Evidence Review
Optimizing Eating Performance for Older Adults With Dementia Living in Long-term Care: A Systematic Review Wen Liu, RN, PhD • Elizabeth Galik, PhD, CRNP • Marie Boltz, RN, PhD, GNP-BC • Eun-Shim Nahm, RN, PhD, FAAN • Barbara Resnick, RN, PhD, CRNP, FAAN, FAANP
ABSTRACT Keywords dementia, eating performance, intervention studies, long-term care, older adults
Background: Review of research to date has been focusing on maintaining weight and nutrition with little attention on optimizing eating performance. Objective: To evaluate the effectiveness of interventions on eating performance for older adults with dementia in long-term care (LTC). Methods: A systematic review was performed. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014. Keywords included dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, and intervention. Intervention studies that optimize eating performance and evaluate change of self-feeding or eating performance among older adults (ࣙ65 years) with dementia in LTC were eligible. Studies were screened by title and abstract, and full texts were reviewed for eligibility. Eligible studies were classified by intervention type. Study quality was accessed using the Quality Assessment Tool for Quantitative Studies, and level of evidence using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence. Results: Eleven intervention studies (five randomized controlled trials [RCTs]) were identified, and classified into four types: training program, mealtime assistance, environmental modification, and multicomponent intervention. The quality of the 11 studies was generally moderate (four studies were rated as strong, four moderate, and three weak in quality), with the main threats as weak designs, lack of blinding and control for confounders, and inadequate psychometric evidence for measures. Training programs targeting older adults (Montessori methods and spaced retrieval) demonstrated good evidence in decreasing feeding difficulty. Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance. Linking evidence to action: This review provided preliminary support for using training and mealtime assistance to optimize eating performance for older adults with dementia in LTC. Future effectiveness studies may focus on training nursing caregivers as interventionists, lengthening intervention duration, and including residents with varying levels of cognitive impairment in diverse cultures. The effectiveness of training combined with mealtime assistance may also be tested to achieve better resident outcomes in eating performance.
INTRODUCTION Eating performance is the functional ability to get food into the mouth. It is one of the most basic and easiest activities of daily living (ADLs) to perform (Liu, Unick, Galik, & Resnick, 2015), as well as the last ADL that older adults living in long-term care (LTC) settings lose (Morris, Fries, & Morris, 1999). LTC residents with dementia are at greater risk of compromised eating performance due to progressive cognitive impairment and behavioral symptoms when compared to residents without
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dementia (Cortes et al., 2008). More than half of the LTC residents with dementia experience loss of independence in eating performance (LeClerc, Wells, Sidani, Dawson, & Fay, 2004). Residents with severe cognitive impairment demonstrated the greatest deterioration in eating performance compared to the other ADLs within 6 months after nursing home admission (Carpenter, Hastie, Morris, Fries, & Ankri, 2006). Autonomy at mealtimes is an important indicator of quality of life, both physically and psychosocially, for older adults living with dementia (Keller et al., 2010). Mealtime is not just Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Evidence Review a process to ensure adequate nutrition and intake, but also a pathway to enjoy social contact and interaction, as well as food (Gibbs-Ward & Keller, 2005; Palacios-Ce˜ na et al., 2013). Mealtime experiences should continue to be pleasurable events for older individuals with dementia, as compromised eating performance has a significant impact on health outcomes and quality of life (Hanson, Ersek, Lin, & Carey, 2013). Appropriate support and commitment from caregivers is critical to help older adults with dementia optimize eating performance and enhance mealtime pleasure (Keller et al., 2010; Pelletier, 2005). However, due to institutional barriers such as insufficient staffing and policies to prevent weight loss, caregivers may primarily focus on maintaining caloric intake and help too much with feeding in order to complete eating tasks quickly (Crogan & Shultz, 2000). Excessive or unnecessary assistance with feeding, regardless of residents’ self-feeding ability, may result in unintended dependence, interfere with residents’ autonomy, decrease mealtime pleasure, and elicit resistance and aggressive behaviors (Amella, 2002; Gibbs-Ward & Keller, 2005).
FACTORS THAT INFLUENCE EATING PERFORMANCE Numerous factors influence eating performance among older adults with dementia in LTC. The social ecological model (SEM), which was developed based on the ecological systems theory (Bronfenbrenner, 1992), provides a comprehensive approach for how to conceptualize and consider these factors. The SEM examines the influential factors of eating performance from a multilevel perspective: intrapersonal, interpersonal, environment and policy (Glanz, Rimer, & Viswanath, 2008; McLaren & Hawe, 2005). The intrapersonal factors that influence eating performance include age, comorbidities, physical capability, motivation, cognitive impairment, mental and psychological disorders, and behavioral problems (Chang & Roberts, 2008; Desai, Schwartz, & Grossberg, 2012; Slaughter, Eliasziw, Morgan, & Drummond, 2011). The interpersonal factors include caregivers’ knowledge, attitude and skills to engage residents to eat as independently as possible (Chang & Lin, 2005), social support from caregivers and peers, and communication and interaction between residents and caregivers (Chang & Roberts, 2008; Crogan & Shultz, 2000). The environmental factors include the physical environment in which individuals eat such as the lighting in the dining room, the availability of assistive devices (e.g., adaptive bowls, plates and utensils, and no-spill cups), the comfort of the chairs or wheelchairs in which residents sit during meals, and the fit between the resident and the chair in terms of optimizing positioning to facilitate eating (Slaughter et al., 2011). The environmental perspective also includes the cultural environment such as the way in which the food is presented (Clay, 2001), and the cultural compatibility of the food choices provided (Altus, Engelman, & Mathews, 2002; Andreoli, Breuer, Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Marbury, Williams, & Rosenblut, 2007). There are also some institutional factors such as appropriate staffing for mealtime supervision and assistance, high workload, and staff turnover (Schnelle et al., 2004). The policy factors include custodial care management styles, policies that are task-oriented instead of resident-oriented, and focus on adequate intake and expediency instead of optimizing self-feeding independence (Gibbs-Ward & Keller, 2005). Effective interventions should target these diverse personal and environmental factors to promote engagement of residents in their highest level of function with regard to eating (Amella, Grant, & Mulloy, 2008; Aselage, Amella, Rose, & Bales, 2015). Multilevel, multicomponent individualized care has been recommended to achieve optimal eating performance among LTC residents with dementia (Keller et al., 2014).
