Browsing by Author "Keller, Heather"

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Dining Environments in Long Term Care: Prevalence of Features and Construct Validity of Two Measures
(University of Waterloo, 2017-04-27) Iuglio, Sabrina; Keller, Heather
Background: Previous research suggests that the physical and psychosocial environments can improve outcomes for residents living in long term care (LTC). However, research has inconsistently implemented interventions that target these environments resulting in the inability to compare results across studies. These inconsistencies are due to a lack of standardized measures that quantify these environments reliably and validly. Thus, instruments that address this gap would result in dependable claims of mealtime experience summarizations and consistent evaluations. Additionally, prior to this study, there has not been an examination of the differences in prevalence of physical and psychosocial dining environments across Canada. At this point it is unclear whether consistency exists nationally with regard to environmental characteristics and delivery of care and it is unknown what areas require further improvements to meet industry standards. Purposes: 1) Assess the construct validity of the dining environment audit protocol (DEAP), 2) assess the construct validity of the Mealtime Scan (MTS), 3) examine the construct validity of the mealtime relational care checklist (M-RCC) and 4) demonstrate the prevalence of key features of these instruments and differences where they exist, among provinces included in this data set. Methods and Findings: This thesis is a secondary data analysis of the Making Most of Mealtimes (M3) study, which is a cross sectional Canadian study conducted in Alberta, Manitoba, New Brunswick and Ontario. This study collected data on the multilevel determinants of food intake in 32 LTC homes, which included 639 residents and 82 dining rooms. Resident energy and protein intake estimated from three weighed and estimated food intake records were proxies for intake. Energy intake per kilogram body weight and protein intake per kilogram body weight variables were created as outcomes for these analyses, and gender, age and cognitive performance score (CPS) were used as covariates in cluster regression stratified by dementia care and general care units. Other constructs compared to measures included: nutritional status, CPS, and dining room level constructs and staff perceptions of person centered care. Features and characteristics of instruments are described and analyzed to determine their association with key summary scales of instruments. Finally, comparisons across provinces were made to determine differences in prevalence of instrument variables. The key methods and findings for analysis of each measure will be discussed. 1) Cluster regression analysis determined that the needs of residents in dementia care and general care units differed. Further, energy and protein intake was minimally influenced by the physical characteristics of the dining room as assessed by the DEAP. Through regression analysis (p<0.05) it was found that the DEAP homelikeness summary scale was positively associated with a view of the garden, clock and posted menu. Functionality summary scale was positively associated with number of chairs and lighting, while negatively associated with furniture with rounded edges and clutter. The construct validity of the homelikeness and functionality scales of the DEAP was determined through correlations (p<0.05). The functionality scale was positively associated (p<0.05) with the MTS physical scale, the dining room M-RCC, the resident M-RCC and the Mini Nutritional Assessment- Short Form (MNA-SF). Homelikeness was positively associated (p<0.05) with the staff person directed care (PDC) score and the Cognitive Performance Scale (CPS), while negatively associated with energy and protein intake. Further, the homelikeness and functionality scales were associated with one another. These associations determined that the DEAP summary scales are construct valid. Few physical characteristics of the dining room as assessed by the DEAP differed (p<0.01) across Alberta, Manitoba. New Brunswick and Ontario. 2) Energy and protein intake was minimally influenced by the physical and psychosocial characteristics of the dining room as assessed by the MTS. Regression analysis revealed that the MTS physical summary scale was positively associated with music availability and the dining room M-RCC ratio, while negatively associated with number of staff passing food and number of residents. The social environment scale was positively associated with social noise, number of residents requiring assistance and the M-RCC ratio. The person centered care (PCC) summary scale was positively associated with adequate lighting, excess noise and the dining room M-RCC ratio. Construct validity of the scales was examined using correlations (p<0.05). The three MTS summary scales were positively associated. The physical scale was also positively associated (p<0.05) with the DEAP functionality scale, the resident and dining room M-RCC and the MNA-SF. The social scale was positively associated (p<0.05) with the dining room M-RCC, the MNA-SF and CPS score. The PCC scale was positively associated (p<0.05) with the dining room and resident M-RCC, the MNA-SF and CPS score. These associations determined that the MTS summary scales are construct valid. Physical and psychosocial environments as assessed by the MTS minimally differed (p<0.01) across Alberta, Manitoba, New Brunswick and Ontario. 3) Correlations were computed to determine the construct validity of the resident level M-RCC ratio. The resident M-RCC was positively associated (p<0.05) with the DEAP functionality scale, the dining room M-RCC, the MTS PCC summary scale, and the MNA-SF score and negatively associated (p<0.05) with protein intake and CPS score. These associations determined that the resident M-RCC is construct valid. RCC and PCC practices as assessed by the resident M-RCC differed (p<0.01) across the provinces of Alberta, Manitoba, New Brunswick and Ontario. Conclusion: In conclusion, the physical and psychosocial environments as assessed by the MTS and DEAP minimally explained the variance of energy and protein intake in both dementia care and general care units, but summary scales were associated with nutritional status. The DEAP, MTS and M-RCC exhibit validity through the significant associations between the summary scales and the individual variables of each instrument. Additionally, the construct validity of these instruments was supported through the significant correlations with other instruments collected in M3. The physical and psychosocial components of the dining environment can be improved in Alberta, Manitoba, New Brunswick and Ontario to promote consistency on a national level. This secondary analysis of the M3 dataset suggests that the DEAP, MTS and M-RCC are construct valid standardized instruments that may be used to quantify the physical and psychosocial environments. Prior to this study, construct valid instruments did not exist, thus this analysis offers a basis for future research. Prevalence estimates identify areas where practices can be improved further to promote the physical and psychosocial environments.
