Joanne Holmes

Measurements of Daily Energy Intake and Total Energy Expenditure in People with Dementia in Care Homes: The Use of Wearable Technology.

ObjectiveTo estimate daily total energy expenditure (TEE) using a physical activity monitor, combined with dietary assessment of energy intake to assess the relationship between daily energy expenditure and patterns of activity with energy intake in people with dementia living in care homes.Design and settingA cross-sectional study in care homes in the UK.ParticipantsTwenty residents with confirmed dementia diagnosis were recruited from two care homes that specialised in dementia care.MeasurementsA physical activity monitor (Sensewear™ Armband, Body Media, Pittsburgh, PA) was employed to objectively determine total energy expenditure, sleep duration and physical activity. The armband was placed around the left upper triceps for up to 7 days. Energy intake was determined by weighing all food and drink items over 4 days (3 weekdays and 1 weekend day) including measurements of food wastage.ResultsThe mean age was 78.7 (SD ± 11.8) years, Body Mass Index (BMI) 23.0 (SD ± 4.2) kg/m2; 50% were women. Energy intake (mean 7.4; SD ± 2.6) MJ/d) was correlated with TEE (mean 7.6; SD ± 1.8 MJ/d; r=0.49, p<0.05). Duration of sleeping ranged from 0.4-12.5 (mean 6.1) hrs/d and time spent lying down was 1.3-16.0 (8.3) hrs/d. On average residents spent 17.9 (6.3-23.4) hrs/d undertaking sedentary activity. TEE was correlated with BMI (r=0.52, p<0.05) and body weight (r=0.81, p<0.001) but inversely related to sleep duration (r=-0.59, p<0.01) and time lying down (r=-0.62, p<0.01). Multiple linear regression analysis revealed that after taking BMI, sleep duration and time spent lying down into account, TEE was no longer correlated with energy intake.ConclusionsThe results show the extent to which body mass, variable activity and sleep patterns may be contributing to TEE and together with reduced energy intake, energy requirements were not satisfied. Thus wearable technology has the potential to offer realtime monitoring to provide appropriate nutrition management that is more person-centred to prevent weight loss in dementia.

Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes

BackgroundThere 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.MethodsWe 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.ResultsThe 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.ConclusionsThis 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.

The use of wearable technology to measure energy expenditure, physical activity, and sleep patterns in dementia

Project Description Unexplained weight loss is frequently observed in dementia leading to further cognitive decline, frailty and disability. Apparent mechanisms that could lead to weight loss (lower energy intake and/or higher expenditure) remain unresolved and may be different in the various stages and types of dementia. During the progression of the illness, the extent to which altered sleep duration and variable physical activity patterns (intermittent or constant pacing/lying down) could affect weight loss is unknown. We have used an innovative light weight physical activity monitor (Sensewear TM Armband, Body Media, Pittsburgh, PA) to objectively determine total energy expenditure (TEE), sleep duration, physical activity and number of steps in people with dementia living in care homes. The armband was placed around the left upper triceps for up to 7 days. The device measures tri-axial acceleration, skin temperature, galvanic skin response and heat flux and has been shown to be valid in resting, exercise and free-living conditions in older people. The mean age of the residents (n=20) was 78.5 (58-99) years, 50% were women with confirmed diagnosis of a range of dementia types. Body Mass Index (BMI) was 23.0 (range 13.7-30.0) kg/m2 with 40% classified as underweight, 50% normal range, 10% overweight. Duration of sleeping ranged from 0.4-12.5 (mean 5.9) hrs/d and time spent lying down was 1.0-16.0 (8.1) hrs/d. On average residents spent 17.4 (6.0-23.7) hrs/d undertaking sedentary activity. Sleeping duration was inversely related to body weight (r= -0.46, p<0.05) and TEE (r= -0.59, P<0.01). There was an inverse association between time lying down for both body weight (r= -0.45, p<0.05) and TEE (r= -0.62, p<0.01).TEE was positively correlated with number of steps per day (r= 0.45, p<0.05). There was no relationship between TEE or BMI and the amount of physical activity. Variable patterns of physical activity and sleep duration demonstrates the need to recognise the influence of these factors on meeting energy requirements and the challenge of providing appropriate food and nutrition within the care home environment. Thus wearable technology has the potential to offer real-time feedback to support better nutritional management and improve efforts to prevent weight loss in dementia.