RATIONALE AND OBJECTIVE OF THE REVIEW The body of literature on mealtime interventions for older adults with dementia has been growing within the last several decades (Liu, Cheon, & Thomas, 2014; Watson & Green, 2006). As a disparate area of research with generally low to moderate quality, mealtime interventions showed potential to positively influence nutritional outcomes and behavioral symptoms, and future testing of theory-based interventions with high-quality trials was recommended (Abbott et al., 2013; Hanson, Ersek, Gilliam, & Carey, 2011; Liu et al., 2014; Whear et al., 2014). The majority of the review work in this field, however, has generally focused on maintaining weight, nutrition and behavioral symptoms with little attention on optimizing eating performance. Evaluation of current research on optimizing eating performance will accumulate evidence and provide important directions for future work. The purpose of this systematic review, therefore, was to summarize available interventions and evaluate their effectiveness on eating performance among older adults with dementia in LTC settings.
METHODS Design and Data Sources The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Liberati et al., 2009) was used to guide this systematic review. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014 for intervention studies published in English and in peer reviewed journals. Other sources included Google Scholar and bibliography of eligible studies with an effort for a complete retrieval of literature. The keywords were dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, intervention, and any matched subjects or MeSH terms. The search strategy for Pubmed is shown in Table S1 (available with online version of this article). The protocol for conducting this review was not published or registered anywhere else previously.
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Eligibility Criteria and Study Selection Studies were included in the review based on the Population, Intervention, Comparator, Outcomes, Timing and Setting of interest (PICOTS; Table S2 available with the online version of this article; Guyatt et al., 2011). Intervention studies that focused on optimizing eating performance and evaluated change of self-feeding or eating performance in older adults (ࣙ65 years) with dementia living in LTC settings were eligible. Studies were excluded if the participants received enteral or parenteral nutrition; the participants were recruited from hospitals, communities, in-home-living or clinic settings; the intervention components were nutritional supplementation, nutritional education or music; the outcomes were nutritional intake, anthropometric and biochemical parameters, behavioral disturbances or other adverse events. Based on eligibility criteria, studies were selected and assessed by two reviewers following three steps: screening by title and abstract, assessing full-text for eligibility, and reviewing full-text for data abstraction and quality assessment. Individual results were compared and discrepancies were discussed to arrive at agreement.
Data Analysis Eligible studies were classified by intervention type as well as by the level of factors (e.g., personal, environmental) associated with eating performance based on the intervention protocol. The quality of the reviewed studies was assessed by the same two reviewers independently using the Quality Assessment Tool for Quantitative Studies ([QATQS]; Table S3 available with the online version of this article; Thomas, Ciliska, Dobbins, & Micucci, 2004). Each individual study was evaluated on eight components: Selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity, and analysis. The first six components were rated as strong, moderate, or weak, and altogether resulted in an overall rating of study quality, while the last two components were not rated according to QATQS. The ratings of each study were compared, and discrepancy was identified and discussed to arrive at agreement. Level of evidence was graded using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Jeremy et al., 2011a,b,c) for each individual study included in the review. The levels of evidence for the treatment benefit question of “does this intervention help” was specifically used to fit the purpose of this review. There are five levels of evidence, levels 1–5, ranging from high certainty to decreasing certainty, respectively. Level 1 is a systematic review of randomized controlled trials or n-of-1 trials; level 2 includes randomized controlled trials or observational studies with dramatic effect; level 3 includes nonrandomized controlled cohorts or followup studies; level 4 includes case-series, case-control studies, or historically controlled studies; and level 5 is mechanism-based reasoning. The quality and quantity of studies as well as the level of evidence were all considered when making recommendations regarding the interventions.
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RESULTS Study Characteristics A total of 1,387 records were identified and 11 studies met inclusion criteria after removing duplicates, screening title and abstract, and assessing full-text for eligibility (Figure S1, available with the online version of this article). Individual study characteristics, including study design and level of evidence, sample and setting, intervention, comparator, duration, outcomes and measures, and outcome changes were present by intervention type (Table S4, available with the online version of this article). The 11 intervention studies (5 RCTs, 2 Controlled Clinical Trials [CCTs], 2 interrupted time series, and 2 single group repeated measures) included a total of 530 older adults with dementia and 86 nursing caregivers (e.g., registered nurses, nursing assistants, certified assistant nurses, licensed practical nurses) from 21 LTC facilities (e.g., nursing home, assisted living, skilled nursing facility, residential geriatric center, veteran’s home). These studies originated from the United States, Taiwan, and Canada. Baseline functional characteristics of older adults (e.g., self-feeding or eating performance, cognitive impairment, physical capability, and level of assistance needed) varied across studies.
