Related Studies

Sandra F. Simmons, Betty Lim, and John F. Schnelle, 2002, in American Medical Directors Association; May/June:140-145.

This study showed that nursing home staff inaccurately documented low oral intake and food complaints among residents, resulting in a significant underestimate of residents with either of these risk factors for under-nutrition. The researchers found a significant discrepancy between nursing home staff estimates on Minimum Data Set (MDS) documentation and their own independent assessments based on direct observations of mealtrays and interviews with residents. Whereas the researchers identified 55 (73%) of the 75 residents who participated in the study as being at risk for under-nutrition due to low food and fluid consumption, nursing home staff failed to identify 27 of these residents. In interviews with research staff, 32% of the residents complained about the facility’s food. By comparison, nursing home staff reported no food complaints by residents. The authors suggest that staff-recorded inaccuracies may stem from nurse aides having too much to do during mealtimes, vague instructions in the MDS manual on how to assess intake and food complaints, and supervisors failing to periodically check nurse aide estimates for accuracy. Nursing home staff also may underestimate the number of residents, including those with cognitive impairments, who can reliably answer questions about the facility’s quality of food and other aspects of their care.

Sandra F. Simmons and David Reuben, 2000, in Journal of the American Geriatrics Society; 48:209-213.

This study showed that two alternative methods for estimating food and fluid intake among nursing home residents are more reliable than documented estimates by nurse aides, who have been shown to consistently overestimate intake levels by 15% or more. In one of the methods tested, trained research staff conducted independent observations of meal trays for 56 residents both before and after each of nine meals and recorded the total percentage of food and fluid intake as well as the percentage of intake for individual food and fluid items. In the second method, a second group of independent research staff took before and after photos of the residents’ mealtrays and used these pictures to calculate their estimates of intake. Both methods yielded comparable, reliable intake estimates. By comparison, nursing home staff overestimated intake levels by 20% or more. As a result, they failed to identify half of the residents who consistently ate less than 75% of their meals, a low intake level that puts them at risk of under-nutrition, according to federal standards. The authors recommend the photography method over direct observations because it provides a permanent record that can be rated by multiple professionals, it allows comparisons to be conducted in a less hurried manner and after hectic mealtimes, and it provides immediate, visual evidence of food volumes both before and after meals.

_{Sandra F. Simmons, Helene Y. Lam, Geetha Rao, and John F. Schnelle, 2003, in Journal of the American Geriatrics Society; 51:69-74.}

What nutrition interventions do family members prefer for their relatives at risk for under-nutrition and weight loss who reside in nursing homes? Given a choice of six possible interventions, the 105 resident representatives, mostly family members, who completed this study’s written questionnaire, rated them, in order of preference, as follows:

• Improve quality of food
• Improve quality of feeding assistance
• Provide multiple small meals and snacks throughout the day
• Place resident in preferred dining location
• Provide oral liquid nutrition supplements
• Provide an appetite stimulant medication

These findings indicate a clear preference among residents’ significant others for behavioral and environmental approaches over the use of supplements or pharmacological approaches to improve food and fluid intake. The authors point out that resident preferences could not be assessed directly in this study due to the questionnaire’s complex design, but future studies should attempt to correct this shortcoming.

Simmons SF, Garcia ET, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil D & Schnelle JF. (2003). in Journal of the American Geriatrics Society 51(10):1410-1418.

Federal regulations require nursing homes to complete resident assessments periodically using the Minimum Data Set (MDS) assessment protocol. Results are used to generate quality indicators (QI) for each facility as a means of identifying poor outcomes in a number of clinical areas. But the use of QIs as a measure of quality of care is controversial due in part to concerns about the accuracy of staff-generated MDS data. This study collected independent data that showed that the MDS-derived “prevalence of weight loss” QI does indeed discriminate between nursing homes with a high percentage of residents at risk for weight loss and those with a much lower percentage of at-risk residents. A desirable, low score on this QI, however, did not mean that the facility provided qualitatively better feeding assistance to its residents. In fact, results indicated that all the facilities needed to improve the adequacy and quality of their feeding assistance. The one consistent, between-group difference in care quality was that the nurse aides in low-weight loss prevalence homes were more likely to interact socially and verbally prompt residents to eat than the nurse aides in high-weight loss prevalence homes. Other studies have shown that verbal encouragement to eat and social interaction at mealtimes leads to increased food consumption among the elderly.

