Staff views on how to improve mealtimes for elderly people with dementia living at home

Abstract

Dementia commonly leads to difficulties in performing daily activities, which can also often affect the ability to prepare and eat meals. As a result, formal support to maintain good nutritional intake might be needed, but there is a lack of knowledge concerning how to support older persons with dementia living at home. The aim of this study was to explore and describe staff views on how to improve mealtimes for persons with dementia who are still living at home. A qualitative descriptive study was performed and data were collected during 2011–2012 through four focus group interviews with staff working in the homes of persons with dementia. Data were analyzed using inductive content analysis. The participants described several ways to improve mealtimes for persons with dementia and advocated adjustments facilitating the preservation of the persons’ independence. Finding suitable actions calls for knowledge about the person and his/her individual situation. Proposed actions were enabling meals at home, taking over, and moving meals outside of the home. In addition, it was found that, the types of meals served to these persons should be as familiar to the individual as possible. The results of this study indicate the importance of using a person-centered approach and meeting the individual needs when supporting people with dementia in regards to their meals when living at home. Individualized care in the home may be expensive, however, it is fair to say that people who become malnourished and admitted to hospitals is even more costly. Furthermore, sharing and reflecting experiences and knowledge can assist staff to identify ways to manage complex situations. Therefore, the use of refection should be a part of staff members’ everyday work.

Keywords

community care content analysis dementia food provision mealtime nutrition older people

Introduction

Dementia commonly leads to difficulties in performing daily activities (Sauvaget, Yamada, Fujiwara, Sasaki, & Mimori, 2002; World Health Organization and Alzheimer’s Disease International, 2012). Problems specifically relating to meals, including how older people choose, prepare, serve, and eat food, may occur as a result of this disease process. Difficulties performing meal activities affect not only the life of the person with dementia but also his/her partner. Several reviews have been found that examine interventions aiming to improve meals and subsequently the nutritional status and their effects among persons with dementia. However, those living at home seem to be either excluded from inclusion (e.g. Abbott et al., 2013; Aselage, Amella, & Watson, 2011; Whear et al., 2014) or sparsely studied (e.g. Cole, 2012; Douglas & Lawrence, 2015; Liu, Cheon, & Thomas, 2014; Watson & Green, 2006). Consequently, knowledge about how to support meal situations for older persons with dementia living at home is lacking and required (Aselage & Amella, 2010).

Among persons with dementia, and living at home, almost 50% are considered to be malnourished or at risk of malnutrition (Roque, Salva, & Vellas, 2013). Interviewing persons with dementia living in their own homes revealed that they had on occasions problems associated with shopping for groceries and preparing food satisfactorily; for example, ingredients may be forgotten or food may be too spicy. Furthermore, problems related to the physical act of eating were also described, such as forgetting what (and even whether) one had eaten and having a decreased appetite (Johansson, Christensson, & Sidenvall, 2011). Yet, such difficulties are commonly overlooked even when people have identified nutritional problems (Amella & Aselage, 2011). In couples, roles and routines change as the disease progresses. The healthy partner is often required to assume greater responsibility during food preparation (Atta-Konadu, Keller, & Daly, 2011; Fjellström, Starkenberg, Wesslén, Tysén Bäckström, & Faxén-Irving, 2010; Johansson, Björklund, Sidenvall, & Christensson, 2014).

In Sweden, approximately 60% of all persons diagnosed with dementia live in their own homes (National Board of Health and Welfare, 2014). According to Swedish national guidelines for care in cases of dementia, these people are permitted to receive healthcare and social services based on their specific individual needs (National Board of Health and Welfare, 2010). Formal care consists of two different systems where the county councils are obligated to provide health care services, whilst the municipals have the responsibility for social care services, including home care. The home care services are designed locally by the municipals and include assistance with household tasks, such as shopping and cleaning, as well as basic personal care needs, for example, bathing and getting dressed (Szebehely & Trydegård, 2011). Home care services are usually provided by nursing assistants, with help ranging from a few hours per week to extensive support several times per day (Ahnlund, 2008). The complexity of dementia may result in a person needing both health care and social care services. To bridge the gap between the two systems interdisciplinary teams, dementia teams, are often used. Such teams commonly consist of nurses, healthcare nurses, care managers, and occupational therapists. Dementia teams are usually responsible for performing assessments, planning, and performing care (Haraldsson & Wånell, 2009).