Quality of Reviewed Studies The quality of the eleven reviewed studies was evaluated using the QATQS criteria and is shown in Table S5 (available with the online version of this article). Specifically, all 11 studies used convenience sampling, which could induce potential selection bias. The sample size varied across studies, with six studies including less than 30 older adults with dementia, four studies including 30–100 residents, and one study including more than 100 residents. Three studies were conducted in a single setting, two studies in two units within one facility, and six studies in two or more facilities. Regarding confounders, four studies controlled for confounders, while the other seven studies introduced confounding bias. The confounding bias included not comparing (Van Ort & Phillips, 1995) or controlling for (Chang & Lin, 2005; Coyne & Hoskins, 1997; Simmons & Schnelle, 2004) baseline differences, new staffing policies during the intervention period (Brush, Meehan, & Calkins, 2002), potential carryover effects of interventions (Simmons & Schnelle, 2004), and potential contextual factors (Altus et al., 2002; Perivolaris, 2006). Use of blinding for outcome assessors or participants was available in four studies (Lin et al., 2010; Lin, Huang, Watson, Wu, & Lee, 2011; Moore, 2010; Wu, Lin, Wu, Lin, & Liu, 2014), unknown in five studies, and unavailable in two studies. Regarding data collection methods, six studies used reliable and valid instruments for measuring eating performance (e.g., EdFED, FAA, FIM), while the other five studies used measures without adequate evidence of reliability or validity (Aselage, 2010; Ottenbacher, Hsu, Granger, & Fiedler, 1996). All 11 studies reported withdrawal rate of less than 20%. Two studies (Altus et al., 2002; Van Ort & Phillips, 1995) applied only descriptive but not inferential statistics. Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Evidence Review Overall, four studies were rated as strong, four moderate, and three weak in quality. The main threats to study quality were weak study designs, lack of blinding and control for potential confounders, and inadequate measurement reliability or validity evidence.
Interventions to Optimize Eating Performance The interventions used in the 11 studies were classified into four types targeting personal or environmental levels of factors associated with eating performance: training programs for residents or nursing assistants at intra- or interpersonal levels, mealtime assistance from nursing caregivers at interpersonal level, environment modification at environmental level, and multicomponent interventions at both personal (i.e., resident or nursing staff) and environmental levels. Diverse forms of self-feeding or eating performance outcomes were evaluated across studies using different objective data and instruments. These outcomes included eating independence by Eating Behavior Scale ([EBS]; Tully, Matrakas, Muir, & Musallam, 1997), Functional Independence Measure ([FIM]; Ottenbacher et al., 1996) and Adapted Level of Eating Independence scale (Coyne & Hoskins, 1997); self-feeding ability by Feeding Ability Assessment ([FAA]; LeClerc et al., 2004); functional feeding by Feeding Traceline Technique (Phillips & Van Ort, 1993); feeding difficulty by Edinburgh Evaluation in Dementia scale (EdFED; Lin, Watson, Lee, Chou, & Wu, 2008; Liu, Watson, & Lou, 2014) and mealtime communication by Communication Outcome Measure of Functional Independence (Santo Pietro & Boczko, 1997).
Training Programs for Residents or Nursing Assistants Four studies (two RCTs and two CCTs) addressed training programs related to intra- or interpersonal factors that influenced eating performance of LTC residents with dementia, and evaluated their impact on eating independence, feeding difficulty and self-feeding frequency. These interventions included the feeding skills training program for caregivers (Chang & Lin, 2005), Montessori-based activities with (Lin et al., 2010; Wu et al., 2014) and without (Lin et al., 2011) spaced retrieval for older adults with dementia. Specifically, Montessori-based activities break down eating-related activities into continuous sequential procedures, and ask residents to practice the procedures in sequence actively and repetitively (Camp et al., 1997), while spaced retrieval consists of presenting residents with information or procedures related to eating and asking them to recall it at increasing time intervals (Vance & Farr, 2007). The study testing training program for caregivers had moderate quality with level 2 evidence, and all the three “training programs for residents” studies that tested Montessori methods with or without spaced retrieval had strong quality with level 2 evidence. Residents were considered to have feeding difficulty if they scored 2 or above using the Edinburgh Feeding Evaluation in Dementia (EdFED) scale (range from 0 to 22; Lin et al., 2008; Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Liu, Watson, et al., 2014). The feeding skill training program for caregivers significantly increased feeding difficulty among residents (e.g., from 7.4 to 10.3), while Montessori-based activities and spaced retrieval for residents demonstrated statistically significant effects in reducing feeding difficulty, enhancing eating independence and increasing self-feeding frequency. Specifically, feeding difficulty among residents decreased approximately from 5 to 3 (Lin et al., 2010; Lin et al., 2011) using Montessori methods and spaced retrieval separately, and decreased further to approximately 2 or below when Montessori methods combined with spaced retrieval were used (Wu et al., 2014). Eating independence level as measured by EBS from 16.18 to 16.79, and self-feeding frequencies from 2.57 to 3.00 were noted with mild but statistically significant improvement using Montessori methods (Lin et al., 2011).
Mealtime Assistance From Nursing Caregivers Three studies (e.g., two RCTs and one interrupted time series) addressed mealtime assistance related to interpersonal factors that influence eating performance of LTC residents with dementia and evaluated the impact on eating independence, functional feeding, and frequency and time for physical or verbal assistance. The interventions included standardized verbal prompts and positive reinforcement (Coyne & Hoskins, 1997), behavioral prompts, cues and reinforcement (Van Ort & Phillips, 1995), and individualized feeding assistance (Simmons & Schnelle, 2004). The two studies testing verbal prompts, cues and reinforcement had moderate quality with level 2 evidence, and the study testing individualized feeding assistance had moderate quality with level 4 evidence. Verbal prompts and positive reinforcement resulted in greater independence in eating solid and liquid foods (Coyne & Hoskins, 1997), and more sustained functional feeding (Van Ort & Phillips, 1995). Individualized feeding assistance, however, increased assistance time (from 5.9 to 35.6 minutes), and episodes of verbal (from 3.3 to 12.2) and physical (from 12.4 to 32.00) prompts offered by staff (Simmons & Schnelle, 2004).
Environment Modification Addressing Environmental Factors One study (one single group repeated measures) addressed the effect of enhanced lighting and table setting contrast on eating performance of residents (Brush et al., 2002) with weak quality and level 3 evidence. The study demonstrated a decrease in assistance needed among residents, and an improvement in the frequency of residents initiating or engaging in conversations with staff as well as residents’ ability to find and use napkins and to follow simple directions during mealtimes.