An Exploration of Residents' and Care Partners' Perspectives on 3D Printed Pureed Food in Long-Term Care Homes in Ontario
(University of Waterloo, 2019-09-30) Awwad, Sarah; Keller, Heather
Dysphagia, or swallowing difficulties, results in the inability to consume foods of regular texture and/or fluids of regular consistency. A large proportion of residents in long term-care (LTC) homes in Ontario suffer from dysphagia and as a consequence receive texture modified foods such as pureed food. Some evidence suggests that the necessity to consume pureed food could negatively impact residents’ health outcomes and quality of life which may be due to the poor sensory properties and inconsistent quality of these foods. This study explores the potential of a novel food development, namely 3D printed pureed food (3DPPF), in overcoming some of the issues associated with traditional pureed food in LTC homes. The aim is to explore how Ontario’s LTC residents and their care partners perceive the potential for 3DPPF in LTC homes. A qualitative methodology and an interpretive description strategy are used to guide the purpose, design, and analysis with the aim of formulating results that are useful and transferable to practice in LTC homes. A total of 39 participants were recruited for semi-structured interviews and discussion groups to explore the perspectives of registered dietitians (RDs), dietary team members, and residents and family members about the potential of 3DPPF in LTC homes in Ontario. An interpretive description approach with an inductive thematic analysis strategy was used to analyze the data generated from this study. Overall, participants shared that this novel development could help improve residents’ dining experience, intake, and quality of life. They described that skills, context, resources, quality, and transparency should be carefully evaluated to ensure that 3DPPF fits within the LTC context. As such, environmental and contextual considerations were thought to influence uptake; environmental restructuring would be necessary to ensure equipment availability, applicability, cost efficiency, and compliance with LTC homes’ standards and policies. All groups described the importance of quality assurance and of meeting requirements and expectations for taste, presentation, visual appeal, texture, variety, nutritional value, and safety. Collaboration of various social actors would also be needed to ensure that the product is workable and acceptable in LTC. Learning from this study could help improve the quality of pureed food in LTC and will be translated to LTC homes, RDs, and industry partners. The results will also be disseminated to inform further research in the area of 3DPPF.
Exploring End-of-Life Nutrition Care for Residents of Long-Term Care: A Retrospective Chart Review
(University of Waterloo, 2023-08-22) Koechl, Jill Marie; Keller, Heather
Introduction: Eating challenges are prevalent in long-term care (LTC) and have been associated with mortality, particularly in older adults with advanced conditions such as dementia. However, changes to eating habits and nutrition care practices to support LTC residents who experience difficulties with eating have not been described within the context of end-of-life decline. Despite a general move towards palliative approaches to care in LTC, research on the implementation of comfort-focused nutrition care practices is lacking to date and the implications of a palliative approach to nutrition care is unknown. Nutrition care is an ideal target for palliative-focused initiatives because of the deeper meaning often placed on food and mealtimes as symbolic of relationships and care and the additional emotional challenges associated with health decline and death. When poorly addressed, severe eating challenges can cause distress among residents and care partners and contribute to decreased quality of life for residents and care providers. As such, best practices to support residents with severe eating challenges moving towards the end of life are needed to maintain quality of life for residents and provide positive care experiences for care providers, but the end-of-life nutrition care experience must first be understood. Towards this end, this dissertation aims to describe longitudinal changes in various aspects of the nutrition care experience for LTC residents approaching the end of life. Methods: Data for this study were obtained from a retrospective resident chart review of a convenience sample of deceased residents from 18 LTC homes in southern Ontario, Canada. Two sampling frames, the “Better tArgeting, Better outcomes for frail ELderly patients (BABEL)” study and a chain of homes were accessed to meet sample size requirements. The latter included random selection of decedents for chart review. Eligible participants were over the age of 65 years at death and living in residence for at least 6 months. Data were collected from electronic charts. Admission forms provided information on demographics (e.g., age at death, sex, length of admission), and resident assessments completed approximately 6 months prior to death provided functional and health characteristics (e.g., cognitive performance, health instability) and diagnoses. Nutrition-related information (e.g., nutrition interventions, eating challenges) were obtained from monthly weight records, progress notes, and care plans, narrowed to four time points at 6-, 3-, 1-month and 2 weeks prior to the date of death. The point at which the first mention of end-of-life decline occurred and the details around this event were also noted. Study 1 described the eating challenges documented at each time point: a mixed effects logistic regression model tested longitudinal within-resident differences in eating challenges, and an unconditional repeated measures latent class analysis identified patterns of change in multiple eating challenges over time. Study 2 described the nutrition care interventions used to support residents and identified resident-level and time-dependent factors associated with comfort-focused nutrition care orders using a mixed methods logistic regression analysis. Study 3 determined which nutrition- and non-nutrition-related challenges factored into the first documentation of suspected end-of-life decline from the care provider perspective and assessed the association of each factor with time to death using a Cox proportional hazards regression analysis. Study 4 described dietitian referrals documented at each of the four time points and identified time-dependent factors, including comfort-focused orders, that were associated with dietitian referrals. Results: The sample was comprised of 164 LTC residents (mean age 88.3±7.5 years at death; 61% female) and had a high level of health challenges and functional impairments, including 79.3% with moderate/severe cognitive impairment and 58.5% who left food uneaten at most meals 6 months prior to death. Study 1: All but 1 resident (99.4%, n=163) exhibited one or more eating challenges in the 6 months prior to death. Likelihood of severe and complex eating challenges (e.g., poor appetite, dysphagia, refusing to eat, decreased food intake) increased in the month preceding death compared to 6 months prior. A significant increase in lethargy at mealtimes was found as early as 3 months (Odds ratio [OR] = 1.78, 95% confidence interval [CI] = [1.06, 3.00]) compared to 6 months prior to death, and increased in a stepwise fashion at 1 month (OR = 4.09 [2.47, 6.76]) and 2 weeks (OR = 8.24 [4.92, 13.78]) before death. Four patterns of eating challenges were identified with the repeated measures latent class analysis, labeled for the most prominent features defining each group over time: “refusing” (20.1%), “complex” (18.9%), “progressive” (30.5%), and “end-stage” (30.5%). Study 2: Restorative nutrition interventions (e.g., physical assistance, oral nutritional supplementation) to support oral nutrient intake were also common (99.4% of the sample) in the last 6 months of life, and nearly half of the sample had nutrition care plan modifications between each time point. Despite a high need for nutritional