Original Study| Volume 16, ISSUE 12, P1062-1068, December 01, 2015

Optimizing Eating Performance for Long-Term Care Residents With Dementia: Testing the Impact of Function-Focused Care for Cognitively Impaired

Published:August 05, 2015DOI:



      The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.


      A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.

      Participants and Setting

      Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.


      Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care “feeding” item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single “chair sit-sitting balance” item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).


      At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).


      Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Zimmerman S.
        • Sloane P.D.
        • Reed D.
        Dementia prevalence and care in assisted living.
        Health Aff (Millwood). 2014; 33: 658-666
        • Thies W.
        • Bleiler L.
        Alzheimer's disease facts and figures.
        Alzheimers Dement. 2013; 9: 208-245
        • Desai A.K.
        • Schwartz L.
        • Grossberg G.T.
        Behavioral disturbance in dementia.
        Curr Psychiatry Rep. 2012; 14: 298-309
        • Carpenter G.I.
        • Hastie C.L.
        • Morris J.N.
        • et al.
        Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment.
        BMC Geriatr. 2006; 6: 7
        • Keller H.H.
        • Martin L.S.
        • Dupuis S.
        • et al.
        Mealtimes and being connected in the community-based dementia context.
        Dementia. 2010; 9: 191-213
        • Lin L.C.
        • Watson R.
        • Wu S.C.
        What is associated with low food intake in older people with dementia?.
        J Clin Nurs. 2010; 19: 53-59
        • Hanson L.C.
        • Ersek M.
        • Lin F.C.
        • et al.
        Outcomes of feeding problems in advanced dementia in a nursing home population.
        J Am Geriatr Soc. 2013; 61: 1692-1697
        • Chang C.C.
        • Roberts B.L.
        Malnutrition and feeding difficulty in Taiwanese older with dementia.
        J Clin Nurs. 2011; 20: 2153-2161
        • Slaughter S.E.
        • Eliasziw M.
        • Morgan D.
        • et al.
        Incidence and predictors of eating disability among nursing home residents with middle-stage dementia.
        Clin Nutr. 2011; 30: 172-177
        • Slaughter S.E.
        • Hayduk L.A.
        Contributions of environment, comorbidity, and stage of dementia to the onset of walking and eating disability in long-term care residents.
        J Am Geriatr Soc. 2012; 60: 1624-1631
        • Amella E.J.
        • Aselage M.B.
        Facilitating ADLs by caregivers of persons with dementia: The C3P Model.
        Occup Ther Health Care. 2014; 28: 51-61
        • Cowan D.T.
        • Roberts J.D.
        • Fitzpatrick J.M.
        • et al.
        Nutritional status of older people in long term care settings: Current status and future directions.
        Int J Nurs Stud. 2004; 41: 225-237
        • Crogan N.L.
        • Shultz J.A.
        Nursing assistants' perceptions of barriers to nutrition care for residents in long-term care facilities.
        J Nurses Staff Dev. 2000; 16: 216-221
        • Aselage M.B.
        • Amella E.J.
        • Rose S.B.
        • et al.
        Dementia-related mealtime difficulties: Assessment and management in the long-term care setting.
        in: Bales C.W. Locher J.L. Saltzman E. Handbook of Clinical Nutrition and Aging. Springer, New York, NY2015: 287-301
        • Gibbs-Ward A.J.
        • Keller H.H.
        Mealtimes as active processes in long-term care facilities.
        Can J Diet Pract Res. 2005; 66: 5-11
        • Palacios-Ceña D.
        • Losa-Iglesias M.E.
        • Cachón-Pérez J.M.
        • et al.
        Is the mealtime experience in nursing homes understood? A qualitative study.
        Geriatr Gerontol Int. 2013; 13: 482-489
        • Liu W.
        • Cheon J.
        • Thomas S.A.
        Interventions on mealtime difficulties in older adults with dementia: A systematic review.
        Int J Nurs Stud. 2014; 51: 14-27
        • Resnick B.
        • Galik E.
        • Gruber-Baldini A.
        • et al.
        Testing the effect of function-focused care in assisted living.
        J Am Geriatr Soc. 2011; 59: 2233-2240
        • Resnick B.
        • Gruber Baldini A.L.
        • Zimmerman S.
        • et al.
        Nursing home resident outcomes from the res-care intervention.
