Innovation in the nutrition care of dementia

Improving the mealtime care for people living with dementia is complex. There are however many things that can be done to help support a person with dementia at a mealtime.

The link below takes you to an article I wrote for Network Health Digest (NHD) which is the UK’s only independent monthly magazine for nutrition and dietetic professionals. The full article also follows in this blog post.

In the article I describe the background to and reasons why I created the Dementia Mealtime Assessment Tool (DMAT).

Innovation in the nutrition care of dementia

Innovation in the nutritional care of dementia

Mealtime eating difficulties are a major contributor to malnutrition in people living with dementia as well as a constant stress to those caring for them. This article will explain the innovative approach taken which led to the development of software to help carers identify, find solutions and create a care plan to over come mealtime eating difficulties.

Introduction

Initial exposure to people living with dementia came from providing a dietetic service to a 99 bed registered dementia care home in 2011 where >90% of the residents had a form of dementia or cognitive impairmentThe dietetic department would receive many referrals for malnutrition which often stated residents were refusing to eat lunch which was the main meal of the day. Very quickly the hardest part of the dietetic role became getting people living with dementia to eat.   

When providing a dietetic assessment all the conventional and recommended evidence based practice approaches to improve nutritional intake were implemented. Often these approaches would not work successfully and the person living with dementia would continue to lose weight.  

This led to trying a completely different approach 

Mealtime observations were commenced on a particularly problematic floor in the care home to see if anything was being missed in the usual assessment approach. More was learnt in that 1 hour mealtime observation than the previous 6 months discussing and planning interventions. Many mealtime eating difficulties were observed which prevented those living with dementia from consuming enough food. 

Eating difficulties at mealtimes in dementia have also been termed as ‘feeding difficulties’ and ‘aversive feeding behaviours’. Whatever the tem used they describe the decline in eating abilities and behaviour associated with mealtimes in people living with dementia 1. The loss of independence in self-feeding associated with mealtime eating difficulties can lead to weight loss, malnutrition and a poorer quality of life. Problems with eating and feeding can often become a stressful time for both the carer and person with dementia2

The difficulties observed made mealtimes a highly complex caring task. For example some residents would struggle getting food off the plate and into their mouth, others would have difficulty chewing or swallowing while some it seemed did not even recognise it was a mealtime.  Those with more advanced dementia would refuse to eat or show signs of aggression. It seemed obvious that until these mealtime difficulties were resolved dietetic advice would not be as effective as it should be. 

Recording mealtime eating difficulties 

It was necessary to find a way to record these mealtime observations and importantly also have suggestions of effective interventions to overcome them.  A quick look at available research showed there was limited information available for recording mealtime eating difficulties3. The tool that had undergone the most rigorous testing for validity and reliability only highlighted a few of the observations witnessed and provided no suggested interventions4, plus it was difficult to find any records of it being used in clinical practice. This prompted creation of a more practical tool to record observations and in addition suggest interventions to overcome the observed eating difficulties. Initially the tool was based on the Caroline Walker Trust practical guidelines ‘Eating Well: Supporting Older People and Older People with Dementia’ (pages 25-27)5 and used elements from the Edinburgh Feeding Evaluation in Dementia Scale4 to provide a simple way of measuring the frequency of the identified eating difficulties. The tool was named the Dementia Mealtime Assessment Tool (DMAT). With the help of a dietetic student the DMAT was used to observe and record eating difficulties in a sample of dementia residents. The DMAT was simple to use and helped identify an individualised treatment plan to target interventions on overcoming the eating difficulties. The DMAT was useful in clinical practice and its use was continued, however, it was felt further advancement was warranted as it provided a simple solution to a complex problem and feedback from the care home was positive.

Research & Development of the DMAT  

DMAT Observation Form

Starting an MSc in Clinical Research (MRES) at University of Hertfordshire six months later provided opportunity to explore the literature on dementia and eating difficulties.  Available tools for measuring mealtime eating difficulties were researched and elements from each tool aided in designing the DMAT ‘Observation Form’3,6,7,4. Most of the research was completed in long term care settings although the findings could be transferrable to home care and acute setting. 

