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Interventions to address mealtime support needs in dementia: A scoping review

  • Lígia Passos ,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

    ligiamaria@ua.pt

    Affiliations Center for Health Technology and Services Research (CINTESIS@RISE), Department of Education and Psychology, University of Aveiro, Aveiro, Portugal, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal

  • João Tavares,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Supervision, Validation, Visualization, Writing – review & editing

    Affiliation Center for Health Technology and Services Research (CINTESIS@RISE), School of Health Sciences, University of Aveiro, Aveiro, Portugal

  • Melissa Batchelor,

    Roles Formal analysis, Investigation, Supervision, Validation, Writing – review & editing

    Affiliation School of Nursing, George Washington University, Washington, DC, United States of America

  • Daniela Figueiredo

    Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing

    Affiliation Center for Health Technology and Services Research (CINTESIS@RISE), School of Health Sciences, University of Aveiro, Aveiro, Portugal

Abstract

The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.

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, 2325]. 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

Design

This scoping review was conducted following the methodology established by The Joanna Briggs Institute (JBI) [33] and its protocol was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) on 04 August 2021 (registration number INPLASY202180015) [34].

Search strategy

A search strategy was developed to identify published and unpublished studies. The first reviewer (LP) searched the following electronic databases: MEDLINE (via PubMed), Web of Science, Scopus, CINAHL Complete (via EBSCO), and SciELO, using a combination of keywords and MeSH terms, along with Boolean operators. The search limits were applied for title/abstract.

The search strategy was reviewed by a university librarian and was adapted according to the search patterns of each database. The following search terms were used: (dement* OR alzheimer*) AND (“older people” OR “old* person” OR elderly OR aged OR senior)) OR (caregiv*OR “formal caregiver” OR “direct care worker*” OR staff* OR nurs*) OR (manager*OR “health manager” OR administrator OR “nurse administrator” OR “nursing home administrator” OR “ALF administrator” OR “assisted living administrator”) AND ((intervention* OR train* OR program*) AND (“feeding difficult*” OR “eating difficult*” OR “mealtime difficult*” OR “mealtime challenge*” OR “mealtime management”)) AND (“nursing home*” OR “long term care” OR “care home*” OR “residential facility” OR “home* for aged” OR “residential home” OR “elderly care” OR “residential care” OR “assisted living facility”).

A manual search for systematic review articles in the databases Cochrane, JBI, and PROSPERO was undertaken to identify additional papers of interest. The search on grey literature included DARTEurope, OpenGrey, and Repositório Científico de Acesso Aberto de Portugal (RCAAP).

Articles written in English, French, Portuguese, or Spanish, published from 1990 onward were considered for inclusion.

Eligibility criteria

This scoping review included studies with interventions designed exclusively for mealtime support needs and implemented and evaluated in residential care settings. Studies needed to include as participants older people with dementia (all types or degrees/stages) living in a residential care setting (residents) who were 60 years or older, care staff, and facilities administrators. Studies with residents in tube feeding (exclusive or not) were excluded, since it could indicate issues associated, such as dysphagia or very advanced dementia (even tube feeding is not recommended at this stage [35]), or other impairments in addition to mealtime support needs. Interventions developed for hospitalized or people with dementia living in the community were excluded, as well as those with participation of informal caregivers. Studies in which interventions were merely nutritional or pharmacological were also excluded.

This scoping review considered quantitative (experimental or quasi-experimental, and observational studies), qualitative, and mixed-method studies. Study protocols, conference abstracts, letters, and correspondence reports were excluded. Studies that were not accessible via university agreements, or even be made available after contact with the authors were excluded.

Study selection

All databases were searched and articles identified, then duplicates were removed. Two reviewers (LP and JT) screened titles and abstracts based on the inclusion criteria. Disagreements were resolved by the fourth reviewer (DF). Then, the studies were retrieved, and the full texts were read. Full-text studies that did not go through the inclusion criteria were excluded. The findings were reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [36].

