Processes of identifying and managing eating problems among
non-demented elderly residents in a nursing home: A preliminary report

Anisha Patel1*, Judith A. Lucas1, Bernadette G. Janas2, and Carole Nussbaum2
1*College of Nursing, Rutgers University, Newark, New Jersey, 07102

2Department of Nutritional Sciences, Rutgers University
New Brunswick, New Jersey 08901-8525

*Rutgers Undergraduate Research Fellow

Keywords: eating problem, nursing home, elderly, nutrition


Abstract

     The purpose of this multi-part qualitative study is to describe the range and patterns of staff-identified problem eating behaviors, and the process of managing these eating problems among 10 non-demented elderly residents in a nursing home. Previous research has described several causes of eating problems, but has not focused on the actual process of managing eating problems. Data were collected over a 6-month period by conducting general and resident-specific mealtime observations, resident, family member and staff interviews, and record review. Preliminary findings have identified higher frequencies in the diminished eating competency areas of dentition, physical-motor function, depression, and environmental areas of drug-induced anorexia, and inadequate feeding assistance and food choices. Two approaches to eating problem interventions, general and specific, have been identified from the data. Processes used for preventing and managing eating problems need to include holistic resident and environmental assessment, and timely reassessment by staff to recognize eating problems early and differentiate root causes.


Background


     Eating is a complex biological, social, cultural, behavioral, and symbolic phenomenon1. Many independent eating functions may be lost, impaired, or misdiagnosed in Nursing Home (NH) residents, who typically have multiple chronic health problems. Problematic eating behaviors in NH residents may result in dehydration, malnutrition, significant weight loss, and feeding tube placement--all significant clinical issues. Research has described: a) several causes of eating problems such as physical problems, medication side effects, puree diets, dementing illness, diseases causing weight loss, unnecessary diet restrictions or unappetizing food, and lack of personnel to assist residents1,2,3,4,5; b) caregiver-resident interactions and a chaotic mealtime environment not conducive to eating6,7,8,9,10; and c) assessments of resident capabilities for self-feeding as non-specific, often not followed during mealtime, and as resulting in rapid decline to total dependence11,12,13,14.

     Most nursing literature concerning processes for recognition and management of eating problems is anecdotal and previous investigators have not focused on the actual process of recognizing, evaluating, and treating resident eating problems. Only one anthropological investigation described a complex constellation of factors influencing eating problems over time and the decision-making processes that led to giving tube feedings. Factors such as poor oral health, undiagnosed swallowing disorders, medications, lack of ethnic food, and lack of staff sensitivity to individual needs were described as influencing resident eating12.


Purpose


     This research is part of a larger qualitative study of the multiple health, social, cultural, and environmental factors that influence eating behavior, self-feeding, and oral consumption in nursing homes. Specific aims of this abstract are to describe: a) the range and patterns of problem eating behaviors; b) caregivers' processes of identifying, and managing eating problems.


Methods


Research design

     Grounded Theory method15 is guiding this multidisciplinary research team's immersion into the world of one purposely selected nursing home to view the perspective of the NH residents. In the first phase, observations were focused on the general nature of staff-and-family resident interactions during meals: how eating problems are recognized, what happens when they occur, and the norms for managing eating problems. In the second phase, in-depth additional open-ended interviews of each resident's caregiver staff and family, observations of mealtime interactions (between 7 am and 7 p.m.), and reviews of health records are being conducted.

Participant selection

     The participants were purposefully selected at one large nursing home (439 beds) to reflect diversity in functional status and length of stay. Staff identified residents with eating problems. For this research, an eating problem was defined by one or any combination of the following criteria: resident a) is eating 75% or less of most meals for 2-3 days; b) experiences an unplanned weight loss of 10% in 180 days, 5% in 30 days, or 1-2% in 1 week; c) shows ineffective or slow eating self-performance or must be physically assisted to ingest food or fluids; d) receives a mechanically altered diet (pureed, all food chopped, thickened liquids); e) is consuming 25% or less of prescribed dietary supplement. All potential participants who scored 24 or greater on the Mini-Mental State Exam (MMSE)16 were then selected for inclusion. Twelve were recruited and ten agreed to participate in the study.