Interventions suitable for other settings might be possible to use also when supporting individuals in the home. However, care in the home is rather complex and specific problems may be identified. Formal caregivers have earlier described that working in municipality care is a unique and complex situation that requires a wide range of skills, knowledge, and experience (Bramadat, Andrusyszyn, & Chalmers, 1996). For instance, delivering care in a person’s home environment can affect the relationship between caregiver and receiver, as the formal caregiver is a guest in the person’s home (Furåker, 2012; Öresland, Määttä, Norberg, Jörgensen, & Lützén, 2008). To support older people living at home who cannot prepare and manage their own meals, a food distribution service is usually offered (Berensson, 2009). Food distribution is internationally referred to as meals-on-wheels. This means that food is cooked, packaged, and delivered to the person’s home (Buys, Marler, Robinson, Hamlin, & Locher, 2010). In Sweden, the municipals provide this service (Elmér, 2000). A review showed that persons using food distribution have reported satisfaction with the service and positive effects in the nutritional status have been reported. However, it was concluded that studies in this area are usually limited and only descriptive in nature which makes it hard to actually draw any conclusions about the effects (Campbell, Godfryd, Buys, & Locher 2015). When interviewing staff, they have argued this to be an ineffective intervention as they do not know what happened after the food was delivered. They were, for instance, uncertain that the person actually ate the food (Pajalic, Persson, Westergren, & Skovdahl, 2012). A food distribution service, where staff instead prepared meals in the home together with the older person, was described as positive and perceived as increasing food intake and improve the quality of life among users compared to meals-on-wheels (Pajalic, 2013). To the researchers knowledge, no similar studies have been conducted focusing specifically on persons with dementia. To optimize and ensure a high-quality service, it is of great importance to improve the food distribution service available for these people. To increase understanding and receive further knowledge of how to support persons with dementia in their home, the experiences from several perspectives are necessary, not least being able to find interventions that later can be tested utilizing empirical methodologies. The aim of this study was, therefore, to explore and describe staff views regarding how to improve mealtimes for persons with dementia who are still living at home.

Methods

Design

This was a qualitative descriptive study with an inductive approach. Data were collected during four focus group interviews during 2011–2012, with staff working within the homes of older persons with dementia. Focus groups are ideal for capturing the interaction between participants (Freeman, 2006) and was considered to be most suitable method as it allows the participants an opportunity to share and compare their experiences and opinions (Morgan, 1997).

Data collection and participants

This study followed standard procedures for performing focus group interviews, as demonstrated by Jayasekara (2012). A convenience sample was used to gain information. The groups comprised of staff working close to persons with dementia, in particular those staff dealing with nutritional status and mealtimes, were included. The participants in each group knew each other, which has been described as an advantage (Kitzinger, 1995). All participants worked in the same municipality in southern Sweden, with approximately 130,000 citizens living in the area. The composition of the focus groups is presented in Table 1.

Table 1.

Characteristics of participants.

Focus group	Age (range)	Education	Years working in elderly care (range)
Dementia Team 1 (six persons)	39–60	University degree: nurse (2), social worker (2), occupational therapist (2)	15–30
Dementia Team 2 (five persons)	40–62	University degree: district nurse (5)	14–45
Nursing assistants 1 (six persons)	21–62	Less than upper secondary school (2), upper secondary school (4)	1–24
Nursing assistants 2 (five persons)	25–52	Upper secondary school (5)	7–29

The interviews lasted between 50 and 85 minutes, a timeframe that had been previously agreed upon by all involved. Two focus groups consisted of staff working in the home-help service. A manager from social services was contacted and informed of the study. This manager was asked to convey details of the study and ask staff from two home-help groups if they were interested in taking part in the study. These home-help groups assist approximately 130 elderly people to some extent and deliver meals to approximately 70 of these people. The other two groups consisted of staff members from a dementia team and included different professionals. Each year approximately 300 people in this community are diagnosed with dementia, with the dementia team establishing a contact. The purpose of the team is to support families, develop the dementia care plans, and supervise staff. In addition to this, these teams serve as a link between specialist care, primary care, and the social service, that is supporting the patient across the health care system. Contact with these staff members had already been established, as they had previously been involved in asking persons with dementia to participate in another study (Johansson et al., 2011). An e-mail was sent to all staff in the dementia team. This included written information about the study and a request to meet with them in person. As a result, meetings were organized with the staff interested in participating; one with each home-help team and one with staff from the dementia team. During these meetings, the researcher provided details about the study, and it was also mutually determined when and where the focus group interviews would be performed.

