Jill Morrison

Prevalence and Determinants of Poor Food Intake of Residents Living in Long-Term Care

OBJECTIVEnPoor food intake is known to lead to malnutrition in long-term care homes (LTCH), yet multilevel determinants of food intake are not fully understood, hampering development of interventions that can maintain the nutritional status of residents. This study measures energy and protein intake of LTCH residents, describes prevalence of diverse covariates, and the association of covariates with food intake.nnnDESIGNnMultisite cross-sectional study.nnnSETTINGnThirty-two nursing homes from 4 provinces in Canada.nnnPARTICIPANTSnFrom a sample of 639 residents (20 randomly selected per home), 628 with complete data were included in analyses.nnnMEASUREMENTSnThree days of weighed food intake (main plate, estimated beverages and side dishes, snacks) were completed to measure energy and protein intake. Health records were reviewed for diagnoses, medications, and diet prescription. Mini-Nutritional Assessment-SF was used to determine nutritional risk. Oral health and dysphagia risk were assessed with standardized protocols. The Edinburgh-Feeding Questionnaire (Ed-FED) was used to identify eating challenges; mealtime interactions with staff were assessed with the Mealtime Relational Care Checklist. Mealtime observations recorded duration of meals and assistance received. Dining environments were assessed for physical features using the Dining Environment Audit Protocol, and the Mealtime Scan was used to record mealtime experience and ambiance. Staff completed the Person Directed Care questionnaire, and managers completed a survey describing features of the home and food services. Hierarchical multivariate regression determined predictors of energy and protein intake adjusted for other covariates.nnnRESULTSnAverage age of participants was 86.3xa0±xa07.8xa0years and 69% were female. Median energy intake was 1571.9xa0±xa0411.93xa0kcal and protein 58.4xa0±xa018.02xa0g/d. There was a significant interaction between being prescribed a pureed/liquidized diet and eating challenges for energy intake. Age, number of eating challenges, pureed/liquidized diet, and sometimes requiring eating assistance were negatively associated with energy and protein intake. Being male, a higher Mini-Nutritional Assessment-Short Form score, often requiring eating assistance, and being on a dementia care unit were positively associated with energy and protein intake. Energy intake alone was negatively associated with homelikeness scores but positively associated with person-centered care practices, whereas protein intake was positively associated with more dietitian time.nnnCONCLUSIONnThis is the first study to consider resident, unit, staff, and home variables that are associated with food intake. Findings indicate that interventions focused on pureed food, restorative dining, eating assistance, and person-centered care practices may support improved food intake and should be the target for further research.

How Swallow Pressures and Dysphagia Affect Malnutrition and Mealtime Outcomes in Long-Term Care

Malnutrition is a major cause of hospitalization for residents of long-term care facilities (LTC). Dysphagia is thought to contribute to malnutrition. Tongue weakness is suggested to predict poor food intake, longer meals, and dysphagia. We explored the relationships between tongue strength, dysphagia, malnutrition and mealtime outcomes in LTC residents. Data were collected from 639 LTC residents (199 male), aged 62–102 (mean 87). Maximum isometric tongue pressures (MIPs) and saliva swallow pressures (MSPs) were measured using the Iowa Oral Performance Instrument. Participants also completed the Screening Tool for Acute Neuro Dysphagia. Nutrition status was assessed using the Patient-Generated Subjective Global Assessment. A series of repeated meal observations provided measures of meal duration and calories consumed. Mean MIPs were 33xa0kPa (95% CI 29–37) and MSPs were 26xa0kPa (95% CI 23–29). The odds of showing signs of dysphagia were 3.7 times greater in those with MSPs less than 26xa0kPa (pxa0<xa00.05). The odds of being malnourished were almost double in those showing signs of dysphagia. Co-occurrence of dysphagia and malnutrition was seen in 29%. Residents with low MSPs also had significantly longer mealtime durations (MTD) (pxa0<xa00.05). Moreover, those with both low swallowing pressures and suspected dysphagia consumed fewer calories/minute (pxa0<xa00.05) and had significantly longer MTDs (pxa0<xa00.05). This study confirms associations between tongue weakness, signs of dysphagia, mealtime outcomes and malnutrition among LTC residents. These findings suggest that saliva swallow pressure measures may be helpful for early identification of dysphagia and nutritional risk in this population.

Inadequate fluid intake in long term care residents: prevalence and determinants

ABSTRACT Dehydration is estimated to be present in half of long term care residents, as many do not consume the recommended levels of fluid intake. This study aims to describe fluid intake in long term care residents and identify the factors associated with fluid intake. Data were collected from 622 long term care residents, with a mean age of 86.8 ± 7.8. Total fluid intake was estimated over three non‐consecutive days. Potential resident and unit‐level variables risk factors for low fluid intake were collected, such as dementia status, activities of daily living, and eating challenges. Average daily fluid intake ranged from 311–2390 mL (1104.1 ± 379.3). Hierarchical regression analysis revealed that fluid intake was negatively associated with increased age, cognitive impairment, eating challenges and increased dining room staffing. Being male and requiring more physical assistance were positively associated with intake. Variables identified to predict intake could help inform strategies and targeted interventions to improve fluid intake.

Nutritional quality of regular and pureed menus in Canadian long term care homes: an analysis of the Making the Most of Mealtimes (M3) project

BackgroundLong term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus.MethodsMaking the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality.ResultsThere were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (pxa0<xa00.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (pxa0<xa00.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (pxa0<xa00.01).ConclusionsThere was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture.Trial registrationClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.