Data collection

     Multiple, open-ended interviews of ten non-demented residents (65+ years), identified by staff as having eating problems on 2 NH units, have been conducted and are on-going over 6 months to explore in detail their experiences, ways of coping with eating problems, and what interventions and outcomes occur. Additional follow-up interviews of residents and staff are continuing to be conducted.

Coding and analysis

     Data from resident-participants and staff were treated as one data set. Interview tapes with transcripts were reviewed to identify incidents, ideas, and events in the data. This process generated an initial concept list used for coding the data. Coding is progressing using constant comparisons between residents and between NH units to identify categories and components of the processes, roles, and outcomes of managing eating problems. The results identify steps and components from the data thus far.


Results

Sample

     Preliminary results are reported for a sample consisting of five core resident-participant cases. All were women, ranging in age from 68-88 years. All were Caucasian and lived in the same northern New Jersey county in which the population is predominantly white. Two were recent admissions to the NH (< 6 mos.), the other three had been at the NH for 1-3 years. All spoke English as their first language. Only one expressed strong ethnic (Italian) food preferences. All scored 24 or higher on the Mini-Mental Status Exam16. The primary caregivers and family members (5-7 participants per resident-case) were also interviewed several times.



Figure 1. A nursing research fellow sharing a mealtime experience with a nursing home resident.



Findings

     All eating problems identified (Table 1) were reported during the 14 month investigation by residents and staff and then confirmed by observations, record review and additional interviews. Preliminary comparisons across cases indicate high frequencies in the diminished eating competency areas of dentition, physical-motor function, depression and the environmental areas of drug induced anorexia and inadequate feeding assistance and food choices. Continuing analysis of interviews are clarifying the staff perspective that anorexia, food refusal, and problem behaviors at mealtimes are most problematic. Preliminary analysis has also identified several processes and their components for managing eating problems (see Table 2). Several resident- related factors that influence variation in the processes are listed in Table 3. In addition, two approaches to eating problem interventions, general and specific, have been identified from the data. General approaches are typical interventions implemented upon recognition of an eating problem, and specific approaches are designed to address a particular cause of an eating problem, or are individualized to meet a resident's special needs.


Discussion

     The variety of eating problems identified and the progressive nature of chronic diseases are indications of the constantly changing multi-dimensional nature of eating problems experienced in the NH. The changing nature of the problems suggests that processes used for preventing and managing eating problems need to include holistic resident and environmental assessment and timely reassessment components conducted by members who are able to recognize eating problems early and differentiate root causes. Several of the eating problems identified (Table 1) have been described as modifiable by Abbasi and colleagues17. Their description suggests improvement opportunities within the processes of eating problem management to reduce undernutrition. Based on the eating problems identified and approaches in place at the NH, systematic screening for depression, early psychiatric evaluation of undiagnosed eating problems, regular review of diet restriction effectiveness and drug assessments for effects on intake, and communication to increase awareness of specific eating problems, new diagnoses, and planned interventions show some promise for reducing undernutrition in the NH setting.

     Analysis using constant comparisons is continuing across the data from additional resident-participants and caregivers. Coding is now centered on resident representations of eating problems, environmental factors, and their outcomes. Future investigations will be needed to clarify the influence resident and staff representations and environmental factors have on eating problem management and undernutrition in NH's.


Acknowledgments

     This research study is partly supported by: a) a Rutgers University Undergraduate Research Fellowship; b) Rutgers University Research Council Grant, and c) the Rutgers College of Nursing.


Endnotes

1Siebens, H., Trupe, E., Siebens, A., Cook, F., Anshen, S., Hanauer, R., and Oster, G. (1986). Correlates and consequences of eating dependency in institutionalized elderly. Journal of the American Geriatrics Society, 34, 192-198.