interventions, only 30.5% of the sample received a comfort-focused nutrition care order, and most often these occurred within two weeks of death. Comfort orders were more likely with health instability (OR = 4.35 [1.49, 13.76]), within two weeks of death (OR = 5.50 [1.70, 17.11]), following an end-of-life conversation (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with the co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]), and with a higher number of eating challenges (OR=1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding time point. Study 3: Several of the eating challenges cited above were documented by care providers to suggest suspected end-of-life decline. Of 7 eating challenges cited, only dysphagia was significantly associated with increased risk of death (HR = 2.99; 95% CI = 1.41, 6.33). Study 4: Dietitian referrals were common (73% of participants) in the last six months of life and were significantly associated with number of eating challenges (OR = 1.38 [1.25, 1.54]). A higher frequency of comfort-focused nutrition care orders was found when a dietitian was referred (24.7%) compared to when not referred (11.9 %) in the final month of life, though a causal association could not be established. Conclusion: Findings demonstrate that nutrition care is an important aspect of the end-of-life experience for LTC residents and that there is potential room for growth in supporting residents with severe and complex eating challenges. Eating challenges were common and increased in prevalence with proximity to death requiring several modifications to nutrition care plans, while comfort-focused nutrition care plans were used infrequently and often late in the end-of-life trajectory. Given the common occurrence of eating challenges with proximity to death and the evidence that they are considered by care providers as informal signals of end-of-life decline in current practice, changes to eating habits (e.g., decreased food intake) may be useful targets for initiating timely comfort-focused nutrition care conversations. The involvement of dietitians at key moments when comfort-focused nutrition care may be appropriate suggests that dietitians are well-positioned to champion palliative approaches to nutrition care within the multidisciplinary LTC team. Future work should explore residents’ and care providers attitudes towards comfort-focused nutrition care to develop best practices that align with their needs and preferences to support quality of life across the final months of life.
Frailty and Health Related Outcomes in Acute Care
(University of Waterloo, 2017-09-08) McNicholl, Tara; Keller, Heather
Background: Current frailty screening tools have not been validated for day-to-day use in acute care (Binder, 2015). Many recommended tools include subjective questions and take too much time to complete in a fast-paced clinical environment (Morley et al., 2013). It is for this reason that hand grip strength and gait speed have been chosen as tools to be evaluated for their feasibility and potential utility as single indicators of frailty for use in acute care. A useful indicator should add value to a clinical assessment, such as predicting key outcomes to identify those patients who need more intensive treatment. The predictive validity of frailty measures has been studied extensively in the literature in connection to many different health related outcomes. However, their predictive validity in relation to length of hospital stay and quality of life during and post-discharge from acute care requires further investigation. The More-2-Eat study provides an ideal opportunity to address these knowledge gaps. Purpose: (1) To determine the feasibility of two frailty indicators (5m and HGS) for acute care patients, (2) to determine the predictive validity of these tools with respect to LOS, and (3) to determine if these frailty indicators predict quality of life during and post-discharge from acute care. Methods and findings: More-2-Eat was a multi-site participatory action research study with a before-after time series design. The primary objective of the study was to implement and evaluate the Integrated Nutrition Pathway for Acute Care (INPAC) in Canadian hospitals. Each site was led by an interdisciplinary team, which offered coaching and improvement strategies towards implementing nutrition care best practices. The study population were all patients on the chosen medical unit for implementation of INPAC at the: Royal Alexandra Hospital (Edmonton, AB), Regina General Hospital (Regina, SK), Concordia Hospital (Winnipeg, MB), Niagara Health System, General Site (Niagara Falls, ON), and Ottawa Hospital (Ottawa, ON). There were two key aspects of data collection at the patient level; an 1) audit of nutrition care practices for all patients on the unit during monthly audit days, and 2) a detailed assessment of nutrition, frailty, disability, quality of life and food intake on a subset of patients recruited each month. This latter data collection was used for this study. There were 1250 detailed patient data collections over a 15-month period for analysis. Data included demographics, primary admission diagnosis, length of stay, nutritional risk (and diagnosis of malnutrition if relevant), an estimate of a single meal’s food intake, barriers to food intake, self-reported quality of life, self-reported disability, frailty indicators, patient reported perceptions on adequacy of food intake and nutritional health, and nutrition care provided in the hospital at the time of the data collection. All data were typically collected over one to three days for each patient. Items used in this thesis include: handgrip strength (HGS) (n=1146, mean=20.82 kg), five meter timed walk (5m) (n=535, median=6.79 sec), subjective global assessment (SGA), perceived functional status (Nagi scale), length of stay (LOS), quality of life (QOL), demographics, and reasons for non-completion of assessments. (1) Descriptive statistics revealed that HGS is a more feasible indicator of frailty than the 5m in acute care medical patients, as the completion rate was over 90%; 5m walk could not be completed in more than 50% of patients. Further, HGS had high completion rates across all sites and for diverse populations (diagnoses, sex). HGS was associated with key patient characteristics such as nutritional status (t=4.13, p<0.0001) and perceived functional status (t=10.69, p<0.0001). (2) Multiple linear regression modeling revealed that the addition of HGS as an indicator of frailty significantly improved the predictive value for both male (X2=3.9, p<0.0001) and females (X2=2.0, p<0.05) for LOS, whereas 5m was not useful as a predictor across sex. Yet, standardized cut-points for both measures had low sensitivity and specificity. (3) Multiple linear regression modeling also revealed that the addition of HGS as an indicator of frailty significantly improved the predictive value of both the male (X2= 31.78, p<0.01) and female models (X2= 21.02, p<0.01) with respect to the physical component of QOL in hospital (PCS1) and post-discharge (PCS2) (X2=10.62, p<0.01; X2= 10.75, p<0.01), whereas 5m added significant predictive value across sexes for the physical component of QOL in hospital (PCS1) (X2=9.42, p<0.01; X2=15.72, p<0.01), but not 30 days post-discharge (PCS2). Conclusion: Overall, HGS appears to be a more appropriate single indicator of frailty for consideration in acute care. This tool is feasible for diverse patients and results are associated with nutritional status and perceived functional disability, indicating that it is likely measuring frailty (as defined by Fried, 2001). HGS also appears to be relevant for predicting important outcomes and clinical decision-making. Lower HGS values were correlated with longer LOS and poorer physical QOL. HGS also provided additional predictive value for LOS and physical QOL in hospital and 30 days post-discharge when adjusting for other covariates that would be collected in a clinical setting, including nutritional status. Consideration for use of this tool in acute care is appropriate once useful cut-points have been determined.