During the interviews, the participants read and discussed two vignettes (Appendix 1) that had been developed based on data from earlier studies (Johansson et al., 2011, 2014). These vignettes related to interviews with people with dementia and their partners regarding their experiences of meals at home. Before the focus group interviews were conducted, the vignettes were reviewed by researchers who were specialists within the area of caring for older people, as well as a district nurse and a nursing assistant. A moderator (the first author) and an assistant (one of the other researchers) participated in all interviews. The assistant was responsible for the practical tasks (e.g. operating the recorder) as well as for taking notes during the interview, whilst the moderator was in charge of conducting the interview (Krueger & Casey, 2009). At the beginning of each interview, the researchers gave a brief introduction regarding the aim of the focus group interview, and after this the first vignette was distributed on sheets of paper. After the participants’ had read this information, the moderator asked, “In an ideal situation, what would you like to do?” Following this, the participants were able to talk freely about the vignette, with the moderator asking follow-up questions such as, “What do you mean by … ” and, “Can you please tell us more about … ” This allowed all of the participants an opportunity to voice their thoughts. A question was also asked how the participants would respond, in their current work situation, when meeting people similar to the one in the vignette. The moderator attempted to include everyone in this discussion in order to gain rich information in accordance with the method (Krueger & Casey, 2009). This ensured that everyone’s opinion was heard and respected. At the end of the discussion, the assistant summarized what had been said, and the second vignette was presented with the same procedure was repeated. All interviews were recorded with the transcriptions transcribed verbatim. This was undertaken by the first author when all interviews had been completed.

Data analysis

Inductive content analysis, according to Elo and Kyngäs (2008), was performed. This entailed deriving categories from the data. The analysis was performed by two of the authors (Linda Johansson and Lennart Christensson) independently. The analysis commenced with the reading of the transcribed interviews several times to obtain an overview of the data. The notes from the focus group interviews, taken by the assistant, were also read through. Open coding was then performed where text in the interviews relating to the aim was marked and labeled with a code describing their content. After the open coding was conducted, the two authors compared and discussed their coding until agreement was reached about how the codes should be labeled. The agreed codes from all of the focus groups were then grouped, compared, and contrasted independently by the two authors, resulting in a number of subcategories being identified. Once again, the authors discussed the subcategories they had identified, until agreement was reached. The same strategy was used during the continuing abstraction process, where the subcategories were merged into five categories: Knowledge-based planning, Enabling meals at home, Taking over meals at home, Moving meals outside of the home, and Making home-like meals. Finally, one main category was identified, Tailor-made mealtimes, expressing the main content of the text. The software program Atlas TI 6.2® was used during the coding and categorization process to structure the data. An example of the analysis process is presented in Table 2.

Table 2.

Example of the different steps of the analysis.

Plain text	Code	Subcategory	Category	Main category
P1: But you’d like to talk to relatives there, Eva, and the sons. Have a discussion together. P2: Yeah, so you get a better picture of the situation.	Investigate problems and needs through relatives	Obtain an idea of the situation	Knowledge-based planning	Tailor-made mealtime
P1: You would like to talk a little with his partner also. How often is she there and has she noticed if he eats . . . She shops and so on for him. She should be able to see if the food disappears.
P1: But it is important that you prepare a plan regarding his weight and so. So that you can really follow up and use interventions to evaluate and so on. Otherwise it will only be words and not do anything	Make a plan and evaluate used interventions	Planning the care
P1: You have to let her be involved also. Because we want every person to feel that they are needed and can take part.	Being involved and feel needed	Preserve own abilities	Enabling meals at home
P1: If she could sit there in the kitchen, just stirring a pot or something. Yeah, that might be fun. Then she might even eat something. P2: Yeah. It would increase her quality of life by feeling that she is contributing.	Being involved in preparation to increase eating and well-being
P1: There are devices helping you to eat during the days and sleep during the nights. There are good devices for that. P2: The watch says ‘It's night’or ‘ìt's day’ when you press the button. So, it can say “it’s eight o’clock in the morning.” So that is good. P1: But you have to understand it. P3: Yeah, you have to [be able to] understand it. So it’s not for the sickest.	A watch to help remembering and assist in the structuring of the day	Using technical devices

