The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review.

Background Older adults with dementia may have feeding difficulties for several reasons: they may experience deterioration in motor and cognitive skills making eating difficult, they may forget to eat, fail to recognise food or they may suffer from dysphagia. Food intake is often poor and malnutrition is common, leading to adverse health outcomes.This review specifically focussed on how best to promote and achieve 'normal' eating and feeding in older adults with dementia, in order that undernutrition and its consequences could be avoided.Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia.Types of Participants Adults over the age of sixty with dementia in any care setting (who were not living independently). People receiving enteral tube feeding were excluded.Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers, family or volunteers, educational interventions, changes in food service.Types of Outcomes The primary outcomes were improvement in dietary intake and/or nutritional status. Measurements included: dietary intake, anthropometry, clinical outcomes, functional indicators.Types of Studies Randomised controlled trials, controlled trials and quasi-experimental studies with a 'before and after' design.Search Strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1999 to 2009 was set.Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data Extraction For quantitative studies, data was extracted using a data extraction form developed to include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. This was based on the JBI data extraction tool from MAStARI and 2 reviewers extracted data independently.Data synthesis Heterogeneity in study designs, interventions and outcomes meant meta-analysis was not possible. Findings were discussed in a narrative summary.Results The review included 11 studies. This included one RCT, 1 randomised crossover study, 3 controlled non-randomised trials, 6 quasi-experimental studies. None of the studies provided robust evidence, however there was moderate evidence (Level 3) to support a Grade B recommendation for improvements in dietary intake and/or nutritional status with the following interventions: education of healthcare staff, simple environmental manipulations such as the use of high contrast tableware or small dining rooms, the introduction of something of interest such as an aquarium or background music, or the provision of feeding assistance, provision of enhanced menus, use of a decentralised food service, enhanced nutritional screening combined with increased dietetic time.Conclusion There is moderate (Level 3) evidence to support each of the interventions appraised in this review.Implications for Practice There is moderate support that warrants consideration of the interventions listed above. Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care.Implications for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following: inclusion of reliable outcome measures, full details of interventions, randomisation of participants, inclusion of control groups, adequate sample sizes, longitudinal follow up, consideration of baseline demographics of intervention groups, and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care.