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ACQ
Volume 11, Number 2 2009
ACQ
uiring knowledge in speech, language and hearing
Dementia
Keywords
dementia
dysphagia
mealtime
behaviours
nursing
education
This article
has been
peer-
reviewed
Berkhout, Cools and Van Houwelingen (1998) reported
feeding dependence is strongly correlated with weight loss.
Difficulty eating and drinking may stem from a combination
of mealtime behaviours, as well as dysphagia. Oral
dysphagia is more common than pharyngeal dysphagia in
the dementia population (Feinberg, Ekberg, Segall & Tully,
1992), but both are observed. There is little research on
swallowing impairment in different types of dementia (Kindell
2002). Both cognitive features (such as memory disturbance)
and non-cognitive features (such as aggression) impact on
eating skills.
It is essential to differentiate between dysphagia and
mealtime behaviours related to dementia. Dysphagia is
defined as disordered swallowing (Brockett, 2006), due
to weakness or incoordination affecting oro-pharyngeal
biomechanics (Hammond & Goldstein, 2006). Mealtime
behaviours, however, are atypical behaviours exhibited
during oral intake related to the dementia process, and
have a negative impact on nutrition, hydration and weight
maintenance (Beattie, Algase & Song, 2004; Kindell, 2002).
People with dementia can have both dysphagia and atypical
mealtime behaviours, but they are not one and the same.
Mealtime behaviours related to dementia often occur in the
absence of dysphagia.
Kindell (2002) described multiple mealtime behaviours
related to the dementia process including food and drink
refusal, spitting out of oral intake, inattention, wandering
during meals, inappropriate speed of intake, and eating of
non-food items. Often these behaviours are misdiagnosed
as dysphagia. Kindell also discussed the importance of
evaluating sensory impairments, dentition, mental state and
ability. It is vital that staff working closely with people who
have dementia identify mealtime challenges and provide
holistic management (LeClerc, Wells, Sidani, Dawson & Fay,
2004).
At Royal Perth Hospital Wellington Street Campus (acute
care), 34 referrals relating to the management of mealtime
behaviours, in the absence of dysphagia, were received from
a particular general medicine/geriatric ward in 2007. These
referrals had a negative impact on resource allocation and
time management of a small speech pathology department.
A new approach to dealing with this issue was prompted
by a presentation at the 2007 Speech Pathology Australia
National Conference by speech pathologists Nailon, Scott
and Benjamin (2007). Nailon, Scott and Benjamin completed
a study focused on nursing education regarding mealtime
management. They compiled a mealtime management
This paper describes a quality improvement
project targeting improved mealtime manage
ment by ward nursing staff of dementia specific
behaviours, with the aim of improving appro
priateness of speech pathology referrals. In
2007, the speech pathology department of
Royal Perth Hospital received a large number
of referrals related to management of
mealtime behaviours in people with dementia
in the absence of dysphagia. A questionnaire
was compiled to assess nursing knowledge of
mealtime management in this population, with
the subsequent development of an education
package to target the gap in knowledge. Post
education questionnaires indicated an
increase in overall knowledge of dementia-
related mealtime behaviours, and improved
management of these behaviours has been
noted at a nursing level. A reduction in
referrals to speech pathology regarding
management of mealtime behaviours was
noted in 2008, after implementation of the
education package. This project highlights the
importance of nursing education with the aim
of improving service provision.
D
ementia refers to a spectrum of brain disorders involving
cognitive decline, that vary greatly in terms of cause,
progression and prognosis (Agronin, 2004). Villareal
and Morris (1999) described dementia as an acquired loss of
cognitive function that may affect memory, attention, language,
personality and abstract reasoning. They explained that the
condition constitutes an emerging public health crisis. In 2006,
it was estimated that 210,000 people in Australia suffered from
dementia (Alzheimers Association of Australia, 2006), and it
is projected that 52,000 people will be newly diagnosed in
Australia each year, equating to 1000 per week.
People with dementia frequently present with challenging
behaviours at mealtimes, which affect oral intake and
compromise nutrition and hydration. Eighty percent of
people with dementia have difficulty eating and drinking,
particularly in the late stages of the condition, with 50%
no longer able to feed themselves (Chang & Lin, 2005).
Mealtime behaviours in
people with dementia in
the absence of dysphagia
Education of nursing staff in an acute care setting
Crystal Ensell and Natasha Matheson
Crystal Ensell
(top) and Natasha
Matheson