Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes
© The Author(s). 2017
Received: 6 August 2016
Accepted: 7 February 2017
Published: 14 February 2017
There is a growing volume of research to offer improvements in nutritional care for people with dementia living in nursing homes. Whilst a number of interventions have been identified to support food and drink intake, there has been no systematic research to understand the factors for improving nutritional care from the perspectives of all those delivering care in nursing homes. The aim of this study was to develop a research informed model for understanding the complex nutritional problems associated with eating and drinking for people with dementia.
We conducted nine focus groups and five semi-structured interviews with those involved or who have a level of responsibility for providing food and drink and nutritional care in nursing homes (nurses, care workers, catering assistants, dietitians, speech and language therapists) and family carers. The resulting conceptual model was developed by eliciting care-related processes, thus supporting credibility from the perspective of the end-users.
The seven identified domain areas were person-centred nutritional care (the overarching theme); availability of food and drink; tools, resources and environment; relationship to others when eating and drinking; participation in activities; consistency of care and provision of information.
This collaboratively developed, person-centred model can support the design of new education and training tools and be readily translated into existing programmes. Further research is needed to evaluate whether these evidence-informed approaches have been implemented successfully and adopted into practice and policy contexts and can demonstrate effectiveness for people living with dementia.
KeywordsNutrition Dementia Residential care Eating Drinking Meal environment Qualitative
The growing prevalence of dementia worldwide in our aging society has been widely reported with estimates of about 65 million people having dementia by 2030, rising further to 113 million by 2015 [1, 2]. Complex nutritional problems arise in dementia over the course of the disease with the progressive decline in cognitive and behavioural functions, finally losing the ability to independently function physically . Thus due to mental and cognitive impairments, physical disabilities and psychological factors (depression and agitation), people living with dementia have difficulties associated with eating and drinking. These include partial or complete help and support required to eat as skills may be lost (access food to mouth), decreased sense of thirst and the ability to chew. People with dementia may experience increased appetite, rapid eating and repeatedly asking for food or have compulsive eating needs associated with some types of dementia. Dysphagia may develop and is reported in 13–57% of people with dementia . Other mealtime behavioural challenges that affect intake include wandering, pacing, refusal behaviour, apathy or indifference. In addition to the dementia-related problems, people with dementia may also be affected by age-related comorbidities and taken together these can exacerbate reductions in intake and undernutrition [5–7].
In the UK the majority of people with dementia live in the community, and this care is provided by formal or informal care givers (family carer or relative) . Nutrition-related complications in dementia can contribute to stress and caregiver burden. In addition this burden can develop into a cycle that can increase the risk of poor eating behaviour  and weight loss [9, 10]. Nutritional interventions that enable improvements in food and drink intake offer an opportunity to interrupt the potential risk of weight loss, undernutrition and dehydration, the consequent decline in cognition as well as alleviating the associated care burden.
A number of recently published articles have reviewed the current research on interventions aiming to improve food and drink in people with dementia including those living in long term residential care [11–14]. Interventions that modify food and drink include—oral nutritional supplements, assistance with eating and drinking, managing swallowing problems as well as those that offer environment-related interventions during mealtimes including eating location and arrangement, ambient sounds and music, aroma, temperature and lighting and food presentation. However there is no definitive evidence on the effectiveness and sustainability of such interventions to improve the nutritional health and wellbeing of people living with dementia in long term care settings or the potential to reduce cognitive decline in dementia [11–13]. Liu et al.  highlight concerns that many training programmes and mealtime assistance interventions in original studies are implemented by trained research assistants or researchers instead of front-line nursing care staff. This could contribute to the lack of effectiveness observed in many studies. Although there is a growing body of research for strategies to improve person-centred food and drink intake in people living with dementia, many existing approaches have not been tested in real-world settings with all those responsible for the delivery of care . Therefore the aim of this study was to provide a research informed model of day-to-day application gathered from multiple perspectives to inform and upskill those responsible for delivering food and nutrition for people to continue living with dementia in care homes. In this way it will be possible to comprehensively shape which aspects are primary targets for further interventions.