Multicomponent Interventions Addressing Personal and Environmental Factors Three studies (one RCT, one single group repeated measures, and one interrupted time series) tested the impact of multicomponent interventions focused on eating performance with
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varied quality and levels of evidence from level 2 to 4. Specifically, family style meal delivery and staff training on prompting and praising appropriate mealtime behaviors improved residents’ participation in eating tasks (e.g., from 10% to 65% of tasks) and intervals of appropriate communication with staff during mealtimes (e.g., from 5.5% to 18%; Altus et al., 2002). The enhanced dining program, staff education (Perivolaris, 2006), and familiar physical activity and music (Moore, 2010) maintained eating performance.
DISCUSSION This review summarized and evaluated 11 published intervention studies that focused on optimizing eating performance for older adults with dementia living in LTC settings. Studies were of moderate quality overall, and the effectiveness of the interventions reviewed on optimizing eating performance outcomes varied.
Training Programs and Mealtime Assistance for Residents Among the interventions evaluated, Montessori methods and spaced retrieval training and were noted effective in improving eating performance. Specifically, spaced retrieval training, which enhanced memory of eating related information and procedures (Camp et al., 1997), and Montessori methods, which focused on repetitive practices of step-by-step procedures associated with independent eating (Vance & Farr, 2007), were helpful in terms of providing residents with adequate information and skills to complete mealtime tasks. This then decreased the likelihood of frustration and increased the possibility that they experienced successful independent eating (Camp & Skrajner, 2004). With good evidence in decreasing feeding difficulty, the Montessori activities and spaced retrieval can be recommended to optimize residents’ performance in self feeding in LTC settings. The one-on-one nursing assistance during eating (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance. Verbal assistance offered by nursing staff encouraged and engaged residents to continue with eating tasks and thereby possibly promoted self-feeding performance. Such verbal assistance can be used to improve selffeeding performance with good evidence, and future work may continue testing the effectiveness of mealtime assistance using strong designs to accumulate evidence. The training programs and mealtime assistance interventions in original studies were implemented by trained research assistants or researchers, instead of nursing caregivers. Future work may focus on training nursing caregivers as interventionists to implement these interventions and evaluate the effectiveness and fidelity in real world settings. Additional consideration of the efficiency of these approaches among individuals with varying levels of cognitive impairment is needed.
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The duration of the approaches in the original studies were relatively short possibly due to training intensity and accessibility of dementia participants. Future work could increase the intervention duration as feasible to maximize the long-term effectiveness for the benefit of residents. Future research may consider testing the training program with more culturally diverse individuals with dementia, not just those from Taiwan, China. In addition, future work testing the efficacy of training combined with mealtime assistance as a multilevel, multicomponent approach would be worthwhile in order to achieve better resident outcomes in eating performance. Since mealtime is viewed as care interaction that is crucial to health and a sense of well-being, future studies that evaluate the cost and resource deployment for approaches which aim at optimizing eating performance are also warranted.
Environment Modification The environment or routine modification (e.g., enhanced lighting, table setting contrast, family style meal delivery) with and without staff training on mealtime assistance was effective in improving some aspects of eating performance. Environment and routine modifications may enhance residents’ comfort during eating and can be easily adopted by LTC staff. Current findings should be interpreted with caution as the quality of these studies was generally weak and the level of evidence was low. These interventions should be more comprehensively evaluated using RCT designs and valid outcome measures, and controlling for potential confounders to accumulate reliable evidence.
Limitations This systematic review was limited mainly by virtue of the number and quality of individual studies included. Only a small number of studies were identified and potential eligible studies may have been missed due to the terms and keywords used for literature search. Also, we only screened peer-reviewed published English studies and did not access unpublished literature or presentations, which may result in the omission of some relevant articles and existence of language bias and publication bias. The quality of individual studies also varied widely. The inclusion of a body of eligible literature with overall moderate quality and existing methodological weaknesses could have introduced biases that can lead to over- or underestimates of intervention effectiveness.
CONCLUSIONS Effective interventions should be based on multilevel, multicomponent individualized care approaches to achieve optimal eating performance among LTC residents with dementia. By evaluating studies within the last three decades, this review provides preliminary support for using training programs and mealtime assistance to optimize eating performance in this population. WVN
Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Evidence Review References
LINKING EVIDENCE TO ACTION r Effective interventions should be based on multilevel, multicomponent individualized care approaches to achieve optimal eating performance among LTC residents with dementia.
r Training programs targeting older adults (e.g., Montessori methods and spaced retrieval) showed good evidence in decreasing feeding difficulty and can be recommended in LTC practice to optimize eating performance for older residents with dementia.
r Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) showed good evidence in improving eating performance, while future work using strong designs is needed to accumulate evidence.
r Recommendations for future effectiveness testing of training and mealtime assistance include training nursing caregivers as interventionists, longer intervention duration including varied levels of cognitive impairment in diverse cultures, and combining training and mealtime assistance.
r Environmental modifications are worthwhile to improve eating performance while reliable evidence is needed with strong RCT designs, valid outcome measures, and minimum confounding bias.
Author information Wen Liu, Assistant Professor, University of Iowa College of Nursing, Iowa City, IA; Elizabeth Galik, Associate Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD; Marie Boltz, Associate Professor, Boston College Connell School of Nursing, Chestnut Hill, MA; Eun-Shim Nahm, Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD; Barbara Resnick, Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD. Address correspondence to Wen Liu, University of Iowa College of Nursing, Iowa City, IA 52242-1121; liuwenring18@ gmail.com Accepted 4 April 2015 C 2015, Sigma Theta Tau International Copyright Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
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SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site: Figure S1. Flow Diagram for Interventions on Optimizing Eating Performance in Dementia. Table S1. Search strategy using Pubmed. Table S2. Eligibility criteria using PICOTS framework. Table S3. Study quality assessment criteria. Table S4. Summary of study characteristics. Table S5. Summary of study quality.