Ethical considerations

According to The Swedish Ethics Act (Ministry of Education and Cultural Affairs, 2003:460), ethical approval was not required for this study. However, the Research Ethics Committee of the School of Health Sciences, Jönköping University, reviewed the study (7/2–12) and raised no objections from an ethical point of view. Written and oral information were distributed before data collection. It was stated that participation was voluntary and that confidentiality was guaranteed since results would only be presented at group level and quotations presented would be de-identified. Staff attending the focus groups interviews was considered to have given their consent. During each focus group, the participants were requested not to discuss the interviews afterwards to maintain the confidentiality of all involved.

Findings

Tailor-made mealtime

The main category that emerged highlighted that regardless of what actions were to be performed, support should be structured. It was found that meals should be familiar to the person with dementia. Therefore, it was important to know the person and his/her meal situation and act according to this. Participants described several ways to improve meals, but this should be understood from the perspective that the actions taken should be individualized, based on identified needs of the person, and provided in a way that preserves the persons’ independence.

Knowledge-based planning. Participants stated that to know how meals should be adjusted for the individual, including support for partners, an initial and systematic structure for understanding the situation, and the needs when planning for care, was essential. First, the underlying causes of problems had to be determined, and participants described that a familiarity with both the person and his/her family members was a significant factor. This was, to a large extent, discussed in the focus groups including staff from the dementia team. Some of the comments made regarding how the participants assessed the situation included:

P1:But in some way try to identify. What is working.

P2:Where something works

P1:And what kind of help he really has from the significant others.

P3:They are really important, so that you get the whole picture.

(Comments by Dementia Team 2)

In addition to the comments above, the other dementia team provided these comments:

P1:Can weigh him and so on. And one might assume that we have looked through his medicines and examined whether it is something medical . . . Because he says that he has lost weight.

P2:Yeah, so that there is not something else.

P1:Does he take any medications that result in weight lose? Is his metabolism okay and so on.

P2:Yeah, malignancy?

P1:So that will be the first thing to do, and then help him.

(Comments by Dementia Team 1)

Involving the partner was shown to be of great importance, as he/she not only played an important role when caring for the person with dementia but may also be in need of support. Furthermore, participants stressed that it was important to be aware of the person’s own resources and not only focus on obstacles. By acquiring this knowledge, interventions could be identified, developed, and introduced. However, participants explained that it was the person him/herself who decided whether or not to accept what had been suggested by the staff. Finally, the care provided should be evaluated.

Participants described how changes occurred successively. Participants found that the time staff spent with the person (during home visits and time spent at a day care center) was beneficial in identifying when/if further support was required. These changes could then be observed repeatedly and result in further actions being taken.

It was also expressed by the participants that care should be given by staff who have special knowledge about dementia, since there was a belief that knowledge of, and interest in, dementia could increase one’s ability to address the issues faced by the individual person at the appropriate level.

P1: What we [the dementia team] fantasize about are dementia education programs and knowledge [for all staff that meets persons with dementia]. And perhaps specialized home-help teams that are good at this [providing specialized care]. Because he is a unique man who lives in a house in the countryside, and we have to act in a way that suits him.

(Comments by Dementia Team 1)

Enabling meals at home. Participants wished to help those with dementia to continue having their meals at home, and this was something especially expressed by staff working in the home-help service. Preserving a person’s abilities and independence was considered important, and participants identified several ways in which they thought staff could help the person with dementia to be involved in food preparation. This could involve, letting the person be responsible for the preparation of parts of the meal, for example, shopping or preparing breakfast or the evening meal, instead of all meals. This could also mean that the person’s ability to eat independently was preserved. Participants highlighted that the important thing was that the person felt he/she was contributing and felt responsible in some way. The following comments were made, which highlight this:

P1:They can be involved and help. “Can you get the pot out so we can peel some potatoes, and then you can cut up the potatoes over there?”