Implementing new nutrition care practices in healthcare: learning from the experience of health professionals in hospitals and Family Health Teams.
(University of Waterloo, 2019-03-06) Laur, Celia; Keller, Heather
Background: When converting evidence into practice to improve patient care, application of implementation, behaviour change and change management theory can help make the changes more effective and sustained. With a third of patients malnourished at admission to hospital and 34% of older adults at nutrition risk in the community, nutrition risk identification is a key care activity. Implementation techniques are needed to integrate screening into hospital and community settings. The overall aim of this dissertation was to understand healthcare professionals’ perspectives on implementing several new nutrition care activities in hospitals and nutrition screening in the community. Methods: Part 1 and 2 of this dissertation are components of the More-2-Eat (M2E) study, which aimed to improve nutrition care by implementing the Integrated Nutrition Pathway for Acute Care (INPAC) in five hospital units across Canada. In Part 1, a knowledge, attitudes and practices (KAP) questionnaire was developed and tested for reliability (test-retest) and then used in the baseline period of M2E. This questionnaire was an implementation technique used to demonstrate barriers to the use of INPAC prior to tailoring to the specific hospital context. Correlation (Intra class correlation; ICC), descriptive, and association analyses were conducted. The questionnaire was then administered to hospital staff on the M2E units before INPAC implementation and again a year later. Paired and unpaired statistical analyses were used to demonstrate changes in staff KAP with implementation of INPAC and associations determined between key staff characteristics and KAP change. For Part 2, key informant interviews and focus groups were conducted with staff and management at the M2E units at baseline, after a year of implementation and a year after project completion. Verbatim transcription was completed for interviews, and focus groups were summarized. Line by line coding was completed followed by thematic analysis. Results collected 1 and 2 years after implementation were analyzed together. Part 3 is focused on stakeholder perceptions of building a program for falls and nutrition risk screening in primary care. Interviews were conducted with staff, management, and clients from six Family Health Teams in the North East Local Health Integration Network; regional representatives were also interviewed as this was a regional initiative. Family Health Team staff, management and regional representative interviews were transcribed verbatim and client interviews summarized. Line by line coding was conducted on all interviews followed by thematic analysis. Results: Results from Part 1 indicate the KAP questionnaire is reliable (knowledge/attitude subscale ICC = 0.69 [95% CI 0.45–0.84]; practice subscale ICC = 0.845 [0.68−0.92]) and several barriers with respect to knowledge and attitudes of team members were noted in the baseline use of this questionnaire in the M2E hospitals. Comparing baseline results (n = 189) with scores after a year of implementing INPAC, (n = 147 unpaired and n = 57 paired with baseline) there was a significant increase in total score in unpaired results (from mean 93.6/128 [range, 51–124] to 99.5/128 [range, 54–119]; t = 5.97, P < .0001). There was also an increase in knowledge/attitudes (t = 2.4, P = .016) and practice (t = 3.57, P < .0001) components. There were no statistically significant changes in paired responses. After the year of INPAC implementation, 59% (n = 86) of staff felt involved in the change process, and these staff had higher knowledge/attitudes and KAP scores than those who did not feel involved. Results from Part 2 provided an understanding of what hospital staff and management considered necessary to make nutrition care improvements. Five main themes were identified from baseline data: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team. Building on these results, 1 and 2 years later, sites described the beginning of a culture change where nutrition care activities were valued and viewed as the expected norm. Results provided an understanding of what was necessary to sustain changes: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread successful nutrition care improvements to other units in the study hospital and other nearby hospitals included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible, and maintaining roles and supporting new champions. For Part 3, a new context was considered, exploring how Family Health Teams developed falls and nutrition risk screening programs for older adults. Four themes were identified, including: setting up for successful screening; making it work; following up with risk; and an overarching theme that the implementation of this care improvement was about building relationships. Discussion: This dissertation provides guidance for healthcare providers on how to implement nutrition care improvements in hospitals and steps for building a falls and nutrition risk screening program in a Family Health Team. This dissertation research has significant impact on understanding the process of change which can impact patient care in both settings. Impact is also visible through its contribution to the M2E project overall, as M2E did improve nutrition care in all five hospital units. Comparisons can be made between how changes were initiated in each setting, specifically regarding their use of implementation, behaviour change and change management theories to support sustainable change. These theories are guides that can ensure the processes and changes are viewed from a variety of perspectives and key steps considered. In the M2E hospitals, the teams making the changes were trained on these theories and applied them throughout their implementation of INPAC, including through considering capability, opportunity and motivation, collecting audit data, involving relevant people in the change process, and more. Family Health Teams had not received such training and although they were thinking through the process and recommended use of change management strategies, they may benefit from applying implementation theories to support their progress. Conclusion: This dissertation has significant impact in terms of understanding the process of change in hospitals and Family Health Teams. Results from the hospital work are already been applied to practice and research in other hospitals in Canada, Australia and the United Kingdom. Understanding the steps used by Family Health Teams to set up their falls and nutrition risk screening will be beneficial for others that are developing their own programs. Learning from and sharing the experiences of health professionals implementing screening and other nutrition care activities in hospitals and Family Health Teams will help to improve patient care and support continued implementation of nutrition care practices in healthcare.