EVALUATION OF INNOVATIVE NUTRITION EDUCATION AND TRAINING FOR CARE STAFF SUPPORTING PEOPLE LIVING WITH DEMENTIA

Nutrition-related interventions that enable improvements in food and drink intake offer an opportunity to prevent the potential risk of weight loss, undernutrition and dehydration, the consequent decline in cognition as well as alleviating the associated care burden. Informed by our own funded evidence-based research and relevant peer reviewed literature and reports, a combination of innovative training tools (workbook and training film) on nutrition and hydration have been implemented for staff caring for people living with dementia in elderly residential, domiciliary care, hospital and other care settings (http://www.bournemouth.ac.uk/nutrition-dementia). The training materials are structured into three sections: Section 1: Food and drink availability, Section 2: Importance of activity: encouraging food and drink intake through activity and Section 3: Importance of communication and relationships. Using qualitative, exploratory methodologies, we report the findings from an evaluation of the impact of the training materials on practice and people living with dementia. Semi-structured telephone interviews were undertaken with 18 care staff (care homes, domiciliary care, hospital) at 3months after receiving the tools. The telephone interviews lasted between 10 and 20 minutes. Conversations were recorded, transcribed, and analysed using thematic analysis. Main themes reported included changing environmental factors (e.g. protected mealtimes), offering choice, recording those at risk of or having undernutrition through nutrition screening (‘MUST’) and monitoring the quantities of drinks consumed, person-centred approach (e.g. aware of persons tastes). The majority of participants (15/18 participants) had changed how food and drink were made available and introduced activity to encourage food and drink intake. 13 of 18 participants had changed practice around communication about food and drink. These preliminary findings show the potential for this platform of training to make positive changes given its flexibly to be either self-completed and/or shared by staff with their colleagues. Further research needs to widen the scope for evaluation to reflect differences in cultural diversity and practice in other areas.

Understanding the strategies required to meet hydration needs of people living with dementia

Background Dementia can increase the risk of dehydration as cognitive impairment and old age reduce the ability to recognise thirst. Dehydration can cause further deterioration in cognitive function and other health problems. There is no consensus on recommended fluid intakes for dementia but generally 1500 ml per day is regarded as sufficient. However the challenges of meeting appropriate hydration continue to be reported. The aim of this study, using quantitative and qualitative methods was to gain a deeper understanding of the strategies required to understand hydration needs of people living with dementia. Methods Quantitative measures of fluid intake were recorded over a period of five days in residents (n=18) who were living in care homes. The mean age of the residents was 79 (104-58) years, 50% were women with a diagnosis of a range of dementia types. Qualitative research using a blend of nine focus groups and five semi structured interviews were conducted with all those involved in the care of people with dementia, including nurses, managers, chefs, care workers, family members, dietitians and speech and language therapists. Thematic analysis of transcripts enabled core themes to be explored. Results The daily intake of fluid was 1065 ± 836 ml (mean ± 2 standard deviations). Fifteen (83%) residents did not meet the recommended fluid intake. The qualitative themes highlighted ways to overcome poor fluid intake and included alternative ways to improve hydration; a person centred approach to delivering fluid with a recognition of psychosocial and cultural influences; communication between front-line staff and key healthcare professionals. Conclusions Using this combined methodological approach, the results show that new strategies are needed to meet the hydration needs, with a person centred approach to care for people living with dementia. It is important to ensure all staff are well trained and competent to encourage sufficient fluid intake.

The use of e-portfolios to support professional development of student nutritionists – a pilot study

Portfolios are a useful approach to present and record evidence for the assessment of skills and competencies. The use of electronic portfolios has been advocated to support personal development planning (PDP) and their use has been shown to be multifunctional to link education and professional practice as well as for developmental purposes such as reflection, competency and skill management and presentation for assessment and professional registration. However little is known about the attitudes of undergraduate nutrition students to e-portfolios and PDP. The aim of this study was to establish if a voluntary e-portfolio would encourage students to reflect on their work and use as an electronic space to record evidence for professional registration after graduation. The e-portfolio was introduced as a pilot in October 2009 to all interested BSc (Hons) Nutrition students at Bournemouth University. The university’s virtual learning environment provided the space to create individual e-portfolios. An online learning tool supported the students and 6 weeks after the introduction a workshop was held to give IT support. A virtual discussion forum enabled users and staff to discuss and monitor issues. Students were invited to complete a short questionnaire encapsulating their experiences at the end of the academic year. Fifty-two (79%) students from a total programme cohort of sixty-six students initially signed up to use the e-portfolio. Ten students, from across the programme, completed the questionnaire and of these two, had created an e-portfolio. Common reasons given for not completing the e-portfolio were: I am in the first year of my studies and finishing my degree and registration seems a long-time away (28.7%); I have had insufficient time (71.4%); the university workload this year has been so great I have not wanted to complete extracurricular projects (57.7%); the system is not transferable to the registration body (42.8%). Nearly two-thirds of respondents felt they would be more motivated to use the e-portfolio if it was assessed. Opinion was equally split as to whether assessment should be across the whole programme or for specific units. Despite initial interest, the very low level of engagement with the e-portfolio was disappointing. The findings indicate that assessment may be required to embed the use of e-portfolios in the undergraduate curriculum. Further work is required to evaluate the use of e-portfolios in the assessment process. Consideration needs to be given to a dedicated e-portfolio system as an integral part of both student training and continued professional development for the registered nutritionist.