Beyond Tube-Feeding: Relationship-Centered, Comfort Care for Individuals with Eating Challenges in Dementia

UCONN Health, Center on Aging, University of Connecticut, Farmington, CT Laura Hatchman, BA School of Medicine, University of Connecticut, Farmington, CT Zhaoyan Fan, PhD Oregon State University, Corvallis, OR Jack M. Guralnik, MD, PhD School of Medicine, University of Maryland, Baltimore, MD Robert X. Gao, PhD Case Western Reserve University, Cleveland, OH George A. Kuchel, MD UCONN Health, Center on Aging, University of Connecticut, Farmington, CT

Intake and Factors Associated with Consumption of Pureed Food in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Abstract Residents living in long term care (LTC) who consume a pureed diet tend to have inadequate intake; understanding factors associated with poor intake in this group of residents is not well established. This study examined the adequacy of nutrient intake among LTC residents consuming a pureed diet and the factors associated with this intake (nu2009=u200967). Data was collected as part of a cross-sectional study conducted in 32 LTC homes. Weighed food intake was measured on three non-consecutive days and analyzed using Food Processor software. Intake of nutrients were adjusted for intra-individual variability and compared to the Estimated Average Requirement or Adequate Intake for women only. Consumers of a pureed diet had low micronutrient intakes. Multivariate analysis found that the average number of staff assisting with a meal was associated with energy and protein intake. Overcoming eating challenges, careful menu planning and nutrient-dense options for pureed diets in LTC are recommended.

Construct Validity of the Mealtime Scan: A Secondary Data Analysis of the Making Most of Mealtimes (M3) Study

Abstract Long-term care (LTC) physical and psychosocial mealtime environments have been inconsistently assessed due to the lack of a standardized measure. The purpose of this study was to examine the construct validity of a new standardized observational measure, the Mealtime Scan (MTS), using the Making Most of Mealtimes data collected on 639 residents in 82 dining rooms in 32 LTC homes. The MTS includes physical, social, and person-centered care summary scales scored from 1 to 8. Mean ratings on these summary scales were moderate for physical (5.6 SD 0.9), social (5.0 SD 0.9), and person-centered care (PCC; 5.5 SD 0.8). Regression analyses determined which items within the MTS were associated with these summary scales: physical – music (Bu2009=u20090.27, pu2009=u20090.04), number of staff passing food (Bu2009=u2009−0.11, pu2009=u20090.03), number of residents (Bu2009=u2009−0.03, pu2009=u20090.01); social – social sound (Bu2009=u2009u20090.31 pu2009<u20090.0001), number of residents requiring eating assistance (Bu2009=u20090.11, pu2009=u20090.02); PCC – lighting (Bu2009=u20090.01 pu2009=u20090.04), and total excess noise (Bu2009=u20090.05, pu2009<u20090.0001). The Mealtime Relational Care Checklist (M-RCC) was associated positively with ratings on all three summary scales. Correlations revealed that the MTS summary scales were associated with other constructs: Dining Environment Audit Protocol functionality scale, resident and dining room level M-RCC, Mini Nutritional Assessment- Short Form, and resident Cognitive Performance Scale. These results demonstrate that the MTS summary scales exhibit construct validity, as the ratings were associated with expected observed mealtime characteristics and correlated with dining room and resident level constructs in anticipated directions.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

ObjectiveModified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.DesignMaking the Most of Mealtimes (M3) is a cross-sectional multi-site study.Setting32 LTC homes in four Canadian provinces.ParticipantsRegular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68).MeasurementsMalnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance.ResultsPrescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment.ConclusionsPrescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Construct validity of the Dining Environment Audit Protocol: a secondary data analysis of the Making Most of Mealtimes (M3) study.

BackgroundResearch has demonstrated the importance of physical environments at mealtimes for residents in long term care (LTC). However, a lack of a standardized measurement to assess physical dining environments has resulted in inconsistent research with potentially invalid and unreliable conclusions. The development of a standardized, construct valid instrument that assesses dining rooms is imperative to systematically examine physical environments in LTC. The purpose of this study was to determine the construct validity of the new Dining Environment Audit Protocol (DEAP) tool.MethodsSecondary data collected from the Making Most of Mealtimes (M3) study was used for this analysis. Data were collected in 32 long term care homes, which included 82 dining rooms and 639 residents. A variety of resident and dining room level constructs were compared to the summative scales found on the DEAP using Spearman correlations and Student t-tests. A regression analysis identified individual characteristics assessed with DEAP that were associated with the summative scales of homelikeness and functionality.ResultsRegression analysis (pxa0<xa00.05) identified that the DEAP homelikeness scale was positively associated with a view of the garden/green space, presence of a clock and a posted menu. The functionality scale was positively associated with number of chairs and lighting, while negatively associated with furniture with rounded edges and clutter. Additionally, the functionality scale was positively associated (pxa0<xa00.05) with the Mealtime Scan physical scale (ρxa0=xa00.52), the dining room Mealtime-Relational Care Checklist (M-RCC) (ρxa0=xa00.25), the DEAP total score (ρxa0=xa00.56), and the Mini Nutritional Assessment- Short Form (ρxa0=xa00.26). Homelikeness was positively associated (pxa0<xa00.05) with the DEAP total score (ρxa0=xa00.53), staff Person Directed Care score (ρxa0=xa00.49) and the resident Cognitive Performance Scale (txa0=xa02.56), while negatively associated with energy (ρxa0=xa0−0.26) and protein intake (ρxa0=xa0−0.24). The homelikeness and functionality scales were also associated with one another (ρxa0=xa00.26).ConclusionThe construct validity of the DEAP was supported through significant correlations with a variety of measures that are theoretically related to the homelikeness and functionality of LTC dining rooms. This secondary analysis supports the use of the DEAP in future research to quantify the physical environment of LTC dining rooms.Protocol registered with ClinicalTrials.gov ID: NCT02800291; Registered retrospectively June 7, 2016.