Improving Nutrition Risk Screening for Community-Dwelling Frail Older Adults
(University of Waterloo, 2024-08-29) Jackson, Meagan; Keller, Heather
Background: As Canada's population continues to age, it is essential to screen for nutrition risk in frail older adults to support older adults to benefit from services and care that can improve their nutrition and prevent outcomes of nutrition risk, such as frailty. Frailty is defined as "an age-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes" (Walston et al., 2022). Over time, insufficient protein and energy intake may increase the risk of malnutrition (Hoogendijk et al., 2019) and may lead to weight loss in an older population, which is an indicator of frailty (Cederholm et al., 2019; Fried et al., 2001: Wei et al., 2018). The Seniors in the Community Risk Evaluation for Eating and Nutrition (SCREEN)-14 is a 17-item questionnaire created to measure nutrition risk in older adults aged 50+ (Keller et al., 2005). As SCREEN was created before frailty became a relevant concept in clinical care, refinements to SCREEN-14 may be needed to specifically target frail older adults. Further, to promote use of nutrition screening tools in practice, they need to be as brief as possible. SCREEN-8 was developed using a mixed method of classical test theory and expert opinion to meet this need. However, it is not known if this is the best short version of the tool, specifically considering frail older adults. Objectives: The objectives of this thesis were to: (1) use expert opinion to determine the minimum set of SCREEN-14 questions needed to identify nutrition risk in potentially frail older adults (i.e., content validity), and if any new questions are required (Chapter 4) (2) use Item Response Theory (IRT) to also identify a minimum data set that can differentiate those most likely to be at risk, and specifically within the oldest age groups (proxy for frailty) (Chapter 5), and (3) evaluate the differences and overlap in these tools as compared to SCREEN-8. (Chapter 5). Two discrete studies will be completed to address these objectives. Methods and results: The first study (Chapter 4) uses a Delphi technique which gathers expert opinion and builds consensus on an issue by way of anonymous surveys. Forty-six experts in the field who have used SCREEN in the past and had contacted the originator were invited to participate in a two-round Delphi process. Eighteen experts participated throughout the two rounds. They were asked to rate (first round survey) and confirm (second round survey) the importance of current SCREEN-14 items for the inclusion in a minimum set that specifically could identify risk in those who are frail. Additional questions were asked on expansion of items (round one) and consensus on inclusion of new items (round two). The experts concluded that eight current SCREEN questions should be included in the final set with no new questions added. The second study (Chapter 5) addresses objectives two and three in a secondary data analysis of the Nutri-eSCREEN dataset. Nutri-eSCREEN contained SCREEN-14 in an online platform as well as self-reported sex, age, and geographic location. After cleaning and applying the exclusion criteria there were n=20,093 participants in the dataset used in the analyses. To address objective two, psychometric models, specifically a Graded Response Model (GRM) was conducted to identify a draft minimum SCREEN (i.e., what items discriminate risk) using the whole sample as well as only participants 75+years (n=2,749) to serve as a proxy for frailty. From both samples eight different questions (six of them overlapping) were identified using the item parameter estimates and consideration on coverage of the concept of nutrition risk. The IRT 75+ version was decided to be a better tool and used in subsequent analyses. Using demographic variables, a bivariate analysis was also completed to determine the statistical differences among SCREEN-14 questions by sex and age groups to demonstrate construct validity of the abbreviated IRT version. Variations of SCREEN (SCREEN-8 and SCREEN resulting from the Delphi) were created for comparison to this IRT version resulting from the GRM analysis to address objective three. SCREEN-8 identified the highest proportion at risk (42.1%) and the SCREEN-IRT the least (27.7%). The overlap of all three versions identifying participants to be at risk was 77.4%. Finally, model fit statistics among the three brief versions were calculated with SCREEN-8 and SCREEN-IRT found to be better tools than SCREEN-Frail. Conclusion: As the population is rapidly aging, easy to use and brief tools that target nutrition risk identification to those most in need of further evaluation are required. These studies helped to identify two separate potential versions of SCREEN through different methods. The different versions both contained eight questions as does SCREEN-8. The conclusion is that although these two new versions were created via consensus and IRT methods they do not appear to be superior to SCREEN-8 with respect to, brevity, model fit, and identification of prevalence of risk. Future work should further test and validate these versions for comparison to SCREEN-8.
