtime verbal interactions were primarily positive, inter-related, and associated with multiple individual characteristics. Findings inform directions to improve mealtime care practice and develop person-centred mealtime interventions targeting modifiable factors, including staff care-giving experiences.

Mealtime Caregiving Engagement for Residents with Advanced Dementia: Item Response Theory Analysis.

The 18-item Mealtime Engagement Scale was developed to measure mealtime caregiving engagement with preliminary reliability and validity. Item Response Theory models (i.e., Rasch model and Rating Response Model) may provide insight into item functioning. This was a secondary analysis of 87 videotaped mealtime observations involving 18 nursing home staff providing care to residents with advanced dementia.In both models, item difficulties were distributed considerably along the latent trait and highly correlated. Two thirds of the 18 items were located at the moderate level of mealtime engagement. "Providing one-on-one assistance" was most frequently observed, and "re-approaching individual to continue meal" was least frequently observed. All items showed desirable fit to the models. The Rasch model had a significantly smaller deviance than the Rating Response Model, indicating an overall better fit. Findings provided preliminary support for item functioning and pointed out directions for item revisions. Future testing in larger diverse samples is needed.

Ease of use, feasibility and inter-rater reliability of the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme.

AIMS: To refine the Cue Utilization and Engagement in Dementia mealtime video-coding scheme and examine its ease of use, feasibility, and inter-rater reliability in assessing the food intake process and dyadic verbal and nonverbal interactions. DESIGN: This study was a secondary analysis of 110 videotaped observations of mealtime interactions collected under usual care conditions from a dementia communication trial during 2011-2014. METHODS: The videos involved 29 staff and 25 residents with dementia (42 unique staff-resident dyads) in nine nursing homes. Data coding and analysis were performed in 2018-2019. Logs of coding challenges with matched solutions and coding time were collected. Inter-rater reliability was examined through rating of randomly selected 22 videos across four trained coders. RESULTS: It took a mean of 10.81 hr to code a one-hour video using the refined coding scheme. Coding challenges, including identification of key intake process characteristics and differentiation of similar verbal or nonverbal behaviours, were identified with appropriate solutions. The refined coding scheme had good inter-rater reliability (Cohen's Kappa range = 0.93 - 0.99, 95% CI = 0.92 - 0.99). CONCLUSION: Findings supported preliminary evidence on feasibility, usability and inter-rater reliability of the refined coding scheme. Future psychometric testing is needed in diverse populations with dementia across different care settings. IMPACT: Existing tools assessing the food intake process and dyadic interactions are few and have limited feasibility and/or reliability and fail to capture the complexity and dynamics of mealtime care. The refined coding scheme showed preliminary feasibility, usability, and inter-rater reliability. In consideration of the balance between time intensity and the richness of data obtained, the tool may be appropriate and useful in addressing certain research inquires (e.g., characterizing and clustering dyadic behaviours, temporal relationship between behaviours and intake) pertaining older adults with or without dementia and their formal or informal caregivers.

Food intake is associated with verbal interactions between nursing home staff and residents with dementia: A secondary analysis of videotaped observations.