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Optimizing Eating Performance for Older Adults With Dementia Living in Long-term Care: A Systematic Review Wen Liu, RN, PhD • Elizabeth Galik, PhD, CRNP • Marie Boltz, RN, PhD, GNP-BC • Eun-Shim Nahm, RN, PhD, FAAN • Barbara Resnick, RN, PhD, CRNP, FAAN, FAANP
ABSTRACT Keywords dementia, eating performance, intervention studies, long-term care, older adults
Background: Review of research to date has been focusing on maintaining weight and nutrition with little attention on optimizing eating performance. Objective: To evaluate the effectiveness of interventions on eating performance for older adults with dementia in long-term care (LTC). Methods: A systematic review was performed. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014. Keywords included dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, and intervention. Intervention studies that optimize eating performance and evaluate change of self-feeding or eating performance among older adults (ࣙ65 years) with dementia in LTC were eligible. Studies were screened by title and abstract, and full texts were reviewed for eligibility. Eligible studies were classified by intervention type. Study quality was accessed using the Quality Assessment Tool for Quantitative Studies, and level of evidence using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence. Results: Eleven intervention studies (five randomized controlled trials [RCTs]) were identified, and classified into four types: training program, mealtime assistance, environmental modification, and multicomponent intervention. The quality of the 11 studies was generally moderate (four studies were rated as strong, four moderate, and three weak in quality), with the main threats as weak designs, lack of blinding and control for confounders, and inadequate psychometric evidence for measures. Training programs targeting older adults (Montessori methods and spaced retrieval) demonstrated good evidence in decreasing feeding difficulty. Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance. Linking evidence to action: This review provided preliminary support for using training and mealtime assistance to optimize eating performance for older adults with dementia in LTC. Future effectiveness studies may focus on training nursing caregivers as interventionists, lengthening intervention duration, and including residents with varying levels of cognitive impairment in diverse cultures. The effectiveness of training combined with mealtime assistance may also be tested to achieve better resident outcomes in eating performance.
INTRODUCTION Eating performance is the functional ability to get food into the mouth. It is one of the most basic and easiest activities of daily living (ADLs) to perform (Liu, Unick, Galik, & Resnick, 2015), as well as the last ADL that older adults living in long-term care (LTC) settings lose (Morris, Fries, & Morris, 1999). LTC residents with dementia are at greater risk of compromised eating performance due to progressive cognitive impairment and behavioral symptoms when compared to residents without
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dementia (Cortes et al., 2008). More than half of the LTC residents with dementia experience loss of independence in eating performance (LeClerc, Wells, Sidani, Dawson, & Fay, 2004). Residents with severe cognitive impairment demonstrated the greatest deterioration in eating performance compared to the other ADLs within 6 months after nursing home admission (Carpenter, Hastie, Morris, Fries, & Ankri, 2006). Autonomy at mealtimes is an important indicator of quality of life, both physically and psychosocially, for older adults living with dementia (Keller et al., 2010). Mealtime is not just Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Evidence Review a process to ensure adequate nutrition and intake, but also a pathway to enjoy social contact and interaction, as well as food (Gibbs-Ward & Keller, 2005; Palacios-Ce˜ na et al., 2013). Mealtime experiences should continue to be pleasurable events for older individuals with dementia, as compromised eating performance has a significant impact on health outcomes and quality of life (Hanson, Ersek, Lin, & Carey, 2013). Appropriate support and commitment from caregivers is critical to help older adults with dementia optimize eating performance and enhance mealtime pleasure (Keller et al., 2010; Pelletier, 2005). However, due to institutional barriers such as insufficient staffing and policies to prevent weight loss, caregivers may primarily focus on maintaining caloric intake and help too much with feeding in order to complete eating tasks quickly (Crogan & Shultz, 2000). Excessive or unnecessary assistance with feeding, regardless of residents’ self-feeding ability, may result in unintended dependence, interfere with residents’ autonomy, decrease mealtime pleasure, and elicit resistance and aggressive behaviors (Amella, 2002; Gibbs-Ward & Keller, 2005).
FACTORS THAT INFLUENCE EATING PERFORMANCE Numerous factors influence eating performance among older adults with dementia in LTC. The social ecological model (SEM), which was developed based on the ecological systems theory (Bronfenbrenner, 1992), provides a comprehensive approach for how to conceptualize and consider these factors. The SEM examines the influential factors of eating performance from a multilevel perspective: intrapersonal, interpersonal, environment and policy (Glanz, Rimer, & Viswanath, 2008; McLaren & Hawe, 2005). The intrapersonal factors that influence eating performance include age, comorbidities, physical capability, motivation, cognitive impairment, mental and psychological disorders, and behavioral problems (Chang & Roberts, 2008; Desai, Schwartz, & Grossberg, 2012; Slaughter, Eliasziw, Morgan, & Drummond, 2011). The interpersonal factors include caregivers’ knowledge, attitude and skills to engage residents to eat as independently as possible (Chang & Lin, 2005), social support from caregivers and peers, and communication and interaction between residents and caregivers (Chang & Roberts, 2008; Crogan & Shultz, 2000). The environmental factors include the physical environment in which individuals eat such as the lighting in the dining room, the availability of assistive devices (e.g., adaptive bowls, plates and utensils, and no-spill cups), the comfort of the chairs or wheelchairs in which residents sit during meals, and the fit between the resident and the chair in terms of optimizing positioning to facilitate eating (Slaughter et al., 2011). The environmental perspective also includes the cultural environment such as the way in which the food is presented (Clay, 2001), and the cultural compatibility of the food choices provided (Altus, Engelman, & Mathews, 2002; Andreoli, Breuer, Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Marbury, Williams, & Rosenblut, 2007). There are also some institutional factors such as appropriate staffing for mealtime supervision and assistance, high workload, and staff turnover (Schnelle et al., 2004). The policy factors include custodial care management styles, policies that are task-oriented instead of resident-oriented, and focus on adequate intake and expediency instead of optimizing self-feeding independence (Gibbs-Ward & Keller, 2005). Effective interventions should target these diverse personal and environmental factors to promote engagement of residents in their highest level of function with regard to eating (Amella, Grant, & Mulloy, 2008; Aselage, Amella, Rose, & Bales, 2015). Multilevel, multicomponent individualized care has been recommended to achieve optimal eating performance among LTC residents with dementia (Keller et al., 2014).
