Introduction

Over 55 million people around the world live with Alzheimer’s disease or other forms of dementia (dementia) [1]. Dementia can be defined as a syndrome of chronic and progressive nature, that causes deterioration in cognitive function affecting memory, orientation, and language (comprehension and expression). The cognitive decline is usually accompanied and sometimes preceded by changes in mood, behavior, motivation, and emotional control [1]. Dementia also impacts functional ability and independence in activities of daily living, such as the ability to use utensils. As cognition declines, people with dementia may become unable to identify and express hunger and thirst and lose the ability to eat independently, increasing dependency on others to provide mealtime support [2, 3].

In addition to cognitive decline and functional disabilities, the environment where people with dementia eat meals can impact their performance [4]. Furthermore, the assistance provided to people with dementia plays an important role in their autonomy and independence at mealtimes. Providing excessive or needless assistance during mealtime, indifference of residents’ self-feeding capabilities, and making mealtime a task to be completed [5] can lead to excess disability, reducing residents’ autonomy and mealtime enjoyment, and triggering resistance as well as aggressive behaviors [6, 7].

According to the dictionary, eating is the act of consuming food and feeding is the act of giving food to a person, an animal, or a plant. In addition, the term mealtime refers to the time in the day when you eat a meal [8]. A medical dictionary defines feeding as giving food or administering nourishment, while eating is defined as taking, chewing, and swallowing food [9]. The terms "feeding" and "eating" are commonly treated as synonyms in literature. This usage has been noted in previous studies, where "feeding difficulties" and "eating difficulties" were used interchangeably [10]. As such, when designing and implementing mealtime interventions, it is important to distinguish between strategies or actions that support eating versus feeding needs. While "eating difficulty" in dementia can be defined as an individual manifestation of psychological and behavioral symptoms, where a person with dementia is unable to properly execute the act of eating [11], "feeding difficulty" is a wider concept, as it includes the one who is aiding the person with dementia with their meal. So, it could be defined as specific challenges faced by the care staff while feeding people with dementia. Eating and feeding are slightly related, but feeding difficulties indicate the caregivers’ problems while feeding people with dementia, instead of the problems experienced by those who are being fed [10]. In order to embrace both the concepts of eating and feeding difficulties, a broader concept is presented as “mealtime difficulties”, which contemplates environmental, social, cultural, and contextual implications with nutritional intake since mealtime involves more than the physical act of eating a meal or feeding someone [12].

The concepts of mealtime and mealtime difficulties meet the principles of the Social Ecological Model, a theoretical framework introduced by Broffenbrenner as an ecological system [13] and subsequently redefined as a model aimed at fostering changes in health-related behaviors [14]. A social ecological model applied to mealtime difficulties seeks to understand factors that influence mealtime performance in a multilevel perspective: intrapersonal (characteristics of the person with dementia), interpersonal (characteristics and skills of the caregiver, and their interaction with the person with dementia), environmental (physical and cultural characteristics of where meals take place) and institutional (caring practices and institutional policies) [15].

Considering the scope of the terms mealtime/mealtime difficulties, relying on the Social Ecological Model, and to ensure the use of a strengths-based language “mealtime support needs” will be used throughout this article.

The decrease in cognitive and functional ability can significantly affect eating performance, and older people with dementia living in residential care settings (residents), especially in the late stages of the condition, can develop mealtime support needs. These individuals may be unable (partially or completely) to start or keep attention to mealtime tasks, take the food to the mouth, chew, or swallow, or have behaviors such as apathy, wandering, refusal, or indifference during mealtime [10]. The consequences of mealtime support needs can lead to a range of complications, from weight loss, malnutrition, and dehydration to caregiver stress and less opportunity to socialize [16, 17].

As dementia progresses, the ability to self-perform activities of daily living, including eating/ self-feeding, combined with the unavailability of family members to provide continuous care often leads to institutionalization [18]. The incidence of institutionalization varies throughout the world, and it is estimated that in industrialized countries about 2 to 8% of people over 65 years of age reside in nursing homes, and this number is expected to increase hereafter [19]. It is estimated that 45% of residents have dysphagia, and 40 to 86% experience some feeding challenges [20, 21]. Mealtime support needs could be related to the behavior symptoms of dementia, inappropriate food consistency, inadequate posture and positioning during meals, fast feeding supply by the caregiver, and due to cognitive, functional, and environmental conditions [22].