        J Am Geriatr Soc. 2009; 57: 1156-1165
        • Bandura A.
        Self-efficacy: Toward a unifying theory of behavioral change.
        Psychol Rev. 1977; 84: 191-215
        • Bandura A.
        Self-efficacy: The exercise of control.
        Freeman, New York, NY1997
        • Galik E.
        Function-focused care for LTC residents with moderate to severe dementia: A social ecological approach.
        Ann Longterm Care. 2010; 18: 27-32
        • Galik E.
        • Resnick B.
        • Hammersla M.
        • et al.
        Optimizing function and physical activity among nursing home residents with dementia: Testing the impact of function-focused care.
        Gerontologist. 2014; 54: 930-943
        • Galik E.
        • Resnick B.
        • Lerner N.
        • Hammersla M.
        • Gruber-Baldini A.l.
        Function Focused Care for Assisted Living Residents With Dementia.
        Gerontologist. 2015; 55: S13-S26
        • Galik E.
        • Resnick B.
        • Gruber-Baldini A.
        • et al.
        Pilot testing of the restorative care intervention for the cognitively impaired.
        J Am Med Dir Assoc. 2008; 9: 516-522
        • Altus D.E.
        • Engelman K.K.
        • Mathews R.M.
        Using family-style meals to increase participation and communication in persons with dementia.
        J Gerontol Nurs. 2002; 28: 47-53
        • Coyne M.L.
        • Hoskins L.
        Improving eating behaviors in dementia using behavioral strategies.
        Clin Nurs Res. 1997; 6: 275-290
        • Van Ort S.
        • Phillips L.R.
        Nursing intervention to promote functional feeding.
        J Gerontol Nurs. 1995; 21: 6-14
        • Liu W.
        • Galik E.
        • Boltz M.
        • et al.
        Optimizing eating performance for older adults with dementia living in long-term care: A systematic review. Worldviews on evidence-based nursing.
        Worldviews Evid Based Nurs. 2015 Jun 29; ([Epub ahead of print])
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Resnick B.
        • Galik E.
        The reliability and validity of the physical activity survey in long-term care.
        J Aging Phys Act. 2007; 15: 439-458
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: The Barthel index.
        Md State Med J. 1965; 14: 61-65
        • Sinoff G.
        • Ore L.
        The Barthel activities of daily living index: Self-reporting versus actual performance in the old-old (> or= 75 years).
        J Am Geriatr Soc. 1997; 45: 832-836
        • Foreman M.D.
        • Fletcher K.
        • Mion L.C.
        • et al.
        Assessing cognitive function.
        in: Mezey M.D. Fulmer T. Abraham I.L. Geriatric Protocol for Best Practice. 2nd ed. Springer, New York, NY2003: 99-115
        • Tinetti M.E.
        Performance-oriented assessment of mobility problems in elderly patients.
        J Am Geriatr Soc. 1986; 34: 119-126
        • Resnick B.
        • Boltz M.
        • Galik E.
        • et al.
        Physical capability scale psychometric testing.
        Clin Nurs Res. 2013; 22: 7-29
        • Alexopoulos G.S.
        • Abrams R.C.
        • Young R.C.
        • et al.
        Cornell scale for depression in dementia.
        Biol Psychiatry. 1988; 23: 271-284
        • Kørner A.
        • Lauritzen L.
        • Abelskov K.
        • et al.
        The Geriatric depression Scale and the Cornell Scale for depression in dementia. A validity study.
        Nord J Psychiatry. 2006; 60: 360-364
        • Cohen-Mansfield J.
        Agitated behaviors in the elderly: II. Preliminary results in the cognitively deteriorated.
        J Am Geriatr Soc. 1986; 34: 722-727
        • Cohen-Mansfield J.
        • Marx M.S.
        • Rosenthal A.S.
        A description of agitation in a nursing home.
        J Gerontol. 1989; 44: M77-M84
        • Finkel S.I.
        • Lyons J.S.
        • Anderson R.L.
        A brief agitation rating scale (BARS) for nursing home elderly.
        J Am Geriatr Soc. 1993; 41: 50-52
        • Miller R.J.
        • Snowden J.
        • Vaughan R.
        The use of the Cohen-Mansfield Agitation Inventory in the assessment of behavioral disorders in nursing homes.
        J Am Geriatr Soc. 1995; 43: 546-549
        • Diggle P.
        • Heagerty P.
        • Liang K-Y.
        • et al.
        Analysis of Longitudinal Data.
        Oxford University Press, Oxford, United Kingdom2013
      1. Centers for Medicare & Medicaid Services C. MDS 3.0 Quality Measures User's Manual (v8.0 04-15-2013). 2013. Available at: Accessed March 20, 2015.