Modified Texture Diet and Long Term Care: A Secondary Data Analysis of Making the Most of Mealtimes (M3) Project
(University of Waterloo, 2017-01-18) Vucea, Vanessa; Keller, Heather
Background: Research has suggested that modified texture diets (MTDs) are prevalent among older adults living in long term care (LTC). Additionally, previous research has also suggested that modified texture food, especially pureed food, contains fewer calories and offers less nutritional quality compared to unmodified food; plus these diets are associated with a high prevalence of under-nutrition and weight loss among older adults in LTC. Residents who require pureed food are often highly vulnerable, with eating challenges and cognitive impairment, requiring total eating assistance. To date, it has been challenging to disentangle these inter-related factors to understand how to improve food intake for those requiring food texture modifications. Purposes: 1) To examine the current prevalence of prescribed MTDs in Canadian LTC homes when applying standardized terminology and the resident characteristics that are associated with the prescription of a MTD. 2) To determine if the pureed diet provided as planned for one week is different in energy, macronutrients, micronutrients, and fibre as compared to the regular texture diet; and examine what home characteristics may be associated with these differences. 3) To examine the current dietary intake of residents in LTC homes consuming a pureed diet, compare this to the Dietary Reference Intake, and assess covariates that are associated with this intake. 4) To examine if prescription of a MTD as compared to a regular texture diet is independently associated with the risk of malnutrition in residents of LTC homes when diverse relevant covariates are considered. Methods and Findings: This thesis work is a secondary data analysis of the M3 project, a cross-sectional multi-site study across Canada, which collected data at the provincial, home, unit, staff, and resident levels from 639 residents across 32 LTC homes in four provinces (AB, MB, NB, ON). Four studies were part of this thesis work, and each method in more detail and respective findings are described below. 1) The use of MTDs and resident characteristics were identified from health records and standardized procedures. Homes used a variety of terms to describe MTDs. Diets were re-categorized using the International Dysphagia Diet Standardization Initiative (IDDSI) Framework: regular, soft, minced and moist, pureed, and liquidized. Modified texture (i.e., pureed, minced and moist, and soft and bite-sized) diets were prescribed to about 47% (n= 298) of residents in the M3 sample (n= 639) and prevalence was significantly different across provinces. Many resident characteristics that were found to be associated with the prescription of a MTD included: longer length of admission, risk of dysphagia, dementia diagnosis, lower number of oral agents (e.g., vitamin/mineral supplementation and drugs), decreased number of vitamins/minerals, prescription of oral nutritional supplementation, lower body weight, higher weight loss, lower body mass index, decreased calf circumference, higher risk of malnutrition, requirement of physical assistance, more eating challenges, poor oral health status, more cognitive impairment, and more impairment in the activities of daily living. 2) A nutrient analysis of pureed (n= 32) and regular (n= 32) menus for the first week of the menu cycle was completed using Food Processor software for all 32 LTC homes. Findings suggest there were significant province and diet texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed, with New Brunswick and Alberta having lower nutrient content for both menus as compared to Ontario and Manitoba. Within each province, similar trends were observed; some homes had significantly lower nutrient content for pureed diets, while others did not. Fibre and nine micronutrients were below DRI recommendations for both menus across the provinces, with variation existing across the sites within each province where some had more or less nutrients meet the specific DRI recommendations. Many home characteristics were found to be associated with a higher energy and protein provision from the regular and/or pureed texture menus, they included: for-profit status; larger homes; three, four, or five week menu cycles; a menu revision every 6−12 months; higher funding for raw food; and higher proportion of commercial food product use. 3) A three-day dietary intake was collected using weighed methods for main dishes and a standardized estimating protocol for side dishes and fluids; intake was analyzed using Food Processor software and only residents consuming a pureed diet (n= 67) were included. When protein, carbohydrate, and micronutrient intakes were compared to the appropriate DRI for females (n= 51) over the age of 70 years, this study found that the prevalence of inadequate intake for the sample widely ranged depending on the specific nutrient, although only six nutrients (vitamin B6, vitamin D, vitamin E, folate, calcium and magnesium) had potential inadequacy for 50% or more of the sample. Additionally, this study found that when adjusted for age and gender, only average number of staff assisting with a meal was independently associated with energy and protein intake for individuals consuming a pureed diet (n= 66). Specifically, as the number of staff increased during mealtimes the amount of energy and protein intake per kilogram of body weight decreased. 4) The MNA-SF score, use of MTDs, and resident characteristics were identified from health records and standardized procedures. This study found that prescribed diet texture, more specifically a pureed diet, was independently associated with risk of or malnutrition among residents living in LTC facilities (n= 364). Other independent covariates were being on oral nutritional supplementation, more cognitive impairment, more eating challenges (e.g., spitting food out of mouth), and a poor oral health rating, after adjusting for age and gender. Overall Conclusion: In conclusion, the prevalence of prescribed MTDs was high and significantly different across provinces in Canada, with a number of resident characteristics associated with a prescribed MTD. There was variability in menu planning across provinces and LTC homes in the M3 sample, plus pureed menus tended to offer a lower amount for many nutrients as compared to the regular menu with some exceptions (e.g., vitamin D and calcium). Among residents consuming a pureed diet, inadequate nutrient intake existed for several nutrients, and specifically of concern were vitamin B6, vitamin D, vitamin E, vitamin K, folate, calcium, magnesium, potassium, and fibre. The number of staff assisting at mealtimes was the only variable independently associated with food intake in this group. Lastly, prescribed diet texture, more specifically a pureed diet, was independently associated with risk of or malnutrition among residents living in LTC facilities. This secondary data analysis of the M3 Project offers a more in-depth and comprehensive contribution to the limited research around older adults and helps to address many of the confounding factors of prior work. Interventions can be targeted to key gaps in care identified in this work.