This qualitative study obtained rich contextual data using focus groups and semi-structured interviews. Participants were purposefully sampled from care homes and healthcare services in the community and carer groups from a local database of care providers specialising in dementia care. In total 27 care organisations were identified across rural and urban locations and care staff invited to participate in the study. Participants represented all those involved in the care of people living with dementia including care staff (health care assistants, nurses, care home and hospitality manager, catering staff) family carers, dietitians and speech and language therapists.
The interview guide was developed by reviewing other qualitative research exploring eating and drinking in people living with dementia in community settings to inform questions that would elicit the most informative responses. This was then discussed with the research team and key stakeholders on the project steering group (comprising a commissioner, lay user, workforce development representative, councillor representing social care) to determine what questions would most thoroughly explore the participants’ experiences.
Tell me about your experiences of providing meals and drinks to residents/family member
What do you enjoy about providing meals and drinks to residents/ family member?
What do you find difficult about providing meals and drinks to residents/ family member?
What would help you in providing meals and drinks to residents/family member?
How do you think these areas could be improved?
What issues do residents with dementia confront when eating and drinking?
What happens when residents don’t like meals or drinks? How can this be improved?
How to make food and drink more familiar to residents/ family member? Are there associations with their past? How is it presented? How it is delivered: plate, bowl and cutlery?
How do residents’ cultural and religious sensitivity affect how they see different foods and drinks?
Focus groups were held in a neutral venue led by the research assistant (CB) for this project with background experience of qualitative methods and prior research experience on a project involving people and staff in healthcare and community settings. Two researchers (CB and either JH or JM) were present in each group or semi-structured interview with the research assistant (CB) leading the discussion each time. At each focus group and interview she was supported by one other researcher to moderate and for quality control purposes.
All focus groups and interviews were recorded and transcribed verbatim to ensure accuracy but anecdotes or jokes were not taken into account. Only comments relevant to the research question were transcribed.
Ethical approval for the study was obtained from Bournemouth University Research Ethics Committee. Informed written and verbal consent was provided throughout the study. Participants were not obliged to participate and had the opportunity to ask questions before the sessions took place.
The data collection and analysis was an iterative process, using Braun and Clarke’s  six-stage method of thematic analysis, and ultimately leading to data saturation. In the first stage, the analysis started with familiarization with data, through reading and rereading the transcripts. This was followed by the generation of coding nodes and features of the data were coded across all the transcriptions. In stage three, initial codes were grouped together which allowed the explanations to be identified. Themes were cross-checked by the research team for agreement to minimise bias. Overarching themes that grouped the initial codes were developed to create a framework for writing up the analysis in stage five. Stage six involved writing up the analysis and selecting extracts to illustrate themes.
Names of participants were replaced with codes to assure anonymity. It was noted if a participant agreed to the comment of another participant. To improve the rigour of the analyses and the trust-worthiness, we introduced a number of strategies including the coding and ordering process of excerpts in the transcripts. Triangulation of researchers was performed: all transcripts were first analysed by two researchers independently (CB and JH).
The coding and the interpretation of the codes were then discussed by these two researchers to deepen their analyses and to reach consensus about what were main themes. In addition, the other author (JM) read and analysed at least one transcript. All authors commented on interim and final analyses of the data. The authors have different educational backgrounds (nutrition, food science, sociology).