2Rudman, D., and Feller, A.G. (1989). Protein-calorie undernutrition in the nursing home. Journal of the American Geriatrics Society, 37, 173-183.

3Kerstetter, J.E., Holthausen, B.A., and Fitz, P.A. (1992). Malnutrition in the institutionalized older adult. Journal of the American Dietetic Association, 92, 1109-1116.

4Holzapfel, S.K., Ramirez, R.F., Layton, M.S., Smith, I.W., Sagel-Massey, K., and Dubose, J.Z. (1996). Feeder position and food and fluid consumed by nursing home residents. Journal of Gerontological Nursing, 22, 6-12.

5Rogers, J., and Snow, T. (1982). An assessment of the feeding behaviors of the institutionalized elderly. The American Journal of Occupational Therapy, 36, 375-380.

6Astrom, S., Nilsson, M., Norberg, A., Sandman, P., and Winbald, B. (1991). Staff burnout in dementia care-relations to empathy and attitudes. International Journal of Nursing Studies, 28, 65-75.

7Norberg, A., Athlin, E., and Winblad, B. (1987). A model for the assessment of eating problems in patients with Parkinson's Disease. Journal of Advanced Nursing, 12, 473-481.

8Van Ort, S., and Phillips, L. (1992). Feeding nursing home residents with Alzheimer's Disease. Geriatric Nursing, 34, 249-253.

9Van Ort, S., and Phillips, L. (1995). Nursing interventions to promote functional feeding. Journal of Gerontological Nursing, 21, 6-14.

10Sidenvall, B., Fjellstrom, C., and Ed, A. (1996). Cultural perspectives of meals expressed by patients in geriatric care. International Journal of Nursing Studies, 33, 212-222.

11Kayser-Jones, J., and Schell, E. (1997). The mealtime experience of a cognitively impaired elder: Ineffective and effective strategies. Journal of Gerontological Nursing, 23, 33-39.

12Kayser-Jones, J. (1997). Inadequate staffing at mealtime: Implications for nursing and health policy. Journal of Gerontological Nursing, 23, 14-21..

13Osborn, C., and Marshall, M. (1993). Self-feeding performance in nursing home residents. Journal of Gerontological Nursing, 19, 7-14.

14Osborn, C., and Marshall, M. (1992). Promoting mealtime independence. Geriatric Nursing, 34, 254-256.

15Glaser, B., and Straus, A. (1967). The discovery of grounded theory. New York: Aldine.

16Folstein, M.F., Folstein, S.E., and McHugh, P.R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. The Journal of Psychiatric Research, 12, 196-198.

17Abbasi, A., Basu, S., Parsa, A., Alverno, L., and Rudman, D. (1994). Nutritional problems in the nursing home population: Opportunities for clinical interventions. In Katz, Kane, and Mezey, Advances in Long Term Care: Vol. 3 (pp. 195-215). New York: Springer.


Table 1. Case frequency (N=5) of reported eating problems
in the nursing home



I. DIMINISHED EATING COMPETENCY RESULTING IN LOW INTAKE

A. Physical/Motor Function

Case Frequency
1. Upper Body
Manual Dexterity 1
Paralysis/Contraction 2
Tremors 3
Posture 2
Slow Movement 2
Pain 1
Fatigue/Strength 1

2. Oral
Dentitiona 5
Pain 1
Salivation/Dry Mouth 2
Mastication 2

3. Swallow Disorders
Physical/Neurogenic 3

4. Sensory Losses
Visual/Smell/Taste 2
B. Impaired Cognitive Ability
1. Easily Distracted 1
2. Needs Stimulation/Socially Withdrawn 2
3. Unable to Learn/Remember Apraxia 1
4. Agitation/Behavior Problem 1
C. Affective

Case Frequency
1. Anorexia
Food Preferences, Habits, Tastes, Representations 3
Anorexigenic Drugsa 2
Drug Induced Depression/ Somnolence/GI Distressa 3
Transitory Illness/Event Leading to Confusion/ Depression 3
Refusal to Eat on Purpose 3