P2:Turn the meat and … So that they feel like “I’m doing something, I can [do this thing],” sort of.

P1:And they will know, if they used to do this.

P3:God yeah.

P1:It (the knowledge) is probably there (inside them) if they start doing it.

(Comments by Nursing Assistants 2)

P1:One can help and hand over [ingredients] and remove it immediately after it has been used, so that there is no opportunity [for the person] to use it twice. But that means that you must be aware of what to do . . .

P2:If you whips that, I will do something else.

P1:But that means that you must be welcomed into the kitchen.

P3:Distribute the tasks and know what she might manage, and what she does not manage.

(Comments by Dementia Team 1)

It was suggested that staff should offer support in a way that allows the individual to remain independent, including being there and supervising, but not taking over. Participants advocated that during the cooking of meals, staff could give instructions and, for instance, make sure that he/she does not burn anything or use too much seasoning. Participants explained that this meant letting the person do things based on his/her own ability, but with the ability of helping or taking over the responsibility during more advanced activities. The eating process might also need attention, and it was suggested that staff could be present and supervise during the meal to ensure that the person started eating, as well as finished the meal:

P1:Helping him to prepare breakfast and supper. And sit together with him and make sure that he eats. That's what I'm thinking.

P2:Yeah, doing things together.

P1:Because if you only tell him that he should eat, then it's not sure [he will actually do].

(Comments by Nursing Assistants 2)

Different resources could be used to maintain independence during the food preparation, including the person’s own strategies and technical devices, for example, talking watches and timers. However, participants explained that technical devices were only of assistance to some people, and something that should be introduced in the early stages of dementia.

Involving the partner in providing support was also considered important, as he/she could help the person with dementia prepare food. However, the partner might require information and support to manage preparing food and to be able to care for the person with dementia. Food classes were suggested as one way to enable partners, unfamiliar with these tasks, to learn how to cook. Participant perceived that food classes also gave partners a possibility to meet others in the same situation.

P1: He can participate in a food class, if he finds it interesting, and learn how to cook. Because then he might also meet other people that are in the same situation as himself.

(Comments by Dementia Team 1)

Taking over meals at home. It was expressed that it was sometimes necessary for staff to take over the responsibility for the preparation of meals to make sure the individual received food. Replacing ordinary meals with meals-on-wheels or pre-packaged products was expressed as something frequently done when the older person with dementia was no longer able to contribute to the meal preparation on his/her own.

P1:Here it probably would have been meals-on-wheels immediately. I'm pretty sure of that. Something else would not have been introduced.

P2:No, meals-on-wheels it would have been.

P1:Yeah, even though you wish for something else.

(Comments by Nursing Assistants 2)

This was not something the participants supported; instead, they advocated for the meals to be cooked in the person’s home as they thought it increased the food intake. If replacing ordinary meals with meals on wheels, should be introduced carefully:

P1:Well this can be really hard when it is a woman and it is her life to cook food. She is responsible for that part, and then if you suggest meals-on-wheels it can be found to be very offensive.

P2:But that you can do it once a week. Perhaps on Sundays

P1:Yeah try to persuade her.

P2:“Saturday, Sunday you can have the time off.”

P1:Yeah, have a little spare time. But then she might not want to have spare time. This is her thing. This is her life, to cook.

P1:But if you are 85 years, then sometimes you can [take time off].

(Comments by Dementia Team 2)

If food was cooked outside of the home, it was felt that the meals needed to be nutritious. The use of oral nutritional supplements was also discussed, and opinions differed as to whether or not they should be given when the person had trouble maintaining good nutritional status.

Moving meals outside of the home. Participants stressed that people could eat at restaurants instead of at home, which could be a solution for both the person with dementia and their partner, as it decreased the demands on the partner:

P1:I had a similar old couple (as in vignette 2) at my old job.// They went out and had their meal instead. He have explained to her that by doing so, they will have more company and meet old friends. That’s why they go there and eat, that is what she believes but really it is because she's not able to cook the meals.