Details of the participants
Speech and Language Therapists
Number of participants
Gender % female
Themes and sub-themes derived from focus groups and interviews
Person-centred nutritional care
Stage of dementia
Availability of food and drinks
Accommodating changing tastes and preferences
Presentation of meals
Modification of food e.g. food fortification and using food
Prioritisation of food and drink
Delivery, prompting and offering a drink
Tools, resources and environment
Ready plated meal choice options
Constant prompting/encouragement/giving time to person
Environmental factors: Setting the table
Relationship to others when eating and drinking
Relationship to family members
Relationship to care staff
Relationship to other residents
Participation in Activities
Create aromas to stimulate appetite and evoke memories
Enhance appetite and sense of purpose and identity
Consistency of care
Prioritisation of nutrition and hydration
Improved communication between all those involved in care
Provision of Information
Access to trusted information and resources
Education and training
The overarching theme of ‘person-centred nutritional care’ identified the need to prioritise the nutrition and hydration needs and preferences of people living with dementia. The second theme related to the importance that food and drink should be readily available, entitled ‘availability of food and drinks’. The third theme, ‘tools, resources and environment’ focused on the range of tools, resources and influential environmental factors needed to support the delivery of food and hydration. The fourth theme, ‘relationship to others when eating and drinking’ was concerned with how the presence of others, including care staff, family members and other residents and the setting (own room, dining room and other communal area) affected the person’s mealtime experience. The fifth theme, ‘participation in activities’ captured the ways in which activities could be used to engage residents and stimulate the appetite. The sixth theme, ‘consistency of care’ recognised the need for prioritisation and consistency in the provision of nutritional care for people living with dementia in care homes but also across health and social care environments (at home, across care sectors – care homes, in hospital, day centres). This led on to the final theme, ‘provision of information’, that embraced the need for better information, education, training and support to guide nutritional care for both formal and informal carers.
Each theme is described in turn below and illustrated through verbatim representative extracts for either focus group or interview. The extracts are labelled according to the type of participant: care staff (CS), dietitian (DT), family carer (FC), speech and language therapist (SLT), director of nursing (DN), hospitality manager (HM).
Person-centred nutritional care
‘There’s the early dementia where those markers [meeting somebody's full nutrition and hydration requirements] are achievable and there’s a point at which those markers just aren't. And I think that’s really hard for the care staff and the families, but I’ve got to make him eat, I’ve got to, he’s got to eat and there’s this kind of force-feeding. That’s where I think there’s a gap in the literature we give people.’ (focus group 9, SLT 2)
‘across the board dementia care is way under-staffed because we’re seeing such higher dependency of people now coming in. People with dementia who traditionally maybe would have come into care homes much earlier are now being cared for at home in the community … it’s really difficult because you might have one member of staff that’s trying to support four people to dine well and it’s quite impossible…’ (focus group 7, CS 2)
‘…and it could be psychological couldn't it, reasoning, people give for dementia if they’re particularly anxious that day, if something’s frightened them or worried them, they may not know what that is … some of us will when we’re worried, eat and others don’t want to eat, and that’s not uncommon, we see that a lot.’ (focus group 3, CS 3)
‘Y’know the resident may no longer be able to ensure they maintain their dignity, but y’know the staff do that. They make sure their hands are clean before they take their meal and that their hands and their face and their clothing is clean … A lot of these residents have very upstanding professions, livelihoods, y’know characters, experiences and it doesn’t mean because they can no longer do it you just ignore it now y’know. It’s very much instilled the dignity side of things.’ (interview 2, DN 1)
‘we had a lady that came into this home and she’d been diagnosed with dementia… her main meal would be put in front of her and the first thing she would do is actually tip one of the drinks she had beside her, whether it be squash or wine or whatever on to her meal … but we then chatted to the family and we actually discovered this lady had been a horticulturalist in her working time, and the plates that we used at that time had a rim of flowers … she wasn’t seeing the meal … she was seeing the flowers and she was watering the flowers. And the minute we changed our crockery, we tried it initially with her on to a plain white plate, it stopped.’ (focus group 5, CS 3)
‘and it’s like food is the last thing many people have any sort of control over, it’s almost like the anorexic, bulimia sort of cycle of I can’t control where I am or what I do or what people are making me do but I can mmm decide what not to eat or not eat lots.’ (focus group 3, CS 2)
‘the important things with dementia is that they can’t tell you that they’re not eating. You need to look for their physical things first. They might just be unwell or they might have a sore throat… to be careful of their dental hygiene as well. Ill-fitting dentures, things like that really have to sort of eliminate those things first.’ (focus group 4, CS 1)
Generational factors were recognised as important in influencing a person’s nutritional and hydration preferences. Food and drink preferences earlier in their life may become more prominent. For instance participants indicated that the age range within one home ranged between 60 and 104 years. They had introduced a range of food to accommodate changing generational tastes, for example moussakas, cannelloni, sweet and sour chicken.