My Meal Intake Tool (MMIT) and the Mealtime Audit Tool (MAT) - Criterion Validity and Inter-rater Reliability Testing of two Novel Tools for Improving Food Intake in Acute Care
(University of Waterloo, 2016-05-19) McCullough, James; Keller, Heather
BACKGROUND: Forty-five percent of patients in Canada are admitted to hospital already malnourished. Compared to well-nourished patients, those with diminished nutritional status are at an increased risk of in-hospital mortality and several medical complications. As a result, malnourished patients take longer to recover, stay hospitalized longer, and are more likely to be readmitted to hospital after discharge, costing the healthcare system more to care for them. Improving nutritional status in hospital can improve recovery and shorten length of stay. Insufficient food intake (FI) is common in hospital and has also been associated with longer lengths of stay (LOS), leading to further declines in nutritional status. Thus, ensuring sufficient patient FI could improve patient outcomes and reduce costs of care by reducing nutritional decline. However, current FI monitoring practices in hospital are generally ad hoc. Most hospitals don’t have the resource capacity to have staff monitor every patient’s FI, so monitoring practices are sparsely or inaccurately completed for only a portion of patients. There are also barriers to FI that occur in hospital, which include a range of potential mealtime issues patients could experience that further prevent them from consuming enough food. These barriers are simple issues that can easily go unrecognized by staff and their existence isn’t formally assessed or monitored in current practice. Creating practices that allow 1) the accurate monitoring of all patients’ FI, and 2) the identification and removal of FI barriers, could increase the efficacy of hospitals to provide sufficient nutrition care and fight the prevalence of malnutrition through increased patient FI. PURPOSE: The purpose of this thesis was to complete key steps in the development and testing of two novel hospital nutrition care tools. The My Meal Intake Tool (M-MIT), a patient-completed FI monitoring tool, was tested for feasibility and criterion validity in a clinical setting. The Mealtime Audit Tool (MAT), a hospital staff-completed tool for the identification of FI barriers, was tested for feasibility and inter-rater reliability in a clinical setting. METHODS & MAJOR FINDINGS: Two studies were conducted as part of this thesis work. Study 1: Patients from four Canadian hospitals (n=120) were recruited to participate in the feasibility testing of both the M-MIT and the MAT, as well as the criterion validation of the M-MIT. Participants estimated their food and fluid intake using the M-MIT at one mealtime. M-MIT results were validated against dietitian visual estimations of their FI for the same meal. At a separate mealtime, a dietitian completed the MAT with the participants, identifying the barriers that they experienced at that mealtime. 78% of participants were able to estimate their FI on the M-MIT without error. Sensitivity and specificity of M-MIT’s ability to identify participants who consumed < 50% of their meal were 76.2% and 74.0% (p <0.001) respectively, indicating sufficient criterion validity; sensitivity analyses including those who did not complete the tool resulted in a range of sensitivity from 53.3% to 83.3% and specificity from 60.0% to 78.9%. The results of the validity analyses, in combination with patient follow-up interviews and clinician feedback, were used to make revisions to the tool to improve the feasibility and ease of use of M-MIT. Descriptive analyses were conducted to characterize barriers experienced by participants according to the MAT, and clinician feedback was used to make revisions to the MAT before Study 2. Study 2: Ninety patients from multiple medical and surgical units in a Canadian hospital were recruited to participate in the inter-rater reliability testing of the MAT across 30 different mealtimes. Two auditors completed the MAT with each of the 90 participants within a few minutes of each other after the participants had completed their meals. The MAT tabulates a total score of the number of barriers (out of 18) experienced at a mealtime. Total MAT scores between the two auditors showed good agreement, with an intra-class correlation coefficient (ICC) of 0.68 (0.52-0.79). About two-thirds of the 18 barrier items listed on the MAT showed good to excellent agreement between the two auditors, according to calculated kappa statistics. The inter-rater reliability analyses, descriptive analyses, and clinician feedback from Study 1 and Study 2 were used to make revisions to improve functionality and ease of use of the MAT. OVERALL CONCLUSIONS: The studies within this thesis have shown the M-MIT and MAT have good potential for use in clinical practice. If implemented into use, the tools have the potential to play a role in improving nutrition care. These tools could help standardize processes (FI monitoring, assessment of FI barriers) that are currently ad hoc or non-existent. However, changing existing care practices is an extremely complex task. There is still work to be done to further test and refine the tools, as well as to determine whether these tools can feasibly be integrated into routine practices, and if their use leads to improvement in patient outcomes.
Relational Mealtimes in Long-Term Care: Understanding the context of care at mealtimes for residents with eating and other mealtime challenges
(University of Waterloo, 2021-09-21) Wu, Sarah; Keller, Heather
Background: Mealtimes in long-term care (LTC) are essential to resident health and well-being, as eating with others helps to reinforce relationships between those who live and work in these homes and their relationships to the greater community. The evolution of the culture change movement within the LTC sector promotes the adoption of social models of care, such as relationship-centred care (RCC), to improve the everyday lives of residents, including at mealtimes. Malnutrition is a serious and on- going issue among residents living in LTC homes, where 44% of Canadian residents were found to be malnourished largely due to food access issues (e.g., eating ability, dysphagia). Addressing these issues requires a relational understanding of factors that can impact resident mealtimes, and the conditions under which care is provided. Families continue to play an important role in the lives of residents and provide additional support when needed, though their contributions continue to be overlooked. Informed by relational theory, this dissertation aimed to understand how multi-level interacting factors shape the conditions of care, the mealtime experience, and ultimately the well-nourishment of residents. Methods: All parts that comprise this dissertation use secondary data from the Making the Most of Mealtimes (M3) Study, a cross-sectional study that examined multi-level factors associated with food and fluid intake among 639 residents across 32 Canadian LTC homes in four provinces (AB, MB, ON, NB). Part 1 of this dissertation aimed to explore the multi-level factors at the resident-, dining room-, and LTC home system- levels that may impact mealtime care, specifically associations with staff RCC and task- focused (TF) mealtime practices. Descriptive and association analyses were conducted to determine independent associations between multi-level factors and these RCC and TF mealtime care practices. Recognizing that relationships and how eating assistance is provided may impact food intake, the study in Part 2 aimed to explore the potential impact of a family member providing mealtime eating assistance on resident energy and protein intake, as compared to when staff provided this assistance. Descriptive andassociation analyses were conducted to determine the independent association between energy and protein intake with family eating assistance versus staff assistance in a subset of residents requiring physical eating assistance (n= 147). Mealtime experiences of food intake and social interactions can be influenced by many factors, including the resident’s capacity for verbal communication, including vision and hearing abilities. Challenges in communication may be exhibited as wayfaring during meals. Part 3 of this thesis explored the association between resident sensory impairment, communication capacity, wayfaring during the meal, staff mealtime care practices (RCC and TF), and family food involvement (providing eating assistance, bringing food into the home) with the outcome of nutrition status (malnourished vs. well-nourished). Descriptive and association analyses were conducted to determine which of these resident, staff and family variables had the potential to impact resident nutritional status. Results: Using a standardized mealtime observation tool to determine mealtime practices in Part 1, it was noted that RCC practices (9.6±1.4) were more common than TF practices (5.6±2.1). Almost one quarter of participants required eating assistance (n=634; 23.2%). Mealtime RCC and TF practices were associated with multi-level factors: TF practices were more likely to occur with larger home size, care continuums, more staff involved in assisting, male residents, and residents requiring eating assistance. RCC practices were observed more often in for-profit homes, those with recent renovations, and female residents. Results from Part 2 found that of those residents who required any physical eating assistance (N=147), almost 40% had a family member provide assistance during at least one of nine meal observations. Statistically significant differences in eating challenges (i.e., dysphagia risk) and type of home area (i.e., specialized dementia care units) were found between those residents who received family assistance (n=56) compared to those who did not (n=91). Family assistance was independently associated with a significantly higher consumption of both protein and energy intake when compared to staff assistance for meals in these same participants (n=56). Results from Part 3 found that 44% of the resident sample were malnourished. Vision and hearing deficits (despite use of usual aids) affected almost 20% of participants, while verbal communication challenges affected over a quarter of residents. Wayfaring at meals was observed among almost 4% of residents. Statistically significant differences in characteristics were found between well-nourished and malnourished residents. Vision impairment, communication challenges, wayfaring, family member mealtime presence, and fewer RCC mealtime practices were independently associated with resident malnutrition. Conclusion: This dissertation provides insight into some of the relational aspects of mealtimes within Canadian LTC homes. More specifically how capacity for resident participation in meals (e.g., wayfaring, verbal communication), requirement of physical eating assistance, staff mealtime care practices, and family participation are linked to higher level structures that impact the innermost mealtime interactions resulting in differences in food intake and malnutrition. Findings from this dissertation support a refocusing of efforts in the culture change movement on these most vulnerable residents with eating and other mealtime challenges. Future work should target the conditions of care as they relate to mealtimes and translate into RCC practices, which includes the dining environment, organizational culture, and governing bodies.