P2:Yeah, that’s clever.

P1:And it works well.

(Comments by Nursing Assistants 1)

Participants stated that assistance could be offered to make it possible for the person with dementia to eat outside the home, which meant making sure he/she had access to a mobility service or someone to accompany him/her to restaurants. Another suggestion was that the person had his/her meals at the day care center. The participants felt that this created better meal routines and food intake for the individual:

P1:But day care feel positive. Because it feels like, he likes to go to restaurants.

P2:Exactly!

P1:And he has more. So he might want to leave home and have.

P3:Yes, it feels like that would be the easiest.

P1:And also increases his appetite and motivation to eat.

(Comments by Dementia Team 1)

At the day care center, the person could be stimulated and take part in the meal preparation. For partners living with someone with dementia, participants thought that the day care center relieved the pressure on the partner since it provided them with assistance, decreased the number of meals at home and gave them time to be alone. The following comments were made in regards to this:

P1:Well, I would’ve given it a try anyway [getting the person with dementia to accept the day care centre]. Just to relieve him [the partner] as well with more help at home, so that he gets more support. Because they have, they have a huge responsibility and it’s a big workload to be a relative, so to speak. Taking care of everything takes so much energy too. So if one can start giving a little help they can sort of let go of some of their responsibility.

(Comments by Dementia Team 2)

Making home-like meals. The participants discussed that it was important to create a home-like atmosphere, with familiar meals, even if there had to be changes, for example, the person had started using meals-on-wheels or eating at the day care center. This means that the food served should be what the individual was used to eating and should taste as if it was cooked at home. However, it was expressed that some people actually liked trying new tastes.

P1:And then the food menus that is now, I mean, it's a lot of meals that the service users don't even know what it is, and not you either.//

P2:Yeah Beef a la Whatever.

P1:Yeah [laughter] they want the old meals still. We haven't reached this generation yet, as us, that like tacos and hamburgers and … Well like this. They want potato dumplings and pork sausages.

P3:But some have said that they actually find it nice to have something new.

Because I have heard that they think it’s nice with new things, hamburgers and lasagna and so on. So it's probably a bit of both.

(Comments by Nursing Assistants 2)

The environment, such as when and where to eat, and other old routines, should also be considered in order to make the meals and mealtimes as familiar as possible. It was also stated that an appetizing atmosphere should be created when food was served. This meant that instead of simply putting a box of food on the table, the food should be served on a plate and while still warm. The following comment was made in regards to this suggestion:

P1:There’s a big difference, you know, between bringing a plastic package as opposed to if you serve directly from the pot.”

(Comments by Nursing Assistants 1)

It was also stated that meals should be more than just food. Instead, a social dimension was emphasized. This included that staff could eat with the person; not only to help the person imitate the staff’s eating behavior but also to allow the person to interact with others. It was also suggested that, during meals, people could meet and eat together with others to increase and maintain their social network.

P1: He seems to like company. //He is used to go to places [restaurants] and have his dinner just like when he was working. //Perhaps he can go to the day care center [and have his dinner], but there can also be other situations where he can meet others. Where they meet and eat together.

P2: Yeah, with some friends.

(Comments by Dementia Team 2)

Discussion

Several actions were described by the participants regarding methods that could be employed to improve meals at home. It was stated that meals should be individually adjusted and based on the person’s own needs, tastes, and preferences. Participants highlighted that meals should be prepared in the home and, as much as possible, by the person him/herself, to preserve and maintain abilities and independence. A suggested way to maintain independence was the use of technical devices, such as timers and talking watches. However, meals-on-wheels were commonly used when a person had trouble preparing food. The partner was described as both a resource for the person with dementia, as well as someone also in need of support.