Simmons SF & Schnelle JF. (2003) in Alzheimer’s Care Quarterly, 4(4):286-296.

This paper reviews recent research findings that underscore the need to improve the adequacy and quality of feeding assistance in nursing homes. Additionally, based on results from Borun Center research, the authors describe a non-medical intervention that has been shown to significantly improve food and fluid consumption among nursing home residents who otherwise would be at risk for under-nutrition and weight loss due to low intake. The implementation process involves four steps:
 

1. Identify residents at risk for under-nutrition and weight loss due to low intake. These residents typically eat less than 75% of most meals
2. Implement a two-day, or six-meal, trial of feeding assistance with each at-risk resident to determine whether he or she is responsive to feeding assistance. Residents who increase their intake by 15% or more should continue to receive the mealtime feeding assistance intervention. Unresponsive residents should be offered between-meal snacks at least twice a day (and ideally three times daily) in order to increase their food and fluid intake.
3. Staffing adjustments should be made as necessary to meet the feeding assistance needs of at-risk residents both during and between meals.
4. Supervisory staff should regularly monitor mealtime and snack routines to ensure that nurse aides or other designated staff members continue to provide adequate feeding assistance to targeted residents. Supervisors can use a standardized observational protocol (Weight-Loss Assessment Forms) paper to effectively manage the feeding assistance intervention.

_{Sandra F. Simmons, Dan Osterweil, and John F. Schnelle, 2001, in Journal of Gerontology: Medical Sciences; Vol. 56A, No. 12, M790-M794.}

This study was designed to answer two questions: 1) How many nursing home residents are responsive to feeding assistance? and 2) How much staff time is required to provide feeding assistance to these residents? Results showed that about half of the 74 residents enrolled in the study increased their intake by an average of 30% in response to a two-day, or six-meal, trial of feeding assistance implemented by trained research staff. This one-on-one intervention, however, required significantly more staff time to implement: an average of 38 minutes per resident per meal compared to 9 minutes rendered by nursing home staff under usual conditions. The authors suggest that the intervention would be more feasible to implement if unresponsive residents were accurately identified in assessment trials; failure to identify these residents would roughly double the number of staff needed during mealtimes. Staff requirements could be reduced further if staff provided feeding assistance to groups of residents. Preliminary data from this study suggests that feeding assistance can be effectively provided in small groups of three for most residents who are responsive to individual assistance, but additional time is required to transport these residents to and from the dining room.

Simmons SF & Schnelle JF. (2004). in Journal of Gerontology: Medical Sciences, 59A(9):966-973.

This study showed that 90% of residents who are at-risk for weight loss will significantly increase their food and fluid intake in response to one of two non-medical interventions: a mealtime feeding assistance intervention and a between-meal snack intervention. A total of 134 residents in three nursing homes received a two-day trial of one-on-one feeding assistance during six meals. Sixty-eight residents who did not increase their food and fluid intake in response to mealtime feeding assistance received a two-day intervention trial during which snacks were offered between meals three times daily. For both interventions, research staff provided assistance that encouraged residents to eat on their own, casually conversed with residents throughout each meal or snack, and offered a variety of foods and beverages. Almost half (46%) of the residents significantly increased their consumption in response to one-on-one mealtime feeding assistance. An additional 44 percent significantly increased their intake in response to the between-meal snack intervention. Both interventions required significantly more staff time to implement than usual care. The authors offer staffing strategies to maximize staff efficiency and effectiveness.

Sandra F. Simmons, Cathy Alessi, and John F. Schnelle, 2001, in Journal of the American Geriatrics Society; 49:926-933.

This study showed that total daily fluid intake among nursing home residents increased when residents were encouraged to drink between meals and given beverages they liked. Eighty-one percent of the 48 residents who participated in the study significantly increased their average daily fluid intake when research staff verbally prompted them to drink on four to eight occasions between meals. Fluid intake increased even more, and refusals to drink dropped, when residents were offered the beverage of their choice. However, average daily increases were small—less than 5 ounces per day—for as many as one-third of the participants. Cognitive status influenced the effectiveness of the intervention. Residents with greater cognitive impairment were more likely to increase their fluid intake in response to verbal prompts alone, whereas cognitively intact residents needed the added incentive of their preferred beverage to increase consumption. Increases in between-meal fluids had no effect on residents’ fluid intake during meals. Residents maintained their responsiveness to this simple intervention over eight months and showed significant improvements in their hydration status as a result of the increase in daily fluid intake. 