‘we’ve always respected and taken on board any faith/cultural background…I think we’re still somewhat sheltered at the minute, maybe the next generation we’ll start to see that mixture…a lot of our older gentlemen have been abroad in their younger years and you can see where perhaps y’know contrary to what their wife might think they might actually love a spicy food.’ (interview 2, DN 1)
‘For our chef…the minute he made the first batch he was so happy that he could actually provide somebody who needed the consistency of diet, something that looked…dignified and we’ve never looked back…Y’know you’re not talking of the average older population, you’re talking about the most vulnerable…highest dependent need and you’ve got to take that on board.’ (interview 2, DN 1)
The following six interconnected themes are discussed and in relation to person-centred nutritional care where relevant.
Availability of food and drinks
‘If they say we need some eggs and bacon because… the resident wants this at this time of the morning…the staff are good because we explain… but they’ve got an appreciation of what that person likes in the day or what a typical behaviours are of the day and they can take that on board on nights…’ (interview 2, DN 1)
‘..and if you educate them, if you actually talk them through then obviously advise people to actually have condiments racks in the room that they will add the salt and pepper and paprika and herbs actually on the meal as it comes in but it’s not something that the homes feel particularly confident, I don’t think in doing off their own back I don’t think they know that bit.’ (focus group 9, SLT 3)
‘My experience is … breakfast and the lunches that’s mainly when they’re interested, then after lunchtime it gets harder and harder for people to, to encourage people to eat and most of our residents would find it difficult to choose.’ (focus group 2, CS 2)
‘Finger food, definitely. As the dementia progresses we tend to see that massively increases because they want to retain as much independence as possible.’ (focus group 2, CS 2)
‘they know it’s fish and chips because of the smell of fish and chips, I mean the aroma…and it’s also like the aroma makes you hungry so if a client doesn’t want to eat and you say well I’ve got a nice bowl of carrot soup…you can smell the beautiful spices or the smell of carrot.’ (focus group 5, CS 3)
‘..and when we started looking…it was often misuse with dentures and other things rather than actually a problem of swallowing… we were in a situation where even when we got the dentures and everything fixed that person had not had solid food for so long… we did have to get a SALT (speech and language therapist) referral done because they couldn’t swallow, everything had changed here and they literally did struggle. (focus group 1, CS 1)
‘we don’t have any diabetic products in our kitchens at all. We advocate that if someone is, has a normal type 2 diabetic then they have little bits, maybe, we might limit the amount of sugar, but we don’t start dishing out diabetic jam, diabetic pudding, low fat cake… it’s all of the same, just maybe a little less of it, and again that’s down to encouraging them.’ (interview 3, HM 1)
‘we’ve made a significant reduction in the amount of supplements that people have, partly that’s been driven by the GPs not being so willing to prescribe it because it’s a cost,….. they’ve been having with more smoothies and shakes and milkshakes which again because they’re sweet the residents tend to really enjoy.’ (interview 3, HM 1)
‘we’ve got one lady whose out and about all day. She walks around and however she prefers tea and coffee, she’s not much of a cold drink girl, so we provide more tea and coffee to her y’know. It’s about what they want… and then carers just go in and encourage fluid intake throughout the day.’ (focus group 4, CS 1)
‘..but some days you have orange juice, blackcurrant juice, different juices and it’s…somebody just gets fed up with every day the same food or the same drinks.’ (interview 1, CS 1)
‘If you ask him if he wants a cup of tea he will have one but unless somebody’s going to keep asking him every half an hour do you want a cup of tea, I doubt if he’d get one.’ (interview 4, FC 1)
Tools, resources and environment
‘…we kind of document that into a care plan and ‘cos we’ve got nutritional care plans and we use the MUST tool and I’ve got a carer who weighs people every month, but if they lose weight then we put them on a special chart and then we weigh them more often and so.’ (focus group 3, CS 4)
‘it’s a colour-coded system… the kitchen staff know that anybody with a red coloured code is, they need to keep a real close eye on those. Amber is yeh OK, and green are low. We just use that as a visual tool.’ (focus group 7, CS 4)
‘Finger food, definitely. As the dementia progresses we tend to see that massively increases because they want to retain as much independence as possible, they tend to prefer food they can access easily so soups they’ll suddenly stop eating, but yeh if you pop like a really nice display of finger food in front they’ll all quite happily sit there and eat those.’ (focus group 7, CS 2)