RATIONALE AND OBJECTIVE OF THE REVIEW The body of literature on mealtime interventions for older adults with dementia has been growing within the last several decades (Liu, Cheon, & Thomas, 2014; Watson & Green, 2006). As a disparate area of research with generally low to moderate quality, mealtime interventions showed potential to positively influence nutritional outcomes and behavioral symptoms, and future testing of theory-based interventions with high-quality trials was recommended (Abbott et al., 2013; Hanson, Ersek, Gilliam, & Carey, 2011; Liu et al., 2014; Whear et al., 2014). The majority of the review work in this field, however, has generally focused on maintaining weight, nutrition and behavioral symptoms with little attention on optimizing eating performance. Evaluation of current research on optimizing eating performance will accumulate evidence and provide important directions for future work. The purpose of this systematic review, therefore, was to summarize available interventions and evaluate their effectiveness on eating performance among older adults with dementia in LTC settings.
METHODS Design and Data Sources The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Liberati et al., 2009) was used to guide this systematic review. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014 for intervention studies published in English and in peer reviewed journals. Other sources included Google Scholar and bibliography of eligible studies with an effort for a complete retrieval of literature. The keywords were dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, intervention, and any matched subjects or MeSH terms. The search strategy for Pubmed is shown in Table S1 (available with online version of this article). The protocol for conducting this review was not published or registered anywhere else previously.
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Eligibility Criteria and Study Selection Studies were included in the review based on the Population, Intervention, Comparator, Outcomes, Timing and Setting of interest (PICOTS; Table S2 available with the online version of this article; Guyatt et al., 2011). Intervention studies that focused on optimizing eating performance and evaluated change of self-feeding or eating performance in older adults (ࣙ65 years) with dementia living in LTC settings were eligible. Studies were excluded if the participants received enteral or parenteral nutrition; the participants were recruited from hospitals, communities, in-home-living or clinic settings; the intervention components were nutritional supplementation, nutritional education or music; the outcomes were nutritional intake, anthropometric and biochemical parameters, behavioral disturbances or other adverse events. Based on eligibility criteria, studies were selected and assessed by two reviewers following three steps: screening by title and abstract, assessing full-text for eligibility, and reviewing full-text for data abstraction and quality assessment. Individual results were compared and discrepancies were discussed to arrive at agreement.
Data Analysis Eligible studies were classified by intervention type as well as by the level of factors (e.g., personal, environmental) associated with eating performance based on the intervention protocol. The quality of the reviewed studies was assessed by the same two reviewers independently using the Quality Assessment Tool for Quantitative Studies ([QATQS]; Table S3 available with the online version of this article; Thomas, Ciliska, Dobbins, & Micucci, 2004). Each individual study was evaluated on eight components: Selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity, and analysis. The first six components were rated as strong, moderate, or weak, and altogether resulted in an overall rating of study quality, while the last two components were not rated according to QATQS. The ratings of each study were compared, and discrepancy was identified and discussed to arrive at agreement. Level of evidence was graded using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Jeremy et al., 2011a,b,c) for each individual study included in the review. The levels of evidence for the treatment benefit question of “does this intervention help” was specifically used to fit the purpose of this review. There are five levels of evidence, levels 1–5, ranging from high certainty to decreasing certainty, respectively. Level 1 is a systematic review of randomized controlled trials or n-of-1 trials; level 2 includes randomized controlled trials or observational studies with dramatic effect; level 3 includes nonrandomized controlled cohorts or followup studies; level 4 includes case-series, case-control studies, or historically controlled studies; and level 5 is mechanism-based reasoning. The quality and quantity of studies as well as the level of evidence were all considered when making recommendations regarding the interventions.
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RESULTS Study Characteristics A total of 1,387 records were identified and 11 studies met inclusion criteria after removing duplicates, screening title and abstract, and assessing full-text for eligibility (Figure S1, available with the online version of this article). Individual study characteristics, including study design and level of evidence, sample and setting, intervention, comparator, duration, outcomes and measures, and outcome changes were present by intervention type (Table S4, available with the online version of this article). The 11 intervention studies (5 RCTs, 2 Controlled Clinical Trials [CCTs], 2 interrupted time series, and 2 single group repeated measures) included a total of 530 older adults with dementia and 86 nursing caregivers (e.g., registered nurses, nursing assistants, certified assistant nurses, licensed practical nurses) from 21 LTC facilities (e.g., nursing home, assisted living, skilled nursing facility, residential geriatric center, veteran’s home). These studies originated from the United States, Taiwan, and Canada. Baseline functional characteristics of older adults (e.g., self-feeding or eating performance, cognitive impairment, physical capability, and level of assistance needed) varied across studies.