The quality of care provided by nursing homes staff and the mealtime environment can contribute to better results in food acceptance [4, 23–25]. Staff who are more aware of poor food intake and an enabling dining environment create a better mealtime experience and therefore improve the nutrition and hydration of residents [4]. Enhancing care staff training in mealtime support needs for people with dementia is crucial, as current programs often prioritize mechanical feeding skills over comprehensive strategies for residents’ participation and communication. A recent review showed that formal caregivers require additional training and education to effectively manage diverse challenges encountered during mealtime [26].

Mealtime support needs in people with dementia have been described in the literature since the early 1990s, and the first evidence-based studies on the effectiveness of interventions appeared more than ten years later [27]. A broad number of interventions were created to improve the nutrition of residents, and each one focuses on distinct factors that may contribute to a better food and fluid intake, as well as on controlling the behavioral and psychological symptoms of dementia [28]. A literature review reported the existing interventions as changed mealtime delivery service and staff allocation patterns, adaptation of food texture, occupational therapy and behavioral interventions, verbal cueing, and dining environmental changes [29].

Despite the number of existing interventions, further research is needed to identify the most effective interventions and inform the mealtime support strategies that should be adopted by care staff [27, 30, 31]. Previous reviews focused on identifying and evaluating existing interventions to minimize mealtime support needs, but to the best of the authors’ knowledge, there are no publications that seek to relate the impact of these interventions on the social-ecological perspective, with an integrated view of the impact on residents and care staff, and from the nursing home administrators’ perspective on the impact of these interventions. The social-ecological model embeds individuals in a broad social system and outlines their interactive characteristics with underlying environments as influencers of health outcomes [32]. The framework considers individual and environmental determinants, supporting the development of systematic intervention mechanisms capable of influencing behavior changes across various levels of influence, including applicability to mealtime support needs [19].

This scoping review aimed to identify and summarize available research literature about mealtime interventions for older people with dementia living in a residential care setting. By adopting a social-ecological perspective, this review seeks to not only summarize the outcomes for residents but also comprehensively examine the impact of these interventions on care staff and the care environment, considering the viewpoints of nursing home administrators.

Methods

Results

Selection process

The database search was carried out between November 2022 and February 2023, and resulted in 193 potentially relevant studies and a manual search, including grey literature and articles references, resulted in 82. A total of 275 studies were reached, and after duplicates removal, 200 studies remained for additional analysis. After screening titles and abstracts, 69 full-text papers were retrieved, 33 of which were included in the final scoping review (Fig 1). Those excluded did not describe an intervention (n = 9), the full text was unavailable (n = 5), the intervention was not designed for people with dementia (n = 4) or was not exclusive to intervene on mealtime difficulties (n = 4), or not performed in nursing homes (n = 3). Three interventions were designed for specific problems, such as dysphagia (n = 2) or hyperphagia (n = 1), or were interventions focused only on nutritional supplementation (n = 2). Six studies were excluded for other reasons, like being from 1986, a conference abstract, a PhD thesis whose paper was already included, design process of an assistive robot, or interventions including informal caregivers or research assistants.

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Fig 1. Flowchart of the selection process.

https://doi.org/10.1371/journal.pone.0300987.g001

Environmental interventions

The type of intervention most frequently found among the studies analyzed was that of an environmental nature (54.5% n = 18). Changes in the environment include adaptations at the level of inclusion of stimuli, such as light and noise levels, and the improvement of the environment of a dining room, use of sound, as well as changes in meal service delivery or food presentation (Table 1).