The results of this study showed that the participants were familiar with several ways to support a person during meals in the home, which specifically related to the person’s own abilities, as well as old routines and habits. The suggestions made by the participants regarding how to improve meals, seems to be closely related to the concept of person-centered care. Person-centeredness in dementia care entails taking into account the person’s subjective experiences, and participation is of great importance (Edvardsson, Winblad, & Sandman, 2008). McCormack and McCance (2011) describe the person-cenetred processes as working with the person’s beliefs and values as well as facilitating participation in decision making. When discussing this, participants mentioned that they could suggest support, but that the person should be able to make his/her own decisions as well as decide whether or not to accept these decisions. Sharing decision making has been said to require the creation of a trustful relationship between the caregiver and the individual, with communication playing a great role to achieve this (McCormack & McCance, 2011). It has also been suggested that there are benefits associated with meeting a person in his/her own home, as the chances of getting to know the person in their environment are enhanced. This is due to being in the person’s own environment offers an understanding of his/her life and routines (Öreland, Määttä, Norberg, Jörgensen & Lützén, 2008) . The participants highlighted the importance to knowing the person. Consequently, conducting home visits can make it easier to build the relationship and, in turn, operationalize person-centeredness. Individually adjusted interventions, which are in line with person-centered care, have previously been found to improve the nutritional status of older persons living in nursing homes (Kuosma, Hjerrild, Pedersen, & Hundrup Andersen, 2008; Lorefält & Wilhelmsson, 2012; Wikby, Ek, & Christensson, 2009). However, when it comes to the home context, there is a lack of knowledge and research (Aselage & Amella, 2010). The results of this study are, therefore, important for practice. It may be argued though that the Swedish care system may differ compared with to that of other countries, which may affect the transferability of knowledge. Conversely, it is possible that these differences are mostly associated with who supports the person, that is, if care is provided by formal or informal caregivers, rather than how the support should be offered. To meet the challenges of people living longer, the World Health Organization (2014) states that, to achieve the ultimate goal of healthy aging, policies and strategies that provide a continuum of care, should be enacted upon. Consequently, to improve older persons’ nutritional status, community support and community-based interventions are needed (World Health Organization, 2014). It is, therefore, envisaged that the results from this study will be of interest to other healthcare professionals and caregivers.

Participants also stressed that they wanted to make it easier for the person to maintain their ability to prepare food in their home, by including the person in these activities, instead of taking over and excluding the person. Contributing to food preparation is of importance, as it can increase the feeling of being needed and preserve the person’s identity, especially when difficulties in managing other daily activities may occur (Genoe et al., 2010). This is in agreement with what older people themselves have described as important: that being able to carry out meal preparation and maintaining their independence (Johansson et al., 2011; Lundkvist, Fjellström, Sidenvall, Lumbers, & Raats, 2010). The results of this current study revealed that when a person was unable to prepare food independently, he/she usually received meals-on-wheels. This is likely related to what McCance, Slater, and McCormack (2009) has described, namely that there are fixed routines and limited influences which make it difficult for staff to achieve a person-centered care approach. In a recent study (Pajalic et al., 2012), staff believed this was actually an ineffective intervention, as they did not know what happened after they delivered the food, and they stressed that it would be preferable to stay while the person ate their meals. As food distribution is complex, it has been proposed that involvement at all levels in the organization is necessary to facilitate changes and improve the service (Pajalic, Persson, Skovdahl, & Westergren, 2012).

The study has also highlighted that partners play an important role when a person has dementia. Participants perceived that the partner are not only a resource for the person with dementia during food preparation but also someone who may need support. Partners sometimes have to take over or increase their responsibility regarding meal preparation (Atta-Konadu et al., 2011; Fjellström et al., 2010; Johansson et al., 2014), and this can be troublesome if they have insufficient knowledge. Supporting partners is important because feelings of stress and burden, as well as declining health, can arise when one is an informal caregiver (Brodaty & Donkin, 2009; Etters, Goodall, & Harrison, 2008). Interventions including education and psychosocial support have been found to be effective in improving quality of life, alleviating burden of care, and symptoms of depression in family members (Mattila, Leino, Paavilainen, & Åstedt-Kurki, 2009). In this present study, participants described how cooking classes could be a way to support partners of persons with dementia, allowing these individuals to not only to learn how to cook but also to meet others in the same situation and exchange experiences and ideas. Researchers of a EU-founded project “Food in later life” have also recommended cooking classes as a way to prevent nutritional problems. These cooking classes have been used to increase older persons’ knowledge about preparing food and help them create new networks (Nydahl, Fjellström, Sidenvall, Raats, & Lumbers, 2008).