BACKGROUND: Nursing home residents with dementia commonly experience low food intake, leading to negative functional and nutritional consequences. While the importance of staff-resident (dyadic) interactions during mealtime is acknowledged, little research has examined the role of dyadic verbal interactions on food intake. OBJECTIVES: This study aimed to examine the relationship between food intake and dyadic verbal interactions. METHODS: This study was a secondary analysis of 110 videotaped observations of mealtime care interactions among 25 residents with dementia and 29 staff (42 unique dyads) in 9 nursing homes. Staff positive utterances and resident positive and negative utterances (independent variables) and food intake (dependent variable) were coded from the videotaped observations using the Cue Utilization and Engagement in Dementia video coding scheme. A linear mixed model was fit to the data. The two-way interaction effects of food type and video duration with each independent variable as well as two-way interaction effects among the independent variables were tested. Covariates included in the model were the number of years staff worked as a caregiver, and resident age, gender, and eating function. RESULTS: The model included three significant interaction effects involving verbal variables: the interaction effect of staff positive utterances with resident positive utterances (p=.030), the interaction effect of staff positive utterances with food type (p=.027), and the interaction effect of resident negative utterances with video duration (p=0.002). Increased number of intakes of liquid food per minute was associated with increased number of staff positive utterances per minute when residents did not make positive utterances. Decreased number of intakes of solid food per minute was associated with increased number of staff positive utterances per minute, especially when residents made between 0 and 3 positive utterances per minute. As the duration of the videos increased, the number of intakes per minute increased for residents who made one or more negative utterances and decreased for residents who made no negative utterances in the videos. The number of intakes per minute was associated with resident gender in that male residents had increased number of intakes per minute compared with female residents (p=.017), and was not associated with other participant characteristics. CONCLUSION: Intake was associated with dyadic verbal interactions, and such relationship was complex in that it was moderated by food type and video duration. Findings support the significant role of dyadic verbal interactions on intake, and inform the development of effective, tailored mealtime care interventions to promote intake.

Mediation of in vivo glucose sensor inflammatory response via nitric oxide release.

In vivo glucose sensor nitric oxide (NO) release is a means of mediating the inflammatory response that may cause sensor/tissue interactions and degraded sensor performance. The NO release (NOr) sensors were prepared by doping the outer polymeric membrane coating of previously reported needle-type electrochemical sensors with suitable lipophilic diazeniumdiolate species. The Clarke error grid correlation of sensor glycemia estimates versus blood glucose measured in Sprague-Dawley rats yielded 99.7% of the points for NOr sensors and 96.3% of points for the control within zones A and B (clinically acceptable) on Day 1, with a similar correlation for Day 3. Histological examination of the implant site demonstrated that the inflammatory response was significantly decreased for 100% of the NOr sensors at 24 h. The NOr sensors also showed a reduced run-in time of minutes versus hours for control sensors. NO evolution does increase protein nitration in tissue surrounding the sensor, which may be linked to the suppression of inflammation. This study further emphasizes the importance of NO as an electroactive species that can potentially interfere with glucose (peroxide) detection. The NOr sensor offers a viable option for in vivo glucose sensor development.

More lipophilic dialkyldiamine-based diazeniumdiolates: synthesis, characterization, and application in preparing thromboresistant nitric oxide release polymeric coatings.

The synthesis, characterization, and biomedical application in preparing more thromboresistant polymeric coatings for a series of lipophilic dialkyldiamine-based diazeniumdiolatesare described. Dialkylhexamethylenediamine diazeniumdiolates of the form RN[N(O)NO](-)(CH(2))(6)NH(2)(+)R, where R = CH(3), CH(2)CH(3), (CH(2))(2)CH(3), (CH(2))(3)CH(3), (CH(2))(4)CH(3,) (CH(2))(5)CH(3), and (CH(2))(11)CH(3), are prepared via reaction of the corresponding diamine with NO. The more lipophilic diazeniumdiolates [e.g., R = (CH(2))(3)CH(3)] can be incorporated into hydrophobic polymeric films (e.g., plasticized PVC), and the resulting materials release NO for extended periods of time upon exposure to PBS buffer. The mechanism of NO release from these films is examined in detail. More stable initial NO release can be achieved by adding lipophilic anionic species (e.g., tetraphenylborate derivative) to the polymeric material to buffer the activity of protons within the organic phase. It is shown that the use of these new lipophilic NO-donors in polymers provides the ability to tailor NO release rates for a variety of medical applications. As an example, polymers doped with N,N'-dibutylhexamethylenediamine diazeniumdiolate and a tetraphenylborate derivative are employed as coatings for vascular grafts in sheep. The NO release grafts exhibited enhanced performance and had an average 95% thrombus-free surface area compared to 42% for the corresponding control grafts when examined after 21d of implantation.