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Table 1. Environmental interventions studies (n = 18).

https://doi.org/10.1371/journal.pone.0300987.t001

Nine studies used music as a factor of change in the environment during mealtime. Three studies [57–59] evaluated the effect of classical music on residents’ agitation during meals. One study [56] associated music from a single piano with sounds of nature, such as the sound of birds, whales and rain, and observed the effect on the residents’ level of behavior problems. Another study [46] observed how staff humming influences residents’ food intake and eating/feeding abilities. The other 4 studies [40, 41, 47, 61] comprised the use of local popular songs, or a music selection based on residents’ preference, and thus assessed the impact of music intervention on food intake and behaviors (agitation, mood, irritability, and restlessness).

Changes in meal service delivery style were presented in three studies. Two studies [38, 42] evaluated the oral intake and nutritional status of residents by changing the way meals are served, testing the bulk style instead of the traditional way of serving meals on a tray. The other study [62] evaluated whether sharing mealtimes with staff impacted the resident’s food intake.

Two studies [44, 45] placed an aquarium in the dining room and looked at the effect that observing it would have on resident’s food intake and body weight. Two studies [37, 39] adjusted lighting and noise conditions in the dining room and then looked at how the changes interfered with residents’ food intake and behavior. Finally, two studies evaluated changes in oral intake by manipulating the color contrast of tableware [43] or adding a sauce to snacks consumed by residents [48].

Impact of environmental interventions.

All intervention based on the environment’s adaptations focused their objectives only on residents, who were the only participants evaluated. The main objectives of these studies were related to the improvement of nutritional status with increased food and fluid intake, and also the control of challenging behaviors during mealtimes, such as agitation or aggression. Two studies evaluated the impact of the intervention on both dimensions.

From the 11 studies that aimed to increase the food intake of residents, 10 had positive results, demonstrating the impact of the intervention in a better and greater food intake, and in some cases even gain (or maintenance) of body weight [37–39, 41–45, 48, 62]. The other study [40] showed that oral intake was only slightly higher compared to the control group. All five studies [47, 56–59] that aimed to reduce behaviors such as agitation or aggression during mealtime demonstrated the satisfactory impact of interventions on residents, evidencing the reduction of agitation and aggression (physical and verbal). Two studies demonstrated the impact of interventions on both oral intake and residents’ challenging behavior. One study showed that the oral intake of the residents was less than or equal to the intake before the intervention while eating behaviors improved during the intervention [46]. The impact of other intervention was more positive, with residents having higher oral intake and being less irritable, anxious, and depressed during the musical intervention [47].

Although the focus of the studies is on the residents’ food intake, two studies reported the impact on care staff and the administrators’ perspective on this impact. A study presented evidence that staff showed less burnout and had a better understanding of resident’s mealtime behaviors due to the nutritional improvement and better interactions between residents and staff [62]. The findings of the other study indicated an institutional interest since residents increased their food intake and needed fewer nutritional supplements, thus resulting in health-care cost savings [44].

Mealtime assistance interventions

Four studies (12.1%) addressed residents’ mealtime support needs through interventions focused on mealtime assistance (Table 2). In this category, interventions focused on improving staff attitudes and behaviors when assisting residents during meals. Three of them are based on staff’s behavioral attitudes when helping residents with meals [50, 63, 64]. One study tested the effects of the use of a nursing intervention on mealtime behavior of people with dementia who wander assessing the frequency of table leaving as well as food intake and body weight [49]. Using a social reminiscence protocol or structured verbal cueing protocol, another study assessed the effects of reminiscence therapy on the residents’ consumption of food [50]. With behavioral strategies such as directed verbal prompts and positive reinforcement, another study evaluated changes in the level of eating independence [63]. Also, to promote functional feeding, using two interventions (one contextual and one behavioral) a study evaluated its impact on resident’s nutritional status [64].

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Table 2. Mealtime assistance interventions studies (n = 4).

https://doi.org/10.1371/journal.pone.0300987.t002

Impact of mealtime assistance.

Three of the 4 mealtime assistance interventions included only residents as participants of the studies, reporting the impact of interventions on them [49, 50, 63]. The other study included residents and "staff feeders" but demonstrated the intervention’s impact only on residents [64].

