Eighty-nine-year-old Rose Kyle, hospitalized for treatment of urosepsis and dehydration, lives at home with her 87-year-old husband of 63 years, Roger, who is her primary caregiver. She had a stroke 10 years ago, which resulted in a partial loss of the use of her left arm and leg and difficulty with fine motor skills in her left hand. Two years ago she was diagnosed with mixed dementia-Alzheimer's disease and cerebrovascular disease-and since then, her eating patterns have changed, and she can transfer from bed to chair only with assistance. Her daily medications are aspirin 81 mg, donepezil (Aricept) 5 mg, lorazepam (Ativan) 0.5 mg, and ranitidine (Zantac) 75 mg, the last three taken at bedtime.

Mr. Kyle's medical history includes dyslipidemia; he has no physical limitations and can help his wife as needed. The couple's son and daughter-in-law, who live nearby, visit them often. The Kyles used to enjoy playing cards with friends, but Ms. Kyle has been increasingly less able to participate in activities requiring such complex cognitive and motor skills. She has become, her husband says, much more isolated. And in recent months, he has had a much harder time managing her cognitive and functional decline.

When passing Ms. Kyle's room at mealtime, the nurse overhears Mr. Kyle shouting at his wife, "Eat!! Or you'll never get out of this place!!" Later, during dinner, Ms. Kyle's son tells his mother that she might "end up in a nursing home with a tube" if she doesn't eat and drink more. The nurse talks with these family members, who say that they're "fed up and worried sick" because Ms. Kyle has been "eating like a bird" over the past year. Mr. Kyle says that she's lost 5 lbs. in six months, but on reflection says she must have lost 20 lbs. in the past two years. He says that