Supportive Hand Feeding in Dementia: Establishing Evidence for Three Hand Feeding Techniques

Purpose: Providing nutritional support has been a cornerstone of nursing practice since its inception.^1-3Many things have changed since 1859: life expectancy has increased, and rates of dementia have increased exponentially. Although times have changed, nursing’s responsibility for basic nursing care has never been more important for persons with dementia (residents) in the nursing home (NH) setting. The establishment of an evidence-base for the complex basic care needs of this vulnerable population is critical for eradicating malnutrition.

      Feeding Assistants, often certified nursing assistants (CNAs), are faced daily with challenging, “aversive” feeding behaviors (e.g., clamping mouth shut, turning head away).⁴ In fact, nearly 86% of residents in the nursing home (NH) setting will experience problems with food intake.⁵ Due to an inadequate evidence base for practice and limited training in dementia care, many CNAs rely on personal beliefs and experiences, often misinterpreting these “aversive” feeding behaviors as “resistance” and they cease attempts to feed.^6-10These factors perpetuate malnutrition; a pervasive, yet reversible problem in the long-term care setting on a global scale.

     Feeding assistants may encounter a wide range of difficulties when providing supportive hand feeding to a resident. These may be issues related to dysphagia, functional/ physical limitations, or feeding behaviors that are generally reflective of the neuropsychiatric symptoms of dementia. Yet, approaches to the actual act of using a particular technique in assisting a resident to eat are often overlooked and the complexity of a meal interaction minimized. Evidence to support use of any hand feeding technique is sparse - only one scientific study has ever designated a hand feeding technique (Over Hand) for use when providing feeding assistance.¹¹

The purpose of this study was to compare the efficacy of three supportive hand feeding techniques for persons with dementia (residents) in the nursing home (NH) setting: Direct Hand (DH), Over Hand (OH), Under Hand (UH). ^8,12The UH technique is an innovative method of providing supportive hand feeding in dementia that taps into remaining sensory ability, and provides  motor cues to residents for eating. Thus, UH was hypothesized to increase meal intake and decrease “aversive” feeding behaviors because the resident is actively engaged in a movement associated with meal intake since early childhood. Primary outcomes were time spent providing feeding assistance, percent of meal intake, and frequency of feeding behaviors.

 Methods: A prospective, Latin-square experimental design was used to randomly assign a designated hand feeding technique to be used when providing feeding assistance to 30 residents. To limit sequence and carry over effect, each resident was randomly assigned to one of the three Latin-square sequences: (1) DH, OH, UH; (2) OH, UH, DH; or (3) UH, DH, OH. Working in pairs, 50 trained Research Assistants (RAs) provided 1:1 meal assistance and video-recorded the meal interactions. Assistance was provided for 3 daily meals over a two day period per hand feeding technique, according to the sequencing of the Latin-square randomization. This method yielded 6 meals per hand technique per resident, 18 meals per resident, and a total of 540 video-recorded meal interactions. One RA recorded outcome measures in “real time”, and the RA partner coded the video-recorded interaction. An independent, second RA rater coded the video to establish inter-rater reliability (IRR). All RAs completed field notes to detail reasons for needing to change from the designated hand feeding technique when the designated technique was not promoting meal intake. Formative debriefs were held with small groups of RAs quarterly to assess fidelity issues related to study design, training process and materials, intervention delivery, and receipt of treatment.¹³Primary study outcomes included (1) the amount of time spent providing feeding assistance, (2) percent of meal intake (based on tray weights and overall visual estimation), and (3) feeding behaviors as measured using the Edinburgh Feeding Evaluation in Dementia (EdFED) Scale. Hierarchical random coefficients regression models for repeated measures were used to evaluate hand feeding technique effects across meals on the feeding time and meal intake outcomes, with statistical significance set at 0.05.

 Results: Inter-rater reliability was high for feeding time (0.91-0.97) and meal intake (0.88-0.91). No significant differences between feeding methods for the mean amount of time spent providing feeding assistance were demonstrated: DH (42.4 min; SD = 9.2), UH (44.1 min; SD = 9.3), and OH (45.2 min; SD = 9.2). Mean meal intake (% eaten) was significantly higher (with a medium effect size) for DH (67%; SD = 15.2) and UH (65%; SD = 15.0) when compared to OH (59.9%: SD = 15.1; both p < .002, Cohen d = 0.52 and 0.40, respectively). Subjective overall percentage estimations of meal intake (customary NH practice) consistently overestimated meal intake by 10% when compared to objective tray weights. IRR for the EdFED was poor with only 0.47-0.59 agreement. Raters struggled to differentiate “refusing to open mouth” and “refusing to eat”. As designed, the EdFED is scored with 0-20 range (0 = no behaviors; 20 = high “aversive” feeding behaviors). For this study, RAs also collected frequency scores for each behavior. While our IRR was lower than previously reported for the EdFED, the mean scores for “resistive” feeding behaviors were more frequent with OH (8.3; SD = 1.8) when compared to DH (8.0; SD = 1.8, p = 0.0412, Cohen d = 0.17) and UH (7.7; SD = 1.8, p = 0.0014, Cohen d= 0.33).

     During a debrief, one of the RAs made the statement, “she (the resident) got a point for turning her head away, and a point for clamping her mouth shut, but she only did those things because she wanted me to give her a sip of water”. This revelation caused a shift in our thinking from the current paradigm of viewing these feeding behaviors as “resistive,” to viewing them as forms of communication. Field notes indicated residents responded differently to the UH technique with active participation in the meal, and one resident stated, “something about this feels powerful”. OH elicited more statements to “let go of my hand” and pushing assistance away. Field notes also detailed rationales for needing to change techniques due to resident ability and individual preferences with the techniques

 Conclusion: The findings from this study suggest a paradigm shift from viewing “aversive” feeding behaviors as negative behaviors that should be extinguished into seeing them as forms of communication. Behavior is often the only form of control a resident has over a meal interaction to indicate preferences when language is lost. The DH and innovative UH techniques showed modest increases in meal intake and decreases in feeding behaviors. The OH technique resulted in the opposite effects, with decreased meal intake and increased feeding behaviors. Results are reported by “designated hand feeding technique”, but field notes detailed conditions under which alternate techniques were required based on the resident’s functional ability, energy level, position, or individual preferences for the meal. These results should be interpreted in light of having a dedicated RA who did not have competing demands on their time deliver the intervention, in contrast to a setting using NH staff.  Future work is needed to determine the conditions under which each technique works best, in order to teach NH staff how and when to use each technique based on the resident’s individual preferences and abilities. In a time when a medical cure does not exist and feeding tubes are not recommended in advanced dementia, this research advances the repertoire of supportive hand feeding techniques to promote meal intake in residents, and offers a nursing care intervention until death.