Data extraction

Data were extracted by the first author into a Microsoft Excel spreadsheet and, afterward, verified by the second and fourth reviewers. The data extracted included specific details about authors and year of publication, country, study aim and design, intervention description, sample size and characteristics, primary outcomes (for residents, staff, and care environment), and main results.

Data analysis and synthesis

As recommended by JBI [33], data extracted from the included studies are presented in both diagrammatic and tabular form, and in a descriptive format to address the review question and objective. In order to organize the description of the results, four general categories of interventions were determined, according to the strategies used by the authors: environmental, mealtime assistance, staff training, and multicomponent.

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.

Characteristics of included studies

The 33 included studies were published between 1995 and 2023 and conducted in nine countries: the United States (n = 13), Canada (n = 6), Taiwan (n = 6), Sweden (n = 3), Australia (n = 1), United Kingdom (n = 1), South Korea (n = 1), France (n = 1), and Japan (n = 1). In 75.7% (n = 25) studies the participants were only residents, while in 21.2% (n = 7) the participants included both residents and nursing staff. Only one study (3.1%) considered the participation of residents, nursing staff, and nursing home administrators. The analyzed studies had a total of 1062 participants, of which 880 were residents, 177 care staff, and 5 nursing home administration. Most of the participants were women, and the mean age of the residents was 80.07 years old.

Study design and outcome measures

The most common study design was the experimental (54.5%; n = 18), such as pretest-posttest, feasibility, prospective, time-series, RCT, followed by quasi-experimental studies (24.2%; n = 8), case studies (9.1%; n = 3), mixed-methods—pre-posttest + focus group or interviews (6.1%; n = 2) and observational (6.1%; n = 2).

Most interventions had two predominant primary resident outcomes: improving residents’ meal intake and reduction in residents’ challenging behaviors during mealtime. Few studies have focused on the mealtime experience or person-centered care.

Oral intake measures.

Measures for meal intake included caloric intake calculations, tray weights, number and amount of snacks/ supplements. Interventions based on changes and adaptations in the environment used the residents’ food intake as a measure of effectiveness, by calculating the calories ingested [3742], carried out with specific software, or by weighing the meal before and after consumption [38, 4347]. A visual estimate of the percentage of food ingested from each meal was also used [41], as well as the number of snacks consumed [48]. Mealtime assistance interventions estimated food intake through consumed meal weights [49, 50] and by the visual percentage of food ingested [49]. Staff training and multicomponent interventions likewise used the proportion of food ingested by weight before and after the meal [5154], as well as the caloric intake and visual percentage of intake [55].

Resident challenging behavior measures.

Measures for residents’ challenging behaviors included, in the group of environmental interventions, an evaluation of agitation, using The Cohen-Mansfield Agitation Inventory (CMAI) [5659]. Among the mealtime assistance, staff training, and multicomponent interventions, the assessment of the feeding behaviors of residents predominates, either using EdFED [5153, 55, 60] or the Eating Behavior Scale [17, 60].

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).

Nine studies used music as a factor of change in the environment during mealtime. Three studies [5759] 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 [3739, 4145, 48, 62]. The other study [40] showed that oral intake was only slightly higher compared to the control group. All five studies [47, 5659] 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].

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].

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, 6668]; 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 [3845, 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.

Limitations

Even though this scoping review was conducted with a rigorous and methodical process there are still some limitations that need to be acknowledged. Only five databases were used in this scoping review, and despite the search being carried out in four languages (English, French, Spanish, and Portuguese) some studies might have been missed. Even with all efforts, some articles published in non-open access journals may not have been reached in this study. Another limitation of this study may be the non-regular use of the terms eating, feeding or mealtime difficulties/support needs across the studies. The variety of strategies found, as well as the diversity of outcome measures applied to each study, limited a fairer comparison between interventions, as well as making it difficult to identify the most effective intervention.

