ACQ Vol 11 no 2 2009

Dementia

Mealtime behaviours in people with dementia in the absence of dysphagia Education of nursing staff in an acute care setting Crystal Ensell and Natasha Matheson

This paper describes a quality improvement project targeting improved mealtime manage­ ment by ward nursing staff of dementia specific behaviours, with the aim of improving appro­ priateness of speech pathology referrals. In 2007, the speech pathology department of Royal Perth Hospital received a large number of referrals related to management of mealtime behaviours in people with dementia in the absence of dysphagia. A questionnaire was compiled to assess nursing knowledge of mealtime management in this population, with the subsequent development of an education package to target the gap in knowledge. Post education questionnaires indicated an increase in overall knowledge of dementia- related mealtime behaviours, and improved management of these behaviours has been noted at a nursing level. A reduction in referrals to speech pathology regarding management of mealtime behaviours was noted in 2008, after implementation of the education package. This project highlights the importance of nursing education with the aim of improving service provision. D ementia refers to a spectrum of brain disorders involving cognitive decline, that vary greatly in terms of cause, progression and prognosis (Agronin, 2004). Villareal and Morris (1999) described dementia as an acquired loss of cognitive function that may affect memory, attention, language, personality and abstract reasoning. They explained that the condition constitutes an emerging public health crisis. In 2006, it was estimated that 210,000 people in Australia suffered from dementia (Alzheimers Association of Australia, 2006), and it is projected that 52,000 people will be newly diagnosed in Australia each year, equating to 1000 per week. People with dementia frequently present with challenging behaviours at mealtimes, which affect oral intake and compromise nutrition and hydration. Eighty percent of people with dementia have difficulty eating and drinking, particularly in the late stages of the condition, with 50% no longer able to feed themselves (Chang & Lin, 2005).

Berkhout, Cools and Van Houwelingen (1998) reported feeding dependence is strongly correlated with weight loss. Difficulty eating and drinking may stem from a combination of mealtime behaviours, as well as dysphagia. Oral dysphagia is more common than pharyngeal dysphagia in the dementia population (Feinberg, Ekberg, Segall & Tully, 1992), but both are observed. There is little research on swallowing impairment in different types of dementia (Kindell 2002). Both cognitive features (such as memory disturbance) and non-cognitive features (such as aggression) impact on eating skills. It is essential to differentiate between dysphagia and mealtime behaviours related to dementia. Dysphagia is defined as disordered swallowing (Brockett, 2006), due to weakness or incoordination affecting oro-pharyngeal biomechanics (Hammond & Goldstein, 2006). Mealtime behaviours, however, are atypical behaviours exhibited during oral intake related to the dementia process, and have a negative impact on nutrition, hydration and weight maintenance (Beattie, Algase & Song, 2004; Kindell, 2002). People with dementia can have both dysphagia and atypical mealtime behaviours, but they are not one and the same. Mealtime behaviours related to dementia often occur in the absence of dysphagia. Kindell (2002) described multiple mealtime behaviours related to the dementia process including food and drink refusal, spitting out of oral intake, inattention, wandering during meals, inappropriate speed of intake, and eating of non-food items. Often these behaviours are misdiagnosed as dysphagia. Kindell also discussed the importance of evaluating sensory impairments, dentition, mental state and ability. It is vital that staff working closely with people who have dementia identify mealtime challenges and provide holistic management (LeClerc, Wells, Sidani, Dawson & Fay, 2004). At Royal Perth Hospital Wellington Street Campus (acute care), 34 referrals relating to the management of mealtime behaviours, in the absence of dysphagia, were received from a particular general medicine/geriatric ward in 2007. These referrals had a negative impact on resource allocation and time management of a small speech pathology department. A new approach to dealing with this issue was prompted by a presentation at the 2007 Speech Pathology Australia National Conference by speech pathologists Nailon, Scott and Benjamin (2007). Nailon, Scott and Benjamin completed a study focused on nursing education regarding mealtime management. They compiled a mealtime management

Keywords dementia dysphagia mealtime behaviours nursing education

This article has been peer- reviewed

Crystal Ensell (top) and Natasha Matheson

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ACQ Volume 11, Number 2 2009

ACQ uiring knowledge in speech, language and hearing