Visual aids such as picture cards and flashing screens could be useful to depict meals, these were recognised as unsuitable especially as dementia advanced. Due to memory loss, cognitive changes and sensory deterioration associated with dementia, identification of food through photographs became more difficult with consequent trouble remembering what had been shown.
‘I don’t see that there is any better yet to me to show me than you showing me two plates of food and saying [name of interviewer] would you like this one or this one? This one’s the lamb and this one’s the chicken …Now if you, depending on the level of dementia and type of dementia you might take quite a long time to choose, it might take you several minutes, you might still when [name of resident] dinner turns up decide you want that one… I think choice has got to be on the plate, in front of you, see it and smell it, have a feel if you want, have a poke of it, but not pictures. Definitely not.’ (interview 3, HM 1)
‘we use the red sensation that actually looked like real crockery and you have to go up to it and pick it up to notice that it’s not, it’s got like a fleck through it black and silvery fleck with a sheen over the top so it looks like porcelain.’ (focus group 3, CS 2)
‘Some people couldn’t pick up that mug so it’s about kind of adapting so we’ve bought plastic ones with two handles, we’ve bought camping mugs because they’re lighter but still resemble a mug. It’s about normalising everyday utensils…’ (focus group 4, CS 2)
‘it’s far more about creating the right atmosphere y’know, all the basics, the lighting, the way the table is set up, background music, having the right implements, the food itself, I think all of these things are what’s creating a relaxed atmosphere.’ (interview 3, HM 1)
Relationship to others when eating and drinking
‘ It depends what stage of the dementia that they’re at because they need quite a lot of support and they need to be told to swallow so yes they need, if someone sits with them they’re more likely to have a meal than if someone, than if they’re just left to it.’ (focus group 6, SLT 5)
This theme is explored further to show the relationship with family members, care staff and other residents.
Relationship to family members
‘some relatives are fantastic, amazing, but some have a limited understanding of dementia and how that can affect taste and appetite … and we try and explain to them things have changed, their needs and their tastes and y’know their abilities are changing‘ (focus group 7, CS 2)
Relationship to care staff
‘each carer can bring a different person out of themselves, I think personality-wise ‘cos it’s how they relate, how they engage with them definitely’ (focus group 5, CS 4)
Relationship to other residents
‘the personalities on the table can have a major effect so you might have somebody who can’t abide noise or is quite noise sensitive, so if somebody’s particularly noisy if you sat them with that person it would probably result in them leaving the table so you’ve got to have a knowledge of your residents as you seat them.’ (focus group 7, CS 2)
Participation in activities
‘It’s amazing and just the smell of a cooked breakfast will start people talking about the cooked breakfast they remember they had after D-Day and you’ll get these amazing conversations y’know that come from just the aromas.’ (focus group 3, CS 3)
‘it’s about stimulation, engagement, occupation so it can be things like y’know food preparation … it’s more about dexterity, it’s more about involvement, inclusion … engaging and doing something so they might be icing cakes … We look at our residents and we see what makes them tick and what they like to do and what we do [is] that with them. So some things can be one-to-one, some things can be group activities and it’s always up for changing.’ (interview 2, DN 1)
‘so we had a French-themed day one day and the chef came up with a beautiful variety of foods and one resident was eating and because the activity staff had put a beret and some onions on completely unprovoked, un y’know un-thought of, this resident started talking very fluently in French. … how important it is to capture all of the information about them because second-hand, third-hand guestimates from others with every best intention and will in the world will not extract the essence of that person.’ (interview 2, DN 1)
Consistency of care
‘It needs to be spread over everything and not just from when [people] come to a care home. It needs to be in the day centres and in the homes, that’s the major problem.’ (focus group 3, CS 2)
Various strategies were proposed to support improvement of communication with participants emphasising how these should be initiated in the early stages of dementia, to ensure that their needs and preferences were being adequately met as their dementia advanced. These strategies included recording and sharing key information, (including life history, nutritional preferences, occupation), the introduction of multidisciplinary meetings, access to a Clinical Nurse Specialist or a Dementia Specialist Nurse to guide and navigate the person living with dementia to relevant services and resources and involvement of the family carer where appropriate.
