Geriatric Nursing and Mealtime Difficulties Introduction
Nutrition plays a fundamental role in promoting health and aiding recovery from illness across the lifespan. This importance is magnified in older adults, where proper nutrition can significantly impact both health outcomes and quality of life. However, the process of eating, including the cultural rituals associated with meals, often receives insufficient attention when addressing nutritional problems in this population. This is paradoxical, given the growing societal obsession with food and culinary arts, often celebrated by media and culinary experts alike (Food Network Chef Bios, 2011). In healthcare institutions, meals can become unappetizing and the dining environment often lacks the warmth and comfort of home, turning what should be a pleasurable experience into a mere task. This article explores the barriers and facilitators to improving mealtime experiences for older adults, with evidence-based strategies to enhance nutritional intake.
Nutritional Problems in Older Adults
Nutrition is particularly critical for maintaining health in older adults. Adequate intake of macronutrients and micronutrients has been shown to affect the risk of chronic illnesses, such as type 2 diabetes, heart disease, osteoarthritis, and certain cancers (US Centers for Disease Control and Prevention (CDC), 2009a). Older adults often face multiple health issues that compromise their nutritional status due to various factors, including social isolation, dependency on others for meal preparation, depression, and cognitive impairments (Arora et al., 2007). These factors can lead to longer hospital stays, increased complications, and higher mortality rates (Arora et al., 2007).
The revised Healthy People 2020 initiative recognizes that health determinants extend beyond individual behaviors to include the social environment, healthcare access, and community factors like poverty, violence, and access to healthy food (US Department of Health and Human Services [USDHHS], 2011). These factors disproportionately affect minorities and underserved groups, further complicating nutritional issues in these populations. Moreover, a good diet in old age can be shaped by socioeconomic status, lifelong habits, and lifestyle choices, such as consuming fruits and vegetables and avoiding smoking (Maynard et al., 2006). Among the top ten causes of death in older adults, a lifetime of good nutrition could positively impact nine, including heart disease, cancer, stroke, and diabetes (CDC, 2009b).
While evaluating nutrition and diet is crucial, the broader context of how older adults choose, prepare, and consume food—or have it done for them—is often neglected. Meals are culturally defined events, and the timing and content of meals are deeply embedded in cultural practices and personal habits. In institutional settings, such as hospitals or long-term care facilities, a different culture may prevail, one that prioritizes patient safety and healthcare outcomes over individual preferences. This institutional focus can conflict with the personal and cultural aspects of mealtimes, often necessitating a paradigm shift toward more holistic approaches that value quality of life alongside quality of care (Mitchell, 2008; Koren, 2010).
Assessment of Nutritional Problems
Effective nutritional assessment in older adults requires a comprehensive approach that considers their living environment, independence level, and health status. Tools like the Mini Nutritional Assessment (MNA) are widely used across various settings, while the SCREEN II tool is more suitable for community-dwelling older adults (Phillips, Foley, Barnard, Isenring, & Miller, 2010). However, many of these tools do not adequately address the broader context of meals, such as the number of meals consumed daily, the social context of eating, and individual preferences (Guigoz, Vellas, & Garry, 1997; Keller, Goy, & Kane, 2005).
More comprehensive tools are available to evaluate different aspects of the eating process. The Level of Eating Independence Scale (LEIS) and the Eating Behavior Scale (EBS) assess eating behaviors, while the Edinburgh Feeding in Dementia Scale (EdFED) focuses on feeding behavior in individuals with dementia (Watson & Deary, 1997). Despite their utility, these tools often have limitations, including length, setting specificity, and limited practical application in clinical settings. The Minimum Data Set (MDS) used in U.S. nursing homes provides minimal information on mealtimes and mainly focuses on the functional status and health problems that may arise if key factors are not addressed (Centers for Medicare & Medicaid Services (CMS), 2010).
As older adults age, they are more likely to experience functional impairments, with the ability to feed oneself often being the last activity of daily living to be lost (Katz et al., 1970). Regular assessment is crucial, especially for those experiencing cognitive decline or life-limiting illnesses. Furthermore, cultural and religious factors can play a significant role in nutritional preferences and practices. Certain religious groups may have strict dietary requirements, which, if not met, can lead to reduced food intake and nutritional deficiencies (Bermudez & Tucker, 2004). For those living near poverty or in areas with limited access to healthy foods, food insecurity may also be a significant concern, potentially necessitating referrals to meal programs or community resources (Coates et al., 2006; Seligman, Laraia, & Kushel, 2010).