Social Factors and Nutrition Risk in Community-Living Seniors During the COVID-19 Pandemic
(University of Waterloo, 2023-01-04) Wei, Cindy; Keller, Heather
Pandemic countermeasures (e.g., lockdown, restrictions) enacted to minimize the spread of COVID-19 may put older adults at nutrition risk. This thesis uses an online/telephone survey to investigate factors associated with nutrition risk for community-dwelling older adults living in Hamilton, Ontario, Canada during the COVID-19 pandemic. Data were collected on nutrition risk, loneliness, mental health, assistance with meal preparation and/or delivery, frequency of making phone/video calls and using social media, and more. Subsequent data were collected in waves approximately three months apart. Objectives of this thesis were to understand the prevalence of high nutrition risk and identify the association with social-related variables that could be impacted by COVID-19 during different time points of the pandemic. Research questions were: 1. What is the prevalence of high nutrition risk (SCREEN-8 score <38) in the IMPACT sample? 2. Are participant-reported variables (self-reported mental health, loneliness over the past week, and receiving assistance with meal preparation or delivery) that could be impacted by COVID-19 shelter-in-place public health policy in the first wave of the pandemic, associated with baseline nutrition risk scores (SCREEN-8) in community-dwelling adults over 65 years old in Hamilton, Ontario, when adjusting for meaningful covariates (e.g., sex, age)? 3. Is there a change in median nutrition risk score over nine months in community-dwelling adults over 65 years old in Hamilton, Ontario? 4. Do participants change nutrition risk categorization over this time frame? 5. Are changes in mental health, loneliness, frequency of video/phone calls and use of social media associated with change in nutrition risk scores over time (from baseline to nine months)? From this sample of older adults (n=272, 78±7.3 years old, 70% female), we found that nutrition risk was prevalent among the community-dwelling older adults (64% at high risk). In a multivariable cross-sectional analysis that examined baseline only, loneliness in the past week (β -2.92, 95% CI [-5.51, -0.34]) and resilience (β 1.28, [0.04, 2.52]) were found to be associated with nutrition risk. In a second longitudinal analysis (n=178) based on a subset with a complete nutrition risk questionnaire nine months later, authors also found that frequency of direct social contacts from phone/video calls was associated with less nutrition risk (β -6.84, [-12.9, -0.77]), but people using more social media are more likely to be at high risk (β 6.19, [0.64, 11.75]). Findings from this thesis may inform public health interventions with respect to social interactions in pandemic circumstances or other challenging situations. This research also implies that it is critical to understand and advocate for healthy social media use to improve nutrition for older adults. Strategies to mitigate the adverse outcomes, such as loneliness and subsequent nutrition risk of future pandemic countermeasures should target this vulnerable group.
Understanding the impact related to lifestyle interventinos for people with dementia: A systematic review protocol
(Public Library of Science (PLOS), 2024) Middleton, Laura; Vucea-Tirabassi, Vanessa; Liu, Grace; Bethell, Jennifer; Cooke, Heather; Keller, Heather; Liu-Ambrose, Teresa; O'Connell, Megan E.; Stapleton, Jackie; Waldron, Ingrid; Wu, Sarah; Yous, Marie-Lee; Aiken, Christine; Heibein, William; Norman, Myrna; McAiney, Carrie
There is growing evidence to suggest that lifestyle initiatives promote brain health and reduce dementia risk. However, there is comparatively limited research focused on lifestyle interventions among people living with dementia. Most recent systematic reviews of lifestyle interventions among people living with dementia centre on the impact of exercise on cognition; yet, functional abilities and quality of life are most consistently prioritized by people living with dementia, care partners, and healthcare professionals. There is insufficient evidence to inform guidelines on effective lifestyle interventions, programs, resources, and policies for people living with dementia. To address this knowledge gap, the objective of this study is to perform a systematic review to understand the impact of lifestyle interventions among people living with dementia. The specific research questions are: "What is the effectiveness of physical activity interventions on improving functional abilities and quality of life among community-dwelling people living with dementia?", "What is the effectiveness of healthy eating/nutrition on improving nutritional status or quality of life among community-dwelling people living with dementia?" and "Does the effectiveness of interventions vary depending on the components (single or multi), setting (in-home or community centre, geography), program structure, mode of delivery, dosage, and participant characteristics (sex/gender, ethno-cultural or language group, race, dementia type)?" The results from this review will inform recommendations of lifestyle interventions and their delivery among people living with dementia in the community. Trial registration: Systematic review registration PROSPERO #CRD42024509408.