Quality of Reviewed Studies The quality of the eleven reviewed studies was evaluated using the QATQS criteria and is shown in Table S5 (available with the online version of this article). Specifically, all 11 studies used convenience sampling, which could induce potential selection bias. The sample size varied across studies, with six studies including less than 30 older adults with dementia, four studies including 30–100 residents, and one study including more than 100 residents. Three studies were conducted in a single setting, two studies in two units within one facility, and six studies in two or more facilities. Regarding confounders, four studies controlled for confounders, while the other seven studies introduced confounding bias. The confounding bias included not comparing (Van Ort & Phillips, 1995) or controlling for (Chang & Lin, 2005; Coyne & Hoskins, 1997; Simmons & Schnelle, 2004) baseline differences, new staffing policies during the intervention period (Brush, Meehan, & Calkins, 2002), potential carryover effects of interventions (Simmons & Schnelle, 2004), and potential contextual factors (Altus et al., 2002; Perivolaris, 2006). Use of blinding for outcome assessors or participants was available in four studies (Lin et al., 2010; Lin, Huang, Watson, Wu, & Lee, 2011; Moore, 2010; Wu, Lin, Wu, Lin, & Liu, 2014), unknown in five studies, and unavailable in two studies. Regarding data collection methods, six studies used reliable and valid instruments for measuring eating performance (e.g., EdFED, FAA, FIM), while the other five studies used measures without adequate evidence of reliability or validity (Aselage, 2010; Ottenbacher, Hsu, Granger, & Fiedler, 1996). All 11 studies reported withdrawal rate of less than 20%. Two studies (Altus et al., 2002; Van Ort & Phillips, 1995) applied only descriptive but not inferential statistics. Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Evidence Review Overall, four studies were rated as strong, four moderate, and three weak in quality. The main threats to study quality were weak study designs, lack of blinding and control for potential confounders, and inadequate measurement reliability or validity evidence.
Interventions to Optimize Eating Performance The interventions used in the 11 studies were classified into four types targeting personal or environmental levels of factors associated with eating performance: training programs for residents or nursing assistants at intra- or interpersonal levels, mealtime assistance from nursing caregivers at interpersonal level, environment modification at environmental level, and multicomponent interventions at both personal (i.e., resident or nursing staff) and environmental levels. Diverse forms of self-feeding or eating performance outcomes were evaluated across studies using different objective data and instruments. These outcomes included eating independence by Eating Behavior Scale ([EBS]; Tully, Matrakas, Muir, & Musallam, 1997), Functional Independence Measure ([FIM]; Ottenbacher et al., 1996) and Adapted Level of Eating Independence scale (Coyne & Hoskins, 1997); self-feeding ability by Feeding Ability Assessment ([FAA]; LeClerc et al., 2004); functional feeding by Feeding Traceline Technique (Phillips & Van Ort, 1993); feeding difficulty by Edinburgh Evaluation in Dementia scale (EdFED; Lin, Watson, Lee, Chou, & Wu, 2008; Liu, Watson, & Lou, 2014) and mealtime communication by Communication Outcome Measure of Functional Independence (Santo Pietro & Boczko, 1997).
Training Programs for Residents or Nursing Assistants Four studies (two RCTs and two CCTs) addressed training programs related to intra- or interpersonal factors that influenced eating performance of LTC residents with dementia, and evaluated their impact on eating independence, feeding difficulty and self-feeding frequency. These interventions included the feeding skills training program for caregivers (Chang & Lin, 2005), Montessori-based activities with (Lin et al., 2010; Wu et al., 2014) and without (Lin et al., 2011) spaced retrieval for older adults with dementia. Specifically, Montessori-based activities break down eating-related activities into continuous sequential procedures, and ask residents to practice the procedures in sequence actively and repetitively (Camp et al., 1997), while spaced retrieval consists of presenting residents with information or procedures related to eating and asking them to recall it at increasing time intervals (Vance & Farr, 2007). The study testing training program for caregivers had moderate quality with level 2 evidence, and all the three “training programs for residents” studies that tested Montessori methods with or without spaced retrieval had strong quality with level 2 evidence. Residents were considered to have feeding difficulty if they scored 2 or above using the Edinburgh Feeding Evaluation in Dementia (EdFED) scale (range from 0 to 22; Lin et al., 2008; Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
Liu, Watson, et al., 2014). The feeding skill training program for caregivers significantly increased feeding difficulty among residents (e.g., from 7.4 to 10.3), while Montessori-based activities and spaced retrieval for residents demonstrated statistically significant effects in reducing feeding difficulty, enhancing eating independence and increasing self-feeding frequency. Specifically, feeding difficulty among residents decreased approximately from 5 to 3 (Lin et al., 2010; Lin et al., 2011) using Montessori methods and spaced retrieval separately, and decreased further to approximately 2 or below when Montessori methods combined with spaced retrieval were used (Wu et al., 2014). Eating independence level as measured by EBS from 16.18 to 16.79, and self-feeding frequencies from 2.57 to 3.00 were noted with mild but statistically significant improvement using Montessori methods (Lin et al., 2011).
Mealtime Assistance From Nursing Caregivers Three studies (e.g., two RCTs and one interrupted time series) addressed mealtime assistance related to interpersonal factors that influence eating performance of LTC residents with dementia and evaluated the impact on eating independence, functional feeding, and frequency and time for physical or verbal assistance. The interventions included standardized verbal prompts and positive reinforcement (Coyne & Hoskins, 1997), behavioral prompts, cues and reinforcement (Van Ort & Phillips, 1995), and individualized feeding assistance (Simmons & Schnelle, 2004). The two studies testing verbal prompts, cues and reinforcement had moderate quality with level 2 evidence, and the study testing individualized feeding assistance had moderate quality with level 4 evidence. Verbal prompts and positive reinforcement resulted in greater independence in eating solid and liquid foods (Coyne & Hoskins, 1997), and more sustained functional feeding (Van Ort & Phillips, 1995). Individualized feeding assistance, however, increased assistance time (from 5.9 to 35.6 minutes), and episodes of verbal (from 3.3 to 12.2) and physical (from 12.4 to 32.00) prompts offered by staff (Simmons & Schnelle, 2004).
Environment Modification Addressing Environmental Factors One study (one single group repeated measures) addressed the effect of enhanced lighting and table setting contrast on eating performance of residents (Brush et al., 2002) with weak quality and level 3 evidence. The study demonstrated a decrease in assistance needed among residents, and an improvement in the frequency of residents initiating or engaging in conversations with staff as well as residents’ ability to find and use napkins and to follow simple directions during mealtimes.