        • Liu W.
        • Unick J.
        • Galik E.
        • et al.
        Barthel Index of Activities of Daily Living: Item response theory analysis of ratings for long-term care residents.
        Nurs Res. 2015; 64: 88-99
        • Morris J.N.
        • Fries B.E.
        • Morris S.A.
        Scaling ADLs within the MDS.
        J Gerontol A Biol Sci Med Sci. 1999; 54: M546-M553
        • Resnick B.
        • Petzer-Aboff I.
        • Galik E.
        • et al.
        Barriers and benefits to implementing a restorative care intervention in nursing homes.
        J Am Med Dir Assoc. 2008; 9: 102-108
        • Keller H.H.
        • Carrier N.
        • Duizer L.
        • et al.
        Making the most of mealtimes (m3): Grounding mealtime interventions with a conceptual model.
        J Am Med Dir Assoc. 2014; 15: 158-161
        • Amella E.J.
        • Grant A.P.
        • Mulloy C.
        Eating behavior in persons with moderate to late-stage dementia: Assessment and interventions.
        J Am Psychiatr Nurses Assoc. 2008; 13: 360-367
        • Lin L.
        • Huang Y.
        • Su S.
        • et al.
        Using spaced retrieval and Montessori-based activities in improving eating ability for residents with dementia.
        Int J Geriatr Psychiatry. 2010; 25: 953-959
        • Lin L.C.
        • Huang Y.J.
        • Watson R.
        • et al.
        Using a montessori method to increase eating ability for institutionalised residents with dementia: A crossover design.
        J Clin Nurs. 2011; 20: 3092-3101
        • Wu H.S.
        • Lin L.C.
        • Wu S.C.
        • et al.
        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
        • Suttanon P.
        • Hill K.
        • Said C.
        • et al.
        Can balance exercise programmes improve balance and related physical performance measures in people with dementia? A systematic review.
        Eur Rev Aging Phys Act. 2010; 7: 13-25
        • Rosendahl E.
        • Lindelöf N.
        • Littbrand H.
        • et al.
        High-intensity functional exercise program and proteinenriched energy supplement for older persons dependent in activities of daily living: A randomised controlled trial.
        Aust J Physiother. 2006; 52: 105-113
        • Rolland Y.
        • Pillard F.
        • Klapouszczak A.
        • et al.
        Exercise program for nursing home residents with Alzheimer's disease: A 1-year randomized, controlled trial.
        J Am Geriatr Soc. 2007; 55: 158-165
        • Dick M.B.
        • Hsieh S.
        • Bricker J.
        • et al.
        Facilitating acquisition and transfer of a continuous motor task in healthy older adults and patients with Alzheimer's disease.
        Neuropsychology. 2003; 17: 202-212
        • Chang C.C.
        • Lin L.C.
        Effects of a feeding skills training programme on nursing assistants and dementia patients.
        J Clin Nurs. 2005; 14: 1185-1192
        • Chang C.C.
        • Wykle M.L.
        • Madigan E.A.
        The effect of a feeding skills training program for nursing assistants who feed dementia patients in Taiwanese nursing homes.
        Geriatr Nurs. 2006; 27: 229-237
        • Galik E.
        • Resnick B.
        • Pretzer-Aboff I.
        ‘Knowing what makes them tick’: Motivating cognitively impaired older adults to participate in restorative care.
        Int J Nurs Pract. 2009; 15: 48-55
        • Pelletier C.A.
        Feeding beliefs of certified nurse assistants in the nursing home: A factor influencing practice.
        J Gerontol Nurs. 2005; 31: 5-10
        • Tully M.W.
        • Matrakas K.L.
        • Muir J.
        • et al.
        The Eating Behavior Scale. A simple method of assessing functional ability in patients with Alzheimer's disease.
        J Gerontol Nurs. 1997; 23 (quiz 54–15): 9-15