Studies that only included residents had the objective of improving food intake and some behaviors, such as wandering and the ability to self-feed. Food intake was improved in a contextual and behavioral intervention [64]. One study did not impact residents’ oral intake, which remained the same or showed no significant differences in pre-post intervention behavior [50]. A study that aimed to assess the residents’ level of eating independence evidenced the positive impact of directed verbal prompts and positive reinforcement in making residents improve their levels of independence to eat, in addition to maintaining nutritional status [63]. Although the authors integrated registered nurses, licensed practical nurses, and nursing assistants among the participants, the impact of the intervention on these professionals was not evidenced, only indicating the potential benefit for the staff in having residents with less eating dependence [64].

Staff training

Five studies (15.1%) presented training programs developed for nursing homes staff to support residents’ mealtime support needs (Table 3). Feeding skills of staff were the focus of the training program in three studies. One study included 3 hours of in-service classes to teach a protocol for mealtime support and 1 hour of hands-on training, and its effectiveness was evaluated through measures of food acceptance by residents, and knowledge and attitudes of staff [55]. Two studies used technology as the method of delivering training to staff. One was a web-based educational intervention using a problem-solving approach associated with the use of hand feeding techniques [51]. Its effectiveness was measured through the staff’s skills and the food intake and feeding behaviors of the residents during meals. The other study developed a mobile application for staff education on meal attendance and its preliminary effects were identified in staff and in residents [17].

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Table 3. Staff training interventions studies (n = 5).

https://doi.org/10.1371/journal.pone.0300987.t003

One study was a staff training based on spaced retrieval and Montessori activities and it was evaluated how these activities affected the mealtime support needs and nutritional status of residents [52]. The last study evaluated how a previously established program, based on relationship-centred care, could change the residents’ dining experience [65]. This study is the only one analyzed in this review that includes results for the residents, care staff, and nursing home administrators.

Impact of staff training.

Studies with staff training were more comprehensive in relation to participants, involving residents, care staff, and nursing homes administrators. Three studies aimed to evaluate the effectiveness of feeding skills training. The impact on residents was demonstrated through food intake, while in the staff aspects such as knowledge, self-efficacy, attitude, and behavior towards residents’ mealtime support needs were evaluated. The impact on staff was evidenced in 2 studies, noting more knowledge, more positive attitude, and better behaviors, and in one of them, there was also an improvement in the residents’ food intake [51]. In one of the studies, despite the positive impact on staff, food intake, and eating behaviors of residents did not change [55]. The intervention through a mobile application did not present significant results either for the residents or for the staff [17].

One study considered only the impact of the intervention on the mealtime support needs and nutritional status of residents, with satisfactory results, where residents presented a reduction in mealtime support needs and maintenance of nutritional status [56].

Only one intervention of all the studies analyzed in this scoping review, considered 3 groups that are directly or indirectly involved at mealtimes: residents, care staff, and nursing homes administrators. The study aimed to assess whether a program had an impact on the dining experience, and staff impressions were collected through semi-structured interviews and qualitative comments [65].

Multicomponent interventions

The remaining six studies (18.3%) reported interventions that combined more than one category within the scope (Table 4). One study combined environment modifications with a workshop aimed at altering “eating” into meaningful dining experiences and looked at the impact on residents’ food intake and behavior, and staff’s care performance [54]. One study evaluated the effect of “family-style” meals with serving dishes instead of prepared plates combined with in-service staff training on prompting and praising appropriate resident behavior [66].

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Table 4. Multicomponent interventions studies (n = 6).

https://doi.org/10.1371/journal.pone.0300987.t004

One study was a Montessori intervention that involved sensory stimulation through music, procedural movements (hand–eye coordination, scooping, pouring, squeezing, and matching), and reviewing the day’s activities with the aim of improving the eating ability and nutritional status of residents [60]. A second multicomponent study also used Montessori-based activities, but combined with spaced retrieval activities, targeting improving mealtime support needs, food intake, and body weight of residents [53]. Other study assessed the impact of a Montessori mealtime intervention on person-centered care by associating environmental modifications, procedural changes to the mealtime services and implementation of policies according to Montessori principles, to staff training and communications methods [67].

Lastly, a spaced retrieval intervention was tested, through sections with activities created to help residents re-learn a fixed series of actions related to recognizing mealtime, feeding themselves, eating and swallowing, while controlling environment settings (lighting, noise) [68].

