Assessment and management of mealtime difficulties In: Evidence-based geriatric nursing protocols for best practice


Guideline Developer(s)

Hartford Institute for Geriatric Nursing

Date Released

2003 (revised 2012)

Evidence Supporting the Recommendations

References Supporting the Recommendations

Berrut G, Favreau AM, Dizo E, Tharreau B, Poupin C, Gueringuili M, Fressinaud P, Ritz P. Estimation of calorie and protein intake in aged patients: validation of a method based on meal portions consumed. J Gerontol A Biol Sci Med Sci. 2002 Jan;57(1):M52-6. PubMed
Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970 Spring;10(1):20-30. PubMed
Watson R. Measuring feeding difficulty in patients with dementia: developing a scale. J Adv Nurs. 1994 Feb;19(2):257-63. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Mobile Device Resources
Resources

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Individual

  • Corrective and supportive strategies reflected in plan of care
  • Quality of life issues emphasized in maintaining social aspects of dining
  • Culture, personal preferences, and end-of-life decisions regarding nutrition respected

Health Care Provider

  • Minimization of system disruptions at mealtimes
  • Family and staff informed and educated to patient's special needs to promote safe and effective meals
  • Maintenance of normal meals and adequate intake for the patient reflected in care plan
  • Competence in diet assessment; knowledge of and sensitivity to cultural norms and preferences for mealtimes reflected in care plan

Institution

  • Documentation of nutritional status and eating and feeding behavior meets expected standard
  • Alterations in nutritional status; eating and feeding behaviors assessed and addressed in a timely manner
  • Involvement of interdisciplinary team (geriatrician, advanced practice nurse, dietitian, speech therapist, dentist, occupational therapist, social worker, pastoral counselor, ethicist) appropriate and timely
  • Nutritional, eating, and/or feeding problems modified to respect individual preferences and cultural norms
  • Adequate number of well-trained staff who are committed to delivering knowledgeable and individualized care
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Not stated

Identifying Information and Availability

Bibliographic Source(s)

Amella EJ, Aselage MB. Mealtime difficulties. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 453-68.

Adaptation

Not applicable: The guideline was not adapted from another source.

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Elaine J. Amella, PhD, RN, FAAN, Professor, Medical University of South Carolina, Mt. Pleasant, SC; Melissa B. Aselage, MSN, RN-BC, FNP-BC, Lecturer, University of North Carolina, Wilmington, NC

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Amella EJ. Mealtime difficulties. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 337-51.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

Availability of Companion Documents

The following are available:

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on July 30, 2003. The information was verified by the guideline developer on August 25, 2003. This summary was updated by ECRI Institute on June 23, 2008. The updated information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 25, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)

Cognitive/neurological, psychological and/or iatrogenic conditions that may contribute to difficulty with eating

Guideline Category

Evaluation
Management

Clinical Specialty

Family Practice
Geriatrics
Nursing
Nutrition

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To provide a standard of practice protocol to maintain or improve nutritional intake at meals and provide a quality mealtime experience that fosters dignity and pleasure in eating, as well as respecting cultural and personal preferences, for as long as possible

Target Population

Hospitalized or institutionalized older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Older adults and caregivers
    • Rituals, blessings, religious rites/prohibitions, cultural issues
    • Respect for preferences as to end-of-life decisions related to food and fluid
  2. Use of assessment instruments
    • Edinburgh Feeding Evaluation in Dementia Scale (EdFED)
    • Katz Index of Activities of Daily Living (ADL)
    • Food diary/meal portion method

Management

  1. Management of mealtime environment
  2. Provision of adequate caregivers and staff
  3. Follow-up monitoring
Major Outcomes Considered
  • Nutritional status
  • Quality of life

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment

Assessment of Older Adult and Caregivers

  • Rituals used before meals (e.g., handwashing and toilet use), dressing for dinner
  • Blessings of food or grace, if appropriate
  • Religious rites or prohibitions observed in preparation of food or before meal begins (e.g., Muslim, Jewish, and Seventh Day Adventist; consult with pastoral counselor, if available)
  • Cultural or special cues: family history, especially rituals surrounding meals
  • Preferences about end-of-life decisions regarding withdrawal or administration of food and fluid in the face of incapacity, or request of designated health proxy; ethicist or social worker may facilitate process

Assessment Instruments

  • Edinburgh Feeding Evaluation in Dementia Scale (EdFED) for persons with moderate- to late-stage dementia (Watson, 1994 [Level III]).
  • Katz Index of Activities of Daily Living (ADL) for functional status (Katz et al., 1970 [Level IV])
  • Food diary/meal portion method (Berrut et al., 2002 [Level III])

Nursing Interventions

Environment

  • Dining or patient room: encourage older adult to eat in dining room to increase intake, personalize dining room; no treatments or other activities occurring during meals; no distractions.
  • Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer, flatware, tablecloth, napkin) versus disposable tableware and bibs
  • Furniture: older adult seated in stable arm chair; table-appropriate height versus eating in wheelchair or in bed
  • Noise level: environmental noise from music, caregivers, and television is minimal; personal conversation between patient and caregiver is encouraged
  • Music: pleasant, preferred by patient
  • Light: adequate and non-glare-producing versus dark, shadowy or glaring
  • Contrasting background/foreground: use contrasting background and foreground colors with minimal design to aid persons with decreased vision
  • Odor: food prepared in area adjacent to or in dining area to stimulate appetite
  • Adaptive equipment: available, appropriate and clean; caregivers and/or older adult knowledgeable in use; occupational therapist assists in evaluation

Caregiver/Staffing

  • Provide an adequate number of well-trained staff.
  • Deliver an individualized approach to meals including choice of food, tempo of assistance.
  • Position of caregiver relative to elder: eye contact; seating so caregiver faces older patient in same plane.
  • Cueing: caregiver cues older adult whenever possible with words or gestures.
  • Self-feeding: encouragement to self-feed with multiple methods versus assisted feeding to minimize time.
  • Mealtime rounds: interdisciplinary team to examine multifaceted process of meal service, environment and individual preferences.

Follow-up Monitoring

  • Providers' competency to monitor eating and feeding behaviors
  • Documentation of eating and feeding behaviors
  • Documentation of care strategies and follow-up of alterations in nutritional status, eating and feeding behaviors
  • Documentation of staffing and staff education; availability of supportive interdisciplinary team

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

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