_{Sandra F. Simmons, Sarah Babineau, Emily Garcia, and John F. Schnelle, 2002, in Journal of Gerontology: Medical Sciences; Vol. 57A, No. 10, M665-M671.}

This study showed that a standardized protocol that calls for direct observations of care can be used to accurately measure the adequacy and quality of feeding assistance in nursing homes. The observational protocol, designed for routine use by licensed nursing home staff, is a practical alternative to reviewing medical chart information to monitor quality of care. Prior studies have shown that chart information is unreliable in that it consistently overestimates residents’ food and fluid intake. The observational protocol assesses the ability of nurse aides to accomplish four tasks deemed critical to the delivery of adequate feeding assistance. These tasks include: 1) accurately identifying residents with clinically significant low oral food and fluid intake during mealtimes; 2) providing feeding assistance to at-risk residents during mealtimes; 3) providing feeding assistance to residents identified in the Minimum Data Set as requiring staff assistance to eat; and 4) providing a verbal prompt to residents who receive physical assistance at mealtimes. The study showed that the protocol is reliable, replicable, and feasible to implement. One staff person can use it to reliably observe 6 to 8 residents during one mealtime period.

Simmons SF, Keeler E, Xiaohui ZM, Hickey KA, Sato HW, Schnelle JF. 2008 in Journal of the American Geriatrics Society, 56:1466-1473.

This study showed that the delivery of optimal feeding assistance twice per day during meals or offering residents snack foods and fluids between meals twice per day, five days per week resulted in significant gains in residents’ daily food and fluid intake and body weight over a 24-week intervention period. The interventions were implemented by research staff and compared to usual nursing home care within the same facilities. All residents were at risk for unintentional weight loss due to low oral intake prior to intervention. The average amount of research staff time spent providing the interventions was 42 minutes per person/meal and 13 minutes per person/between meal snack compared to usual care during which residents received, on average, 5 minutes of assistance per person/meal and less than one minute per person/snack. However, residents could be grouped together for mealtime feeding assistance (1 staff member to 3 residents seated at the same table) and snack delivery (1 staff member to 4 residents) to make it more time-efficient in daily care practice.

Simmons SF, Bertrand R, Shier V, Sweetland R, Moore T, Hurd D, Schnelle JF. 2007 in The Gerontologist, 47(2):184-192. 

This study was sponsored by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) to evaluate the impact of the new “paid feeding assistant” regulation that allows nursing homes to hire single-task workers or cross-train existing non-nursing staff within the facility to provide feeding assistance to residents. This preliminary evaluation study evaluated mealtime feeding assistance care quality in a group of 7 facilities in 3 states with active programs in place. Results showed that most of these facilities cross-trained existing non-nursing staff (e.g., administrative, housekeeping, laundry, social activities personnel) to help with feeding assistance care during meals and the quality of care provided by these workers was comparable to, if not better than, the care provided by certified nurse aides within the same facilities. Non-nursing staff trained as “feeding assistants” actually spent significantly more time with individual residents and, as a result, residents assisted by these workers ate more than residents assisted by nurse aides. There were no reported staffing changes at the nurse aide or licensed nurse level as a result of having a program in a facility and all levels of staff reported positive benefits of the program to both staff and residents. This study demonstrates that the use of non-nursing staff within a facility can serve to supplement existing nurse aide staff during meals to improve feeding assistance care quality.

Simmons SF, Peterson, EN, You, C 2009 in Journal of Nutrition, Health and Aging; 13(3) 284-8

The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss. Methods: A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: > 5% in 30 days or > 10% in 180 days. Results: The total frequency of eight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol. Conclusions: A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.

Simmons SF, Cleeton, P, Porchak, T 2009 in Journal of Gerontology: psychological Sciences 

Most nursing home (NH) residents are not interviewed about their satisfaction with the food service due to cognitive impairment. The purpose of this study was to determine the proportion of NH residents able to complete a structured interview to assess food complaints when no cognitive status criteria were used to exclude residents from interview. Eighty-nine percent of 163 residents were able and willing to complete the interview, and 65% expressed complaints about the NH food service. Residents who expressed complaints ate less of their meals, had less cognitive impairment, and had more depressive symptoms than those who did not. This study shows that the majority of NH residents are able to reliably answer questions about their satisfaction with the food service, regardless of cognitive status, and the presence of complaints is related to poor meal intake and depressive symptoms.