Some methodological considerations have arisen during this study. First, the selection of participants must be considered in the light of establishing transferability (Lincoln & Guba, 1985). The focus groups were comprised of a convenience sample of staff that had volunteered to participate. This has previously been described as a less preferable method as it may not provide the most information-rich sources (Polit & Beck, 2012). Each group consisted of staff working together on everyday basis. However, their education differed, especially in the dementia team groups, as they are interdisciplinary teams. Homogeneity is considered important in focus group interviews (Krueger & Casey, 2009). However, this might have been a disadvantage since the participants agreed with each other to a large extent and few different opinions were raised. Between the focus groups, some differences were noticed. The focus groups, including staff from the home-help service, mainly focused on how meals can be enhanced and prepared at home, whilst staff from the dementia teams mostly discussed how they assessed the individual needs for the person and what support was needed. The staff involved gave rich details into the topic and indicated that they were interested in participating in the study and felt confident to express their opinions. Additionally, the researchers’ background and knowledge of the topic may cause advantages as well as limitations and may affect the researcher’s neutrality concerning the data analysis and interpretation, that is, affect the confirmability (Lincoln & Guba, 1985). The first author was the focus group moderator as well as involved in the data analysis, which may have caused some degree of bias. During the interviews, the moderator tried to let the participants discuss the vignettes without interfering. Furthermore, the assistant summarized the discussion and gave the participants an opportunity to comment and respond. To ensure that the results were consistent with the collected data, the analysis was conducted separately by two authors. There were no major differences found between the authors’ analyses, and any differences were largely related to the various ways of labelling of the data, not the content itself. The final results were presented and discussed with the other authors, who had previous experience with both focus-group interviews with staff and content analysis, as well as other researchers who had no relationship to the study. Altogether this is ways to strengthen the credibility, dependability, and confirmability of the study (Lincoln & Guba, 1985).

Conclusion and clinical implications

During the interviews, participants stressed that to improve meals at home for a person with dementia, support should be based on the individual needs of these persons, rather than on general interventions. This suggests that a person-centered care approach should be used where the staff need to understand the home situation of each individual. The quality of home help services regarding appropriate meals for persons with dementia, may improve when a person-centered approach is used, with the person with dementia being able to stay independent and live at home for a longer period of time. However, there is currently a lack of research where individualized meal support in the home context has been tested and evaluated. Consequently, there is a need of interventional studies within this area, with a requirement to also investigate possible health-economic benefits. As more people are living to an older age and many are diagnosed with dementia, there is a need to find solutions to meet these challenges. Individualized care in the home may be costly; however, it should be considered that some of the older people may become malnourished and admitted to nursing homes or hospitals, which will result in it being more expensive. Several ways to improve meals were described by the participants, which indicate that reflection sessions in everyday work are of use. Sharing and reflecting experiences appear to be a good way to learn and increase knowledge on how to act in complex situations like meals for persons with dementia.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was conducted with support from KP-stiftelsen and Jönköping University, School of Health and Welfare.

Linda Johansson is a registered nurse with a PhD in nursing. She is a senior lecturer at the Nursing Department as well as has a postdoc position at Institute of Gerontology, School of Health and Welfare, Jönköping University, Sweden. Her research is focusing on health and care for older persons.

Anita Björklund is a senior lecturer and professor in occupational therapy at the Department of Rehabilitation, School of Health and Welfare, Jönköping University, Sweden. Her research mainly focuses on elderly people’s mealtimes, food and eating habits. She has described encourage and interrupt eating both from elderly people’s and staff’s perspectives.

Birgitta Sidenvall is since two years back retired from the post of a professor in nursing at School of Health and Welfare, Jönköping University, Sweden. Her research mainly focusses on elderly people's mealtimes, food, and eating habits. She have described what encourage and what interrupt eating both from elderly people's perspective and from the staff's perspective.

Lennart Christensson is a senior lecturer and an associate professor in nursing at Department of Nursing, School of Health and Welfare, Jönköping University, Sweden. His research includes nutritional problems in elderly people in need of nursing and social care and support. His research focusses on describing why malnutrition arise, how to assess the risks, and how to prevent nutritional problems.

Appendix 1: Vignettes

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