Multicomponent Interventions Addressing Personal and Environmental Factors Three studies (one RCT, one single group repeated measures, and one interrupted time series) tested the impact of multicomponent interventions focused on eating performance with
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varied quality and levels of evidence from level 2 to 4. Specifically, family style meal delivery and staff training on prompting and praising appropriate mealtime behaviors improved residents’ participation in eating tasks (e.g., from 10% to 65% of tasks) and intervals of appropriate communication with staff during mealtimes (e.g., from 5.5% to 18%; Altus et al., 2002). The enhanced dining program, staff education (Perivolaris, 2006), and familiar physical activity and music (Moore, 2010) maintained eating performance.
DISCUSSION This review summarized and evaluated 11 published intervention studies that focused on optimizing eating performance for older adults with dementia living in LTC settings. Studies were of moderate quality overall, and the effectiveness of the interventions reviewed on optimizing eating performance outcomes varied.
Training Programs and Mealtime Assistance for Residents Among the interventions evaluated, Montessori methods and spaced retrieval training and were noted effective in improving eating performance. Specifically, spaced retrieval training, which enhanced memory of eating related information and procedures (Camp et al., 1997), and Montessori methods, which focused on repetitive practices of step-by-step procedures associated with independent eating (Vance & Farr, 2007), were helpful in terms of providing residents with adequate information and skills to complete mealtime tasks. This then decreased the likelihood of frustration and increased the possibility that they experienced successful independent eating (Camp & Skrajner, 2004). With good evidence in decreasing feeding difficulty, the Montessori activities and spaced retrieval can be recommended to optimize residents’ performance in self feeding in LTC settings. The one-on-one nursing assistance during eating (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance. Verbal assistance offered by nursing staff encouraged and engaged residents to continue with eating tasks and thereby possibly promoted self-feeding performance. Such verbal assistance can be used to improve selffeeding performance with good evidence, and future work may continue testing the effectiveness of mealtime assistance using strong designs to accumulate evidence. The training programs and mealtime assistance interventions in original studies were implemented by trained research assistants or researchers, instead of nursing caregivers. Future work may focus on training nursing caregivers as interventionists to implement these interventions and evaluate the effectiveness and fidelity in real world settings. Additional consideration of the efficiency of these approaches among individuals with varying levels of cognitive impairment is needed.
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The duration of the approaches in the original studies were relatively short possibly due to training intensity and accessibility of dementia participants. Future work could increase the intervention duration as feasible to maximize the long-term effectiveness for the benefit of residents. Future research may consider testing the training program with more culturally diverse individuals with dementia, not just those from Taiwan, China. In addition, future work testing the efficacy of training combined with mealtime assistance as a multilevel, multicomponent approach would be worthwhile in order to achieve better resident outcomes in eating performance. Since mealtime is viewed as care interaction that is crucial to health and a sense of well-being, future studies that evaluate the cost and resource deployment for approaches which aim at optimizing eating performance are also warranted.
Environment Modification The environment or routine modification (e.g., enhanced lighting, table setting contrast, family style meal delivery) with and without staff training on mealtime assistance was effective in improving some aspects of eating performance. Environment and routine modifications may enhance residents’ comfort during eating and can be easily adopted by LTC staff. Current findings should be interpreted with caution as the quality of these studies was generally weak and the level of evidence was low. These interventions should be more comprehensively evaluated using RCT designs and valid outcome measures, and controlling for potential confounders to accumulate reliable evidence.
Limitations This systematic review was limited mainly by virtue of the number and quality of individual studies included. Only a small number of studies were identified and potential eligible studies may have been missed due to the terms and keywords used for literature search. Also, we only screened peer-reviewed published English studies and did not access unpublished literature or presentations, which may result in the omission of some relevant articles and existence of language bias and publication bias. The quality of individual studies also varied widely. The inclusion of a body of eligible literature with overall moderate quality and existing methodological weaknesses could have introduced biases that can lead to over- or underestimates of intervention effectiveness.
CONCLUSIONS Effective interventions should be based on multilevel, multicomponent individualized care approaches to achieve optimal eating performance among LTC residents with dementia. By evaluating studies within the last three decades, this review provides preliminary support for using training programs and mealtime assistance to optimize eating performance in this population. WVN
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Evidence Review References
LINKING EVIDENCE TO ACTION r Effective interventions should be based on multilevel, multicomponent individualized care approaches to achieve optimal eating performance among LTC residents with dementia.
r Training programs targeting older adults (e.g., Montessori methods and spaced retrieval) showed good evidence in decreasing feeding difficulty and can be recommended in LTC practice to optimize eating performance for older residents with dementia.
r Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) showed good evidence in improving eating performance, while future work using strong designs is needed to accumulate evidence.
r Recommendations for future effectiveness testing of training and mealtime assistance include training nursing caregivers as interventionists, longer intervention duration including varied levels of cognitive impairment in diverse cultures, and combining training and mealtime assistance.
r Environmental modifications are worthwhile to improve eating performance while reliable evidence is needed with strong RCT designs, valid outcome measures, and minimum confounding bias.
Author information Wen Liu, Assistant Professor, University of Iowa College of Nursing, Iowa City, IA; Elizabeth Galik, Associate Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD; Marie Boltz, Associate Professor, Boston College Connell School of Nursing, Chestnut Hill, MA; Eun-Shim Nahm, Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD; Barbara Resnick, Professor, University of Maryland School of Nursing, Department of Organizational Systems and Adult Health, Baltimore, MD. Address correspondence to Wen Liu, University of Iowa College of Nursing, Iowa City, IA 52242-1121; liuwenring18@ gmail.com Accepted 4 April 2015 C 2015, Sigma Theta Tau International Copyright Worldviews on Evidence-Based Nursing, 2015; 12:4, 228–235. C 2015 Sigma Theta Tau International
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SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site: Figure S1. Flow Diagram for Interventions on Optimizing Eating Performance in Dementia. Table S1. Search strategy using Pubmed. Table S2. Eligibility criteria using PICOTS framework. Table S3. Study quality assessment criteria. Table S4. Summary of study characteristics. Table S5. Summary of study quality.
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