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

References

  1. 1. World Health Organization (WHO). Dementia. In: 2021 [Internet]. [cited 27 Dec 2021]. Available: https://www.who.int/en/news-room/fact-sheets/detail/dementia
  2. 2. Cipriani G, Carlesi C, Lucetti C, Danti S, Nuti A. Eating Behaviors and Dietary Changes in Patients With Dementia. Am J Alzheimers Dis Other Demen. 2016;31: 706–716. pmid:27756815
  3. 3. Murphy JL, Holmes J, Brooks C. Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes. BMC Geriatr. 2017;17: 1–14.
  4. 4. Reed PS, Zimmerman S, Sloane PD, Williams CS, Boustani M. Characteristics Associated With Low Food and Fluid Intake in Long-Term Care Residents With Dementia. Gerontologist. 2005;45: 74–81. pmid:16230753
  5. 5. Dakkak H, Wu SA, Trinca V, Cammer A, Harvie R, Lengyel C, et al. Navigating Mealtimes to Meet Public Health Mandates in Long-Term Care During COVID-19: Staff Perspectives. Journal of Long Term Care. 2023; 260–272.
  6. 6. Liu W, Galik E, Boltz M, Nahm E-S, Resnick B. Optimizing Eating Performance for Older Adults With Dementia Living in Long-term Care: A Systematic Review. Worldviews Evid Based Nurs. 2015;12: 228–235. pmid:26122316
  7. 7. Amella EJ. Resistance at mealtimes for persons with dementia. J Nutr Health Aging. 2002;6: 117–122. Available: https://pubmed.ncbi.nlm.nih.gov/12166364/ pmid:12166364
  8. 8. Oxford University Press. Oxford Learner’s Dictionaries. 2022 [cited 18 Mar 2022]. Available: https://www.oxfordlearnersdictionaries.com/
  9. 9. Dox IG, Melloni BJ, Eisner GM, Melloni JL, editors. Melloni’s Illustrated Medical Dictionary. Fourth Edition. Boca Raton: CRC Press; 2001. https://doi.org/10.1201/9781439809907
  10. 10. Chang C, Roberts B. Feeding difficulty in older adults with dementia. J Clin Nurs. 2008;17: 2266–2274. pmid:18705703
  11. 11. Kai K, Hashimoto M, Amano K, Tanaka H, Fukuhara R, Ikeda M. Relationship between Eating Disturbance and Dementia Severity in Patients with Alzheimer’s Disease. PLoS One. 2015;10: e0133666. pmid:26266531
  12. 12. Aselage MB, Amella EJ. An evolutionary analysis of mealtime difficulties in older adults with dementia. J Clin Nurs. 2010;19: 33–41. pmid:20500242
  13. 13. Bronfenbrenner U. Toward an experimental ecology of human development. American Psychologist. 1977;32: 513–531.
  14. 14. McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Educ Q. 1988;15: 351–377. pmid:3068205
  15. 15. Liu W, Galik E, Boltz M, Nahm E-S, Lerner N, Resnick B. Factors associated with eating performance for long-term care residents with moderate-to-severe cognitive impairment. J Adv Nurs. 2016;72: 348–360. pmid:26552367
  16. 16. Egan A, Andrews C, Lowit A. Dysphagia and mealtime difficulties in dementia: Speech and language therapists’ practices and perspectives. Int J Lang Commun Disord. 2020;55: 777–792. pmid:32706516
  17. 17. Jung D, De Gagne JC, Lee M, Lee H, Lee K, Choi E, et al. Feasibility of a Mobile Meal Assistance Program for Direct Care Workers in Long-Term Care Facilities in South Korea. Clin Interv Aging. 2020;Volume 15: 2019–2029. pmid:33149563
  18. 18. Lini EV, Portella MR, Doring M. Fatores associados à institucionalização de idosos: estudo caso-controle. Revista Brasileira de Geriatria e Gerontologia. 2016;19: 1004–1014.
  19. 19. Shune SE, Linville D. Understanding the dining experience of individuals with dysphagia living in care facilities: A grounded theory analysis. Int J Nurs Stud. 2019;92: 144–153. pmid:30822707