’we have a new…electronic patient record system that both ourselves and speech and language therapy use …so as long as there has been some sort of consent from the patient to share their record then we can see what speech and language therapists have said and they can see what we have said.’ (focus group 8, DT 2)
‘but then that becomes an issue of confidentiality and consent and all the rest of it doesn’t it … do you remember that when we used to put communication plans above the bed, and oh no you can’t do that, you can’t … What about with your family member who took this journey?’ (focus group 9, SLT 2)
‘…and for the carers themselves they’re not sure how to approach that individual person to support them or think how they should be supported could be different to what happened on the previous day’ (focus group 8, DT 3)
‘food…just being left in front of them and yet this person doesn’t know that you’ve got to lift the lid off to get to the food. Y’know they shouldn’t be drinking from like y’know a cup, like in their care plan they need to be drinking from a lidded beaker and y’know all these things they know that on some days when they’re having a good days, but they’re not having good days ‘cos they’re in hospital…on a bad day they need full assistance to dine, and that’s just not happening.’ (focus group 7, CS 2)
‘Sometimes I find when our chef comes out and he’s obviously got all his chef uniform on it’s quite reminiscent of that, there’s a lot of sit up and oh this is just going to be just lovely and [he] comes back round and has a chat and I think it kind of puts them in a place oh, maybe we are in a restaurant find of thing…‘ (focus group 7, CS 6)
Provision of information
‘Yes I had to just learn by trial and error…It would have been nice to have had some knowledge. Y’know whether the tastes buds disappear… ‘ (interview 4, FC 1)
‘… there’s a balance…and what are the best interests, is it y’know keeping them safe no matter what or is it actually acknowledging that they should actually have some enjoyment and pleasure from their food as well in the later stages of their life.’ (focus group 6, SLT 4)
‘And I think also y’know we’ve had experience recently of nursing homes, training staff supposedly in … dysphagia and dysphagia management […] and by people working in the home who haven’t necessarily got the competency to do so and it’s kind of like tick in the box…whereas actually to what competency level and who’s been monitoring that’.. (focus group 6, SLT 3)
Importantly it was emphasised that any training and education provided needs to be monitored to determine if and how it is being implemented, to ensure the best quality care.
Model to inform strategies for the provision of good nutritional care in dementia
The present study was undertaken to develop a model for understanding the provision of good nutritional care for people living with dementia in nursing homes. Our approach differs from that of previous studies that have explored eating and drinking from either the perspective of the formal or informal care giver [19, 20]. Specifically we developed this model empirically by engaging with stakeholders from multiple perspectives to identify care aspects and processes that could lead to improvements in the delivery of nutritional care in the real world.