2. Chronic Medical Disorders
Parkinson's Disease 1
Depressiona 4
Stroke(s) 2
DM
Dementia


II. ENVIRONMENTAL FACTORS RESULTING IN LOW INTAKE


A. Food Preparation
1. Consistency, Portions, Timed Offerings 1
2. Appearance of Pureed Foods 2
B. Mealtime Atmosphere
1. Noisy/Chaotic 1
2. Low Social Interaction 1
C. Inadequate Feeding Assistance/ Devices/Cues/Time to Eata
3
D. Excessive/Total Feeding Leading to ADL Declinea
1
E. Limited Menu Choices/Ethnic Foods/Varietya
2
F. Inappropriate Diet Restrictionsa
1. Delayed Diet Changes 1
2. NIDDM, Fat, or Na Restrictions 1
G. Undiagnosed, Confounding, Psychomedical Problems
2
H. Low Physical Activities
4
I. Weight Loss During Hospitalization
1
J. Staff Awareness of Eating Problem or Strategy
3
K. End Stage Disease:
Pulmonary, Cardiac, Renal or Hepatic


III. HEALTH PROBLEMS CAUSING INCREASED NUTRITIONAL DEMANDS


A. Infections
(Occult/Untreated)a
B. Pressure Ulcers
C. Malignancy

a Undesirable and modifiable (Abbasi, 1994).



Table 2: Process of eating problem management
in the nursing home


I. Resident Admissiona II. Discoveryb III. Figuring Outc
1. Nurse's aide observes eating behavior, and reports to RN. 1. Meal monitoring and Observations by nursing Staff. 1. Recheck weight, follow-up with weekly weight checks (i.e. if on diuretics).
2. Start initial assessment. 2. Rehabilitation staff observations at mealtime. 2. Calorie counts and fluid calculations
3. Rehabilitation screen-record review. 3. R/O physical (i.e. infection, diseases), and Psychogenic causes via diagnostic testing.
4. History, physical and MMSE by NP/MD. 4. OT evaluation of functional hand-to-mouth positioning.
5. Height, weight, VS. 5. Swallow testing and oral motility.
6. Dental screening.
7. Dietary/Nutrition History by RD.

IV. Interventions
1. General Approachesd 2. Specific Approaches
Problem Specifice Resident Specificf
a. Change diet consistency. a. Change/discontinue medications. a. Cues to eat/swallow.
b. Provide supplements. b. Psychiatric evaluation. b. Preferences/choices.
c. Meal monitoring. c. Restrictions: dietary, food, and fluids. c. Feed vs. teach.
d. Encourage patient to eat. d. Safety issues (i.e., thickened liquids). d. Specific assistive devices.
e. Provide substitutions. e. Enteral/parenteral nutrition. e. Behavioral approach: teach, contract.
f. Conduct quarterly screens. f. Change environment at mealtime. f. Special ways of assisting to eat.
g. Therapy Program specific interventions. g. Remove restrictions/ provide comfort measures.

a The systematic assessment process conducted with each resident upon admission to facility.
b The process of ways by which staff become aware of an eating problem.
c The assessment of resident's eating behavior to determine if eating problem is transient, and/or significant or lasting.
d Typical interventions implemented upon recognition of an eating problem.
e Interventions designed by staff to help resolve the root cause(s) of the eating problem.
f Strategies modified to the specific behavior of the resident.


Table 3: Patient clinical information/behaviors that influence the process of eating problem management



A. Known high-risk factors
1. Parkinson's Disease
2. Stroke
3. Aphasia
4. Choking
5. Aspiration

B. Severe weight loss in hospital

C. Panic laboratory values

D. Prior therapy program orders

E. Severe behavior problems




Copyright 1999 by Judith A. Lucas
Current URL: http://rutgersscholar.rutgers.edu/volume01/lucapate/lucapate.htm