  20. 20. Volicer L, Seltzer B, Rheaume Y, Karner J, Glennon M, Riley ME, et al. Eating difficulties in patients with probable dementia of the Alzheimer type. J Geriatr Psychiatry Neurol. 1989;2: 188–195. pmid:2483945
  21. 21. Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, et al. Decision-Making and Outcomes of Feeding Tube Insertion: A Five-State Study. J Am Geriatr Soc. 2011;59: 881. pmid:21539524
  22. 22. Santos BP, Andrade MJC, Silva RO, Menezes E da C. Disfagia no idoso em instituições de longa permanência-revisão sistemática da literatura. Revista CEFAC. 2018;20: 123–130.
  23. 23. Chaudhury H, Hung L, Badger M. The role of physical environment in supporting person-centered dining in long-term care: A review of the literature. Am J Alzheimers Dis Other Demen. 2013;28: 491–500. pmid:23687182
  24. 24. Liu W, Williams K, Batchelor-Murphy M, Perkhounkova Y, Hein M. Eating performance in relation to intake of solid and liquid food in nursing home residents with dementia: A secondary behavioral analysis of mealtime videos. Int J Nurs Stud. 2019;96: 18–26. pmid:30660444
  25. 25. Abbott RA, Whear R, Thompson-Coon J, Ukoumunne OC, Rogers M, Bethel A, et al. Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: A systematic review and meta-analysis. Ageing Res Rev. 2013;12: 967–981. pmid:23811415
  26. 26. Li Y, Zhang X, Su J, Li H, Meng X, Zhang S, et al. Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research. Int J Nurs Stud. 2021;123: 104046. pmid:34407465
  27. 27. Rehman S, Likupe G, Watson R. Mealtime difficulty in older people with dementia. WikiJournal of Medicine. 2019;6: 6.
  28. 28. Fetherstonhaugh D, Haesler E, Bauer M. Promoting mealtime function in people with dementia: A systematic review of studies undertaken in residential aged care. Int J Nurs Stud. 2019;96: 99–118. pmid:31060734
  29. 29. Watson R, Green SM. Feeding and dementia: a systematic literature review. J Adv Nurs. 2006;54: 86–93. pmid:16553694
  30. 30. Watkins R, Goodwin VA, Abbott RA, Backhouse A, Moore D, Tarrant M. Attitudes, perceptions and experiences of mealtimes among residents and staff in care homes for older adults: A systematic review of the qualitative literature. Geriatr Nurs (Minneap). 2017;38: 325–333. pmid:28089317
  31. 31. Jung D, Lee K, De Gagne JC, Lee M, Lee H, Yoo L, et al. Eating Difficulties among Older Adults with Dementia in Long-Term Care Facilities: A Scoping Review. Int J Environ Res Public Health. 2021;18: 10109. pmid:34639409
  32. 32. Golden SD, Earp JAL. Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions. Health Education & Behavior. 2012;39: 364–372. pmid:22267868
  33. 33. Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Chapter 11: Scoping Reviews. JBI Manual for Evidence Synthesis. JBI; 2020. https://doi.org/10.46658/JBIMES-20-12
  34. 34. Passos L, Tavares J, Figueiredo D. Mealtime difficulties in dementia: a scoping review protocol about the impacts of interventions on people with dementia, care staff and care context/environment. Inplasy protocol 202180015. 2021.
  35. 35. American Geriatrics Society Ethics Committee. American Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement. J Am Geriatr Soc. 2014;62: 1590–1593. pmid:25039796
  36. 36. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169: 467–473. pmid:30178033
  37. 37. Brush J, Meehan R, Calkins M. Using the Environment To Improve Intake for People with Dementia. Alzheimers Care Q. 2002;3: 330–338. Available: https://journals.lww.com/actjournalonline/Abstract/2002/03040/Using_the_Environment_To_Improve_Intake_for_People.7.aspx