Interventions and Nursing Care Strategies for Nutritional Health
Given the complex nature of nutritional health in older adults, an interdisciplinary approach is often the most effective. This team may include dietitians, healthcare providers, speech and language pathologists, occupational therapists, and social workers, all working together to create a comprehensive nutritional care plan. Early identification of residents at risk for nutritional problems, especially those with dysphagia or who require meal assistance, allows for prompt intervention and collaboration between healthcare professionals (Keller, 2006).
Addressing Cognitive Impairments
Cognitive deficits can significantly impact an individual’s ability to eat and drink. Those with severe cognitive impairments may exhibit aversive behaviors at meals, which are associated with increased mortality (Amella, 2002; Mitchell et al., 2009). Studies have shown that high-calorie supplements are effective in increasing intake in this group, although other interventions may have limited impact (Hanson, Ersek, Gilliam, & Carey, 2011). As dementia progresses, individuals may become resistant to eating, with behaviors ranging from pushing food away to allowing it to fall from the mouth (Watson & Deary, 1997). In these cases, respecting the individual’s prior wishes regarding food and fluid intake is critical, and the focus may shift towards quality of life (Amella, 2004).
Improving Nutritional Intake
Modifying mealtime practices can have a significant impact on nutritional outcomes, such as increasing food and fluid intake. Interventions may include liberalizing therapeutic diets, incorporating favorite foods, and promoting socialization during meals. Liberalizing diets can be particularly important for individuals with life-limiting illnesses, where maintaining quality of life becomes the primary goal (Dorner, Friedrich, & Posthauer, 2010).
Research on specific strategies to enhance nutritional intake has produced mixed results. For example, offering smaller, more frequent meals may increase fluid intake but not necessarily food intake (Taylor & Barr, 2006). Enhanced caloric and protein content in meals may benefit “smaller eaters,” while dining room environments may encourage calorie consumption without necessarily increasing protein intake or promoting weight gain (Castellanos, Marra, & Johnson, 2009; Gaskill et al., 2009; Wright, Hickson, & Frost, 2006).
Feeding Assistance and Staff Training
Recent years have seen an increased emphasis on preparing staff to assist with meals in nursing homes, though similar initiatives are often lacking in acute care settings, where older adults may be most vulnerable. Research shows that feeding assistance significantly improves nutritional intake and weight in older adults with functional impairments (Simmons et al., 2008). However, many healthcare workers lack formal training in mealtime assistance and may rely on personal beliefs and preferences to guide their practices (Lopez, Amella, Mitchell, & Strumpf, 2010).
Formal dining assistant programs, such as those supported by state survey and certification bodies, aim to improve nutrition among residents and often include training on interpersonal communication, environmental modifications, and collaboration with families. However, some programs still focus heavily on the task of feeding rather than fostering a supportive dining environment (Bertrand et al., 2010). In acute care, there is a notable lack of training materials on how to alter environments or personalize mealtime strategies for direct care workers.
Enhancing the Dining Environment
The environment in which meals are consumed can greatly influence nutritional intake. Small changes, such as reducing noise, increasing lighting, playing relaxing music, and using contrasting colors for tableware, can enhance the dining experience (Hicks-Moore, 2005; McDaniel, Hunt, Hackes, & Pope, 2001). Providing appropriate seating and positioning, such as using supportive chairs instead of eating in bed, also promotes a better eating posture and can facilitate self-feeding (Rappl & Jones, 2000). Encouraging family members to eat with the patient has been shown to increase food intake and improve motor function in older adults (Altus, Engelman, & Mathews, 2002; Nijs et al., 2006).
Meals served in small, family-like groups are often considered ideal, fostering a more social and engaging atmosphere. However, this approach may affect staff perceptions of meals more than the actual nutritional intake of patients (Kofod & Birkemose, 2004). The quality of interaction between caregivers and patients during meals is crucial, with effective caregivers allowing patients to set the tempo of the meal and make choices, which can significantly increase intake (Altus et al., 2002; Amella, 2002).
Conclusion
Addressing nutritional problems in older adults requires a holistic approach that considers the broader context of meals, from the dining environment to the social and cultural factors influencing eating behaviors. A comprehensive assessment using validated tools and regular reassessment are vital to identifying and addressing the complex nutritional needs of this population. Interventions should focus on creating supportive mealtime environments, providing personalized assistance, and fostering social engagement to enhance nutritional intake and overall well-being. By prioritizing a patient-centered approach and involving a multidisciplinary team, healthcare providers can improve both the nutritional health and quality of life for older adults.