This document discusses research into helping older people with dementia during mealtimes. Dementia can cause problems with intelligence, memory, language, wandering, aggression and more. It also raises ethical questions around feeding. The Edinburgh Feeding Evaluation in Dementia scale is presented as the most validated measure of feeding difficulty. Several studies testing interventions like music or Montessori-based activities found positive outcomes, though more rigorous research is still needed. Factors like environment, social interaction and individualizing care can help promote independence in feeding for longer. Spaced retrieval training also showed promise in reducing mealtime difficulties. While numbers of those with dementia will rise, targeted interventions may help alleviate associated problems like eating.

1. Research into mealtimes and
older people with dementia
Roger Watson
Academic Dean, Southwest Medical University, Luzhou, China

4. What does dementia affect?

5. Problems associated with dementia
• Intelligence
• Lose problem solving ability
• Memory
• Become forgetful and lost
• Language
• Difficulty communicating

6. Problems associated with dementia
• Wandering
• Aggression
• Incontinence
• Feeding and nutrition

7. Ethical and legal dimensions
Because we cannot readily interpret the actions of a person
with dementia we do not know what to do for the best
Questions:
How do we alleviate eating difficulty?
What constitutes force feeding?
When do we stop feeding a person with dementia?

9. The Edinburgh Feeding Evaluation in
Dementia (EdFED) scale
Watson R, Deary IJ (1994) Measuring feeding difficulty in patients with dementia:
multivariate analysis of feeding problems, nursing interventions and indicators of
feeding difficulty Journal of Advanced Nursing 20, 283-287

10. (2014)

11. The EdFED
• The most widely used and best validated measure is the 10 item Edinburgh
Feeding Evaluation in Dementia Scale (EdFED), developed for those with
moderate to late-stage dementia, and brief and simple enough to be used
in routine care.
• The EdFED has been subject to extensive psychometric testing
demonstrating internal consistency, hierarchical scaling properties (items
5–10), confirmatory factor analysis, construct, convergent and discriminant
validity, inter-rater and test-retest reliability

14. Results
• Sixty-seven papers were retrieved, of which 13 addressed interventions aimed at
helping older people with dementia to feed
• All studies reported positive outcomes but only one randomized controlled trial
was reported
• Music was the most common intervention
• There were no standardized interventions or outcomes across the studies
• None reported the use of power analysis to decide on sample size
• There were problems in some studies with confounding variables

15. 2010

16. Montessori

19. Results
• After receiving the intervention, the Edinburgh Feeding Evaluation in Dementia
(EdFED) scores and assisted feeding scores for the SR and Montessori-based
activity groups were significantly lower than that of the control group
• In terms of the effects of nutritional status after intervention, Mini-Nutritional
Assessment (MNA) in the SR group was significantly higher than that of the
control group.

21. Results
• At the individual level, the increased functional dependence raised the
proportional odds ratios (4.36 times) of an increased dependence in self-feeding
• the degree of cognitive impairment, the lack of social interactions, the occurrence
of pressure sores, comorbidities, as well as the clinical instability and time all
raised the risk of self-feeding dependence progression
• At the nursing home level, an increased number of beds emerged as a factor
also increasing the proportional odds of dependence in self-feeding

23. Results
The promotion and maintenance of eating performance for as long as possible is
ensured by a set of interventions targeting three levels:
• (a) environmental, by ‘Ritualising the mealtime experience by creating a
controlled stimulated environment’
• (b) social, by ‘Structuring effective mealtime social interactions’
• (c) individual, by ‘Individualising eating care’ for each resident.

25. Results
Factors preventing eating dependence were:
(a) at the individual level
• increased functional dependence measured with the Barthel Index (β − 2.374)
• eating in the dining room surrounded by residents (β − 1.802) as compared to
eating alone in bed
• having a close relationship with family relatives (β − 0.854)
(b) at the nursing care level
• the increased number of interventions aimed at promoting independence (β −
0.524)
(c) at the NH level
• high scores in ‘Space setting’ (β − 4.446), ‘Safety’ (β − 3.053), ‘Lighting’ (β −
2.848) and ‘Outdoor access’ (β − 1.225)

27. Results
• Alongside individual and nursing care factors, in poor NH unit environments,
residents with severe cognitive impairment showed increased eating
dependence
• in contrast, in better environments, similar residents showed maximal eating
performance.

29. Results
• A mean 104.4 h were needed to deliver the intervention. The number of sessions
required ranged from 90–222
• The length of time each participant retained information (for all sessions) ranged
from 13–28 min
• A reduction in the difficulty with mealtimes occurred between phase A1–A2 for
most participants
• Spaced retrieval is useful in reducing mealtime difficulties in older participants
with dementia

40. Economic analysis
Items entered into economic costing
Item Value
Nurse labour per hour (a) £40.00
Length of intervention (b) 105 h
Total cost of intervention (c)[a/b] £4200
Value of I unit change in EdFED (kcal) (d) 63 kcal
Mean decline in EdFED score A1-A2 (e) 1.36
Change in kcal (f) [d × e] 86 kcal
Cost per kcal [c/f] £50.00 ) (~RMB432)

41. Summary
• We are unlikely to see a decline in the numbers of people with dementia in the
next few decades
• Problems associated with dementia (eg mealtime difficulties) will increase
• It is possible to alleviate mealtime difficulties through a range of strategies
• Environmental
• Group level
• Individual interventions (eg spaced retrieval)

42. rwatson1955@gmail.com
0000-0001-8040-7625
@rwatson1955