Person-centred nutritional care was an overarching aspect of delivering nutritional care in dementia. The importance of ‘person-centred residential dementia care’ has been increasingly recognised over the last 20 years since the publication of Kitwood’s Seminal work, Dementia Reconsidered in 1997 [21, 22]. More specifically, there is recent literature showing the importance of mealtimes for families living with dementia highlighting strategies to promote meaningful mealtimes for family and how to stay socially engaged and continue mealtime routines and activities as dementia progresses . Yet there would appear to be a lack of understanding about the role of eating and drinking and the meaning of the mealtime experiences of people living with dementia in the context of person-centred care. Thus the findings from the present study have illuminated a number of factors that directly contribute to person-centred care for nutrition in people with dementia that could be readily translated into existing programmes for providers of care.
The availability of food and drinks refers to the need for regular main meals and snacks. It recognises that energy needs may not be satisfied adequately through conventional food intake patterns and adaptations need to be made in response to differences in wandering behaviours, sleep patterns and physical activity. The present study offers a broader view of the traditional focus of the ‘meal experience’ in dementia with reference to three meals a day and to take a more holistic view of person-centred food and drink delivery over the whole day when people living with dementia are ready to eat . Meals may need to be enriched with additional energy and protein, fortified snacks offered if weight loss has occurred, thus highlighting the need to identify those who have lost weight and at risk from under nutrition [24, 25]. The findings supported the need to modify food to encourage independent eating e.g. finger foods, use of mini meals, grazing menus particularly for people who elicit wandering patterns of behaviour [26, 27]. In some people food texture may require modification if there is difficulty chewing (though attention to dentition was emphasised as a common issue) and swallowing problems . However the importance of maintaining dignity was highlighted and the use of innovative ways to improve the presentation of foods.
As sensory systems decline with aging, the findings support the need to present food and drink in an appealing and appetizing way in order to facilitate and encourage intake by working with a person’s preferences by boosting flavour, colour, taste and appearance [29, 30]. This aspect may also be determined by other diet-related issues e.g. food allergies, constipation or comorbidities e.g. type 2 diabetes.
As dementia progresses the decreased ability to remember to eat, to recognise food and eat independently and the need for constant negotiation and support during meals were reported. The findings support previous observations to encourage eating and drinking and that caregiver assistance should be tailored to suit a person’s needs, using verbal cues, positive reinforcement whilst helping to retain independent eating and ensuring dignity . Studies have shown that increased time spent by care staff and nurses to support people during meals may positively affect eating behaviour, intake and nutritional status [26, 31].
The findings supported the use and application of nutrition screening , to identify those at risk of undernutrition and ensure a person-centred approach is taken to provide food and drink to people with dementia to improve intake. The use of appropriate resources and specialised equipment (e.g. adaptive crockery and utensils, no-spill cups) to support eating and drinking were recommended, with guidance offered by health care professionals as required. Previous studies support the use of high-contrast coloured crockery and tableware , though there is a lack of consensus of which type of colour to use to improve eating performance of food intake they point towards recognising a person’s preferences.
Environmental factors including eating location and arrangement, ambient sounds and music, smell, temperature, lighting and food presentation were reported to have an important role in reducing stress and anxiety at mealtimes and support previous observations . These aspects have been the attention of recent systematic reviews [3, 16], that have described improvements in behavioural symptoms and dietary intake as a result of improved lighting, relaxing music and offering more homelike food service and environment.
The relationship to others when eating and drinking was another theme that emerged from the presence of others—other residents, staff and family members. This observation supports a previous study that demonstrates positive effects on body weight and eating behaviour in care units as a consequence of shared mealtimes between residents and care givers . However the present study adds that it was important to recognise and respect a person’s preferences to eat alone and that preferences can change with the progression of dementia, mood and personalities.