  38. 38. Desai J, Winter A, Young KWH, Greenwood CE. Changes in Type of Foodservice and Dining Room Environment Preferentially Benefit Institutionalized Seniors with Low Body Mass Indexes. J Am Diet Assoc. 2007;107: 808–814. pmid:17467377
  39. 39. McDaniel JH, Hunt A, Hackes B, Pope JF. Impact of dining room environment on nutritional intake of Alzheimer’s residents: A case study. American Journal of Alzheimer’s Disease & Other Dementiasr. 2001;16: 297–302. pmid:11603166
  40. 40. McHugh L, Gardstrom S, Hiller J, Brewer M, Diestelkamp WS. The Effect of Pre-Meal, Vocal Re-Creative Music Therapy on Nutritional Intake of Residents with Alzheimer’s Disease and Related Dementias: A Pilot Study. Music Ther Perspect. 2012;30: 32–42.
  41. 41. Thomas DW, Smith M. The Effect of Music on Caloric Consumption Among Nursing Home Residents with Dementia of the Alzheimer’s Type. Act Adapt Aging. 2009;33: 1–16.
  42. 42. Shatenstein B, Ferland G. Absence of Nutritional or Clinical Consequences of Decentralized Bulk Food Portioning in Elderly Nursing Home Residents with Dementia in Montreal. J Am Diet Assoc. 2000;100: 1354–1360. pmid:11103658
  43. 43. Dunne TE, Neargarder SA, Cipolloni PB, Cronin-Golomb A. Visual contrast enhances food and liquid intake in advanced Alzheimer’s disease. Clinical Nutrition. 2004;23: 533–538. pmid:15297089
  44. 44. Edwards NE, Beck AM. Animal-Assisted Therapy and Nutrition in Alzheimer’s Disease. West J Nurs Res. 2002;24: 697–712. pmid:12365769
  45. 45. Edwards NE, Beck AM. The Influence of Aquariums on Weight in Individuals With Dementia. Alzheimer Dis Assoc Disord. 2013;27: 379–383. pmid:23138175
  46. 46. Engstrom G, Marmstal Hammar L. Humming as a Potential Tool for Facilitating Feeding Situations Between Persons With Dementia and Their Caregiver: A Single Case Study. Music Med. 2012;4: 231–236.
  47. 47. Ragneskog H, Bråne G, Karlsson I, Kihlgren M. Influence of Dinner Music on Food Intake and Symptoms Common in Dementia. Scand J Caring Sci. 1996;10: 11–17. pmid:8715781
  48. 48. Kimura A, Yamaguchi K, Tohara H, Sato Y, Sawada N, Nakagawa Y, et al. Addition Of Sauce Enhances Finger-Snack Intake Among Japanese Elderly People With Dementia. Clin Interv Aging. 2019;Volume 14: 2031–2040. pmid:31814715
  49. 49. Beattie ERA, Algase DL, Song J. Special Section—Behavioral symptoms of dementia: their measurement and intervention. Keeping wandering nursing home residents at the table: improving food intake using a behavioral communication intervention. Aging Ment Health. 2004;8: 109–116. pmid:14982715
  50. 50. Cleary S, Hopper T, van Soest D. Reminiscence therapy, mealtimes and improving intake in residents with dementia. Canadian Nursing Home. 2012;23: 8–13.
  51. 51. Batchelor-Murphy M, Amella EJ, Zapka J, Mueller M, Beck C. Feasibility of a web-based dementia feeding skills training program for nursing home staff. Geriatr Nurs (Minneap). 2015;36: 212–218. pmid:25769703
  52. 52. Lin L-C, Huang Y-J, Su S-G, Watson R, Tsai BW-J, Wu S-C. Using spaced retrieval and Montessori-based activities in improving eating ability for residents with dementia. Int J Geriatr Psychiatry. 2010;25: 953–959. pmid:20054841
  53. 53. Wu HS, Lin LC, Wu SC, Lin KN, Liu HC. The effectiveness of spaced retrieval combined with Montessori-based activities in improving the eating ability of residents with dementia. J Adv Nurs. 2014;70: 1891–1901. pmid:24444172
  54. 54. Perivolaris A, LeClerc C, Wilkinson K, Buchanan S. An Enhanced Dining Program for Persons With Dementia. Alzheimer’s Care Quarterly. 2006;7: 258–267. Available: https://journals.lww.com/actjournalonline/Abstract/2006/10000/An_Enhanced_Dining_Program_for_Persons_With.7.aspx