Interventions for eating difficulties  

The literature was researched for effective interventions for the many different types of eating difficulties, including how manipulation of the environment and social interactions at mealtimes could aid in improving eating difficulties and nutritional intake. Research in this area has been neglected with much of the research completed over a decade ago. Recently there has been a resurgence of interest in the topic with literature or systematic reviews and guidelines published8,9,10,11,12,13,14.  Guidelines however are limited in their recommendations with many potential interventions that could help improve eating difficulties not mentioned, despite the authors suggesting assessment of eating difficulties13. Reading and critiquing all the different interventions makes one thing completely clear; that one intervention alone is not going to work. Mealtimes are complex and there is a need for multi-component interventions to address this while ensuring individualisation of the care plan. When translating the evidence into practical interventions this was kept in mind.   

DMAT Pilot Projects

The DMAT has been piloted by several NHS trusts and private organisations during its development. Feedback from these experiences highlighted that DMAT needs to become more accessible with an emphasis placed on providing easy to initiate interventions.  

The reports from these Pilot Projects of The DMAT can be found linked in our About Page.

DMAT Online System

With the help of a software developer the DMAT was transformed from a paper based resource into web based software compatible across multiple devices. The DMAT aims to help carers identify, find solutions and create a care plan for overcoming mealtime eating difficulties in dementia.   

Figure 1: The DMAT software works in 3 simple steps

How to use The DMAT

Step 1. The figure (1) provides an overview of how to use the DMAT. First you create an account and log into the system17 and use the DMAT. When you log on you can download instructions and the ‘Observation Form’ in paper format to use during mealtimes if required. Based on the research literature and feedback from pilot projects the measurement form helps identify 37 common eating difficulties and is split into 4 sections,which is shown below. 

The DMAT Observation Form : Common mealtime eating difficulties

Step 2. The DMAT system allows you to choose 2 interventions per eating difficulty and any combination of interventions can be trialled. Limiting the interventions to two should keep the care plan simple and allow more accurate outcome monitoring. Different eating difficulties require different approaches but generally the first set of interventions are aimed at improved caring techniques. The next set of interventions aim to enhance catering and nutrition support. Further interventions are aimed at adapting the mealtime environment to make it more dementia friendly as provided in the example. Finally referral to healthcare specialists may be indicated.  

Example: Range of interventions that could be trialled for overcoming the mealtime eating difficulty ‘Stares at food without eating’

Image from the DMAT online system: You can choose up to 2 interventions to implement per identified mealtime ability, reassess, and then make further changes…

The DMAT is not a dysphagia tool but does highlight swallowing difficulties in the ‘Oral Difficulties and Behaviours‘ section on the Initial Measurement Form. The DMAT is however very useful in the management of dysphagia as highlighted in some research articles: Read more on Research featuring The DMAT. The intervention choices associated with these highlight to care staff the importance of patient safety in regard to certain oral difficulties and levels of risk in dysphagia15. If any texture modified food is recommended as an intervention users are also reminded to refer to the national descriptors16 and from 2019 the IDDSI Framework www.iddsi.org/framework

Step 3. The system will generate a care plan based on the identified eating difficulties and chosen interventions (see figure 2 for example). The care plan is saved on the system and can be downloaded, printed and shared with health and social care teams.

Figure 2: Example of The DMAT Care Plan

Image from the DMAT online system: The care plan will highlight the reduced mealtime abilities, their frequency observed and the interventions to be put in place

For monitoring it is recommended to use the DMAT monthly or fortnightly if you have concerns about the individual. Comparisons of previous care plans and results can help measure improvements in eating difficulties.  

Summary

Maintaining independence at mealtimes by preventing and overcoming mealtime eating difficulties should be a more prominent feature of nutritional care for people living with dementia.  A recent systematic review on supporting improved nutrition and hydration in dementia concluded there was ‘no specific evidence or lack of effectiveness of specific interventions’. The authors also stated, with good judgement, that ‘people with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence’8.  

The DMAT has not undergone psychometric evaluation for validity or reliability but provides a much needed resource to quickly and easily capture common eating difficulties people with dementia may present with. Perhaps more importantly it provides carers with evidenced based simple, practical and cost effective interventions to create a care plan to overcome them.  

The DMAT will continue to be developed and is in the process of becoming involved in research trials. You can try the DMAT Online System yourself with a 30 day trial by signing up below. 

Online article link:
Innovation in the nutritional care of dementia (NHD, 2016) This article will explain the innovative approach taken which led to the development of software to help carers assess, choose evidenced based intervention and create a care plan to support mealtime abilities, by Lee Martin MSc RD. 

For a list of the references used in this article please visit the NHD website here.