The findings in the present study demonstrated the way in which ‘participation in activities’ around mealtimes can engage residents to evoke memories (e.g. through themed days, celebratory events). They can stimulate appetite through the physical nature of the activity e.g. gardening, preparing meals but also positively impact on quality of life. Thus these activities were key to engage residents with past memories and providing a sense of purpose and involvement whilst promoting a person’s independence and promote dignity. A previous study has shown that activity associated with living in ‘care farms’ can stimulate dietary intake through additional leisure and recreational activities . There is also growing interest in the benefits of growing food and horticultural therapy as a means to improve physical and psychological wellbeing and social integration [36, 37]. Moreover behavioural interventions in residential long term care such as involving people with dementia in meal preparation have been shown to support social engagement and self-feeding . However what has been revealed in the present study is the importance and benefits of providing and engaging residents in a wide range of food-related activities. More research is needed to understand how participation in activities can improve eating performance and food intake and the overall health and wellbeing of people living with dementia.
The prioritisation and consistency in the provision of nutritional care was reported by all those responsible for the delivery of food and nutritional care. The central importance of communication (both verbal and non verbal) and relationship building in the provision of compassionate care across all settings in general has been discussed in the literature . However in the present study, the findings reveal the barriers evident to providing good nutritional care that could be attributed to poor communication between carers (both formal and informal), high staff turnover and poor record keeping.
The provision of evidence-based information on nutrition and hydration in an accessible format was clearly articulated by participants who discussed the need for education and training. Knowledge of nutrition in the course of the disease and on adequate intervention and communication is essential to provide appropriate nutritional care for people with dementia. There have been several studies that have tested teaching and training interventions for caregivers and nursing staff. They have shown positive effects of caregiver training and education with respect to knowledge and attitudes of caregivers and the nutritional situation of people with dementia . Specifically certain interventions such as ‘Montessori methods’ and ‘spaced retrieval training’ have been shown to be effective in improving eating performance . However the review by Liu et al.  showed that the duration of such approaches in studies were relatively short and implemented by trained research assistants/researchers and recommend that training should be undertaken by nursing caregivers (rather than research assistants) to improve eating performance.
We used several strategies to improve the quality of analysis and trustworthiness of results: triangulation of researchers, and discussions of interim and final analyses with authors who have different backgrounds. However the present study may be limited by collection of data across one regional area. The findings may not reflect the opinions and perceptions of those who work in other nursing homes or live in other parts of the country that would capture more diversity across different cultures and ethnic groups. However the region covered reflects disproportionately more older people than the rest of the country and offers a unique mixture of care staff in different roles and positions and levels of leadership. Thus by drawing on combinations of front-line staff managers and informal carers it has been possible to explore nutritional care from multilevel perspectives of ‘what works’. As such the sampling approach was purposive for those organisations known for their ‘good practice’. We recognise that the present research did not seek the perspectives of people living with dementia in care homes and would require further investigation.
In conclusion, the present study has identified key themes that have informed the development of a conceptual model to guide improvements in nutritional care by those responsible for the delivery of food and nutrition in dementia in nursing homes. Through this evidence-informed model we have since implemented new education and training tools (workbook and film) for caregivers to improve their knowledge, understanding and delivery of nutrition in dementia (www.bournemouth.ac.uk/nutrition-dementia). Further research is needed to evaluate the effectiveness of such evidence-based interventions and their impact on practice to directly support eating and drinking in people with dementia.
Director of nursing
Malnutrition Universal Screening Tool
Speech and language therapist
We thank and acknowledge the cooperation of all the participants in the study who volunteered their time and gave accounts of experiences without which none of the work would have been possible.
Research funding support was provided by the Burdett Trust for Nursing (REF 353) and is gratefully acknowledged.
Availability of data and materials
The raw data is available by email on reasonable request to the corresponding author. E-mail: email@example.com
JM was the primary investigator, leading the study, conceptualization and study design, analysis and writing of the manuscript. JH was a co-investigator, conceptualization and study design, participated in data collection, analysis and writing of the manuscript. CB was a research assistant who was funded by the study, involved in collecting and analysing data and helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Ethical approval for the study was obtained from Bournemouth University Research Ethics Committee. Informed written and verbal consent was provided throughout the study.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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