  55. 55. Chang C, Lin L. Effects of a feeding skills training programme on nursing assistants and dementia patients. J Clin Nurs. 2005;14: 1185–1192. pmid:16238764
  56. 56. Chang F-Y, Huang H-C, Lin K-C, Lin L-C. The effect of a music programme during lunchtime on the problem behaviour of the older residents with dementia at an institution in Taiwan. J Clin Nurs. 2010;19: 939–948. pmid:20492038
  57. 57. Denney A. Quiet music. An intervention for mealtime agitation? J Gerontol Nurs. 1997;23: 16–23. pmid:9287602
  58. 58. Hicks-Moore SL. Relaxing Music at Mealtime in Nursing Homes. J Gerontol Nurs. 2005;31: 26–32. pmid:16375095
  59. 59. Ho S-Y, Lai H-L, Jeng S-Y, Tang C, Sung H-C, Chen P-W. The Effects of Researcher-Composed Music at Mealtime on Agitation in Nursing Home Residents With Dementia. Arch Psychiatr Nurs. 2011;25: e49–e55. pmid:22114806
  60. 60. Lin L-C, Huang Y-J, Watson R, Wu S-C, Lee Y-C. Using a Montessori method to increase eating ability for institutionalised residents with dementia: a crossover design. J Clin Nurs. 2011;20: 3092–3101. pmid:21981704
  61. 61. Ragneskog H, Kihlgren M, Karlsson I, Norberg A. Dinner Music for Demented Patients: analysis of video-recorded observations. Clin Nurs Res. 1996;5: 262–277. pmid:8850771
  62. 62. Charras K, Frémontier M. Sharing Meals With Institutionalized People With Dementia: A Natural Experiment. J Gerontol Soc Work. 2010;53: 436–448. pmid:20603753
  63. 63. Coyne ML, Hoskins L. Improving Eating Behaviors in Dementia Using Behavioral Strategies. Clin Nurs Res. 1997;6: 275–290. pmid:9281930
  64. 64. van Ort S, Phillips LR. Nursing intervention to promote functional feeding. J Gerontol Nurs. 1995;21: 6–9. pmid:7594252
  65. 65. Wu S, Morrison JM, Dunn-Ridgeway H, Vucea V, Iuglio S, Keller H. Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care. BMC Geriatr. 2018;18: 277. pmid:30424725
  66. 66. Altus DE, Engelman KK PhD, Mathews RM. Using Family-Style Meals to Increase Participation and Communication in Persons with Dementia. J Gerontol Nurs. 2002;28: 47–53. pmid:12240521
  67. 67. Cartwright J, Roberts K, Oliver E, Bennett M, Whitworth A. Montessori mealtimes for dementia: A pathway to person-centred care. Dementia. 2022;21: 1098–1119. pmid:35259303
  68. 68. Rehman S, Likupe G, McFarland A, Watson R. Evaluating a brief intervention for mealtime difficulty on older adults with dementia. Nurs Open. 2023;10: 182–194. pmid:35856469
  69. 69. Borders JC, Blanke S, Johnson S, Gilmore-Bykovskyi A, Rogus-Pulia N. Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons with Dementia: A Systematic Review. Alzheimer Dis Assoc Disord. 2020;34: 366. pmid:32530831
  70. 70. Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. J Acad Nutr Diet. 2018;118: 724–735. pmid:29576092
  71. 71. Aggio NM, Ducatti M, de Rose JC. Cognition and language in dementia patients: Contributions from behavior analysis. Behavioral Interventions. 2018;33: 322–335.
  72. 72. Trivedi DP, Braun A, Dickinson A, Gage H, Hamilton L, Goodman C, et al. Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions. Dementia. 2019;18: 2925–2949. pmid:29557183
  73. 73. Backhouse T, Dudzinski E, Killett A, Mioshi E. Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review. Int J Nurs Stud. 2020;109: 103640. pmid:32553994
  74. 74. Liu W, Jao Y, Williams K. Factors influencing the pace of food intake for nursing home residents with dementia: Resident characteristics, staff mealtime assistance and environmental stimulation. Nurs Open. 2019;6: 772–782. pmid:31367399