The multicomponent interventions were equally divided regarding the inclusion of residents and staff as participants. Three studies that included only residents had similar objectives, which included improving oral intake and eating abilities [53, 60], relieving the mealtime support needs [68]. The impact of the interventions was positive, as there was an increase in oral intake, body weight, and a reduction in inappropriate mealtime behaviors, with a consequent improvement in the ability to eat. In these three interventions, Montessori-based and spaced retrieval activities were used.

Impact of multicomponent interventions.

Interventions that included residents and staff among participants had different objectives and both associated changes in the environment with staff training. The study that aimed to increase residents’ participation in mealtime tasks resulted in greater involvement and more adequate communication between residents, in addition to the care staff being more satisfied with the higher level of residents’ participation during mealtimes [66]. Another study aimed at reducing agitation and improving eating abilities and oral intake of residents also showed a positive impact, with evidence of increased food and fluid intake and better physical and social functioning. Regarding the staff, there was a report of increased satisfaction with the use of ability-enhancing interventions and best practices [54]. The study that evaluated a Montessori mealtime intervention in person-centered care, showed a significant positive change in staff-resident interactions, opportunity for residents’ choice, and support for mealtime independence [67].

Discussion

This scoping review analyzed the literature on interventions for mealtime support needs of people with dementia, and its impacts on residents, care staff, and care context/environment. The social ecological model was the framework used to connect the perspectives of these three stakeholders’ groups since it is helpful to understand the interaction of factors influencing challenges during mealtime for residents. Overall, several studies have described interventions designed to address residents’ mealtime support needs, leading to better food intake and nutritional status, but also to make mealtimes a more pleasant time, adjusting the residents’ behavior.

Thirty-three mealtime interventions were identified in this review and were classified into four types according to the nature of the strategies chosen by the authors. Most of the interventions were environmental, with changes in the dining room based on use of music, meal service delivery and presentation of food, placement of aquariums, and adequacy of lighting and noise. Some interventions focused on improving the quality of mealtime assistance, while others consisted of staff training with different techniques. A fourth group of interventions can be considered multicomponent as they include more than one type of strategy.

Overall, the objectives of the selected studies were to test the effectiveness of different types of intervention in two main dimensions of the mealtime support needs: food intake and challenging behaviors of the residents, specifically agitation. Although the common objective of the studies was to test the effectiveness of the interventions, they differ between the proposed intervention actions and in relation to the outcome measures selected to identify improvements in the participants involved. The absence of a consensual definition of the concepts of eating/feeding/mealtime difficulties/support needs may be one of the reasons for interventions focusing on different aspects, be it the person with dementia, the staff, or the environment.

Based on the definitions presented in the introduction of this article, the studies analyzed in this review predominantly used the concept of eating (n = 22). For the remaining articles six used the concept of mealtimes [57, 59, 62, 66–68]; and 5 studies used the concept of feeding [17, 46, 51, 55, 64]. It was expected to find a relationship between the studies that used the concepts of feeding or mealtime support needs and outcomes for both residents and staff, but it was not possible to establish such association. Most studies (n = 23) demonstrated the effectiveness of interventions through outcomes presented by residents. As expected, 19 of them referred to the term eating difficulty [38–45, 47, 49, 50, 52, 53, 56, 58, 60, 61, 63, 65]. Despite presenting only residents’ outcomes, one study [46] considered the context as feeding support needs and two others as mealtime support needs [57, 59]. One study [68] included an economic evaluation of intervention costs related to daily calorie and protein intake.

Nine studies assessed the effectiveness of the proposed intervention presenting outcomes for residents and staff. Four of these studies [17, 51, 55, 64] were based on the concept of feeding support needs, two [37, 54] were about eating support needs, and three [62, 66, 67] were about the context of mealtime support needs. Only one study showed the impact of the intervention on residents, nursing staff and also reported how nursing home administrators comprehend this impact [65].

Since malnutrition and weight loss are prevalent in residents, and associated with functional decline, increased hospitalizations, and more dependence on activities of daily living [69], it is to be expected that interventions will seek results in improving food intake. Food and liquid intake have been recognized as an important interventional target for improving nutritional status of residents, being a concern for the development of interventions [70].

Cognitive impairments typically found in residents cause difficulties in performing tasks such as self-feeding, handling cutlery, or behaving at the table. They also induce to depression, aggressive behavior, agitation, apathy, wandering, and emotional distress that can cause or intensify mealtime support needs [71, 72]. Interventions that propose to create a calm environment for mealtime, leading to better residents’ behaviors, need to consider that the eating behaviors of residents are likely motivated by personal antecedents and environmental factors and must be considered as [73].

This scoping review identified several ways to intervene in the mealtime support needs of residents, either by directly support resident independent eating or improving staff’s ability to provide mealtime assistance or increase food intake. The use of the concept of mealtime support needs was not consensual among the results, and studies that referred to feeding support needs or eating support needs were also analyzed. The interventions mainly focused on dining room changes/adaptations, mealtime assistance methods, training of nursing staff, or even a combination of both.

As mealtime involves factors related to residents, staff, and the environment where the meal occurs, including institutional factors such as organizational culture, limiting the scope of interventions can lead to the improvement of isolated factors, like better food and liquid intake. From the perspective of the Social Ecological Model, mealtime support needs can be interpreted and managed through multiple factors that influence mealtimes. Besides intrapersonal factors and the interaction between residents and staff, policies, routines, and institutional culture, at a macro level, must be considered in an intervention [74]. Most of the interventions mapped in this scoping review centered their objectives at the intrapersonal, interpersonal, and environmental levels (care context), focusing essentially on residents and care staff separately, and also on the dyad formed between these two. These studies demonstrated the effectiveness of interventions in outcomes directly related to the residents, and a few to the staff. Interventions focused only on isolated factors may not be completely effective when considering the concepts used, whether eating, feeding, or mealtime support needs.

Only one study [65] analyzed the impact of the intervention at the macro-level (institutional policy/systems factors) and indicated the importance of the nursing home administrator’s integration in the intervention. This integration can result in the development of better strategies to support the care team for continuity of the intervention. Multicomponent interventions allow for a comprehensive and multidimensional approach to the challenge. Rather than focusing only on resident factors, a broader perspective that considers interactions between residents, care staff, and nursing home administrators in the care environment is encouraged. By addressing challenges and solutions at multiple levels simultaneously, interventions can be more comprehensive, promoting a better mealtime experience for residents and potentially improving their nutritional status and general well-being. Including, for example, staff training or even assessing the involvement of the administrators in these issues, the outcomes could be much more comprehensive.

There is a lack of information about the role of nursing home administrators in handling mealtime support needs. Future research should explore the role of nursing home administrators in managing residents’ mealtime support needs, analyzing institutional policies, care protocols, and standards of good practice in residential care settings. Administrators play a key role in decision-making processes and shape the institutional culture, and their support is essential for the successful integration of interventions. By understanding administrators’ viewpoints, researchers can tailor interventions that align with the existing culture, potentially increasing adhesion from staff and facilitating smoother implementation. Therefore, the results of this review may inform future research and also in the creation of care protocols within institutions to minimize mealtime support needs for people with dementia.

Conclusion

This article broadened the comprehension of the effects of mealtime interventions as perceived by crucial stakeholders: residents, care staff, and nursing home administrators. Of the studies identified and analyzed, the interventions were grouped into four categories: environmental, mealtime assistance, staff training, and multicomponent. Most interventions analyzed the impact only in residents, namely in oral intake and behavior of people with dementia, specifically agitation. Unlike many previous reviews that predominantly focus on residents, this scoping review emphasizes the impact of interventions on care staff, revealing correlations between staff training and improved knowledge and attitudes.

This review underscores the necessity for mealtime intervention studies to assess outcomes from a comprehensive or multi-level perspective. Studies that assess the impact on administrators are necessary to understand the perspective of different hierarchical levels of an organization on mealtime support needs. The findings of this scoping review can support the creation of new supportive programs, or strategies to improve mealtime experience with positive impacts according to the reality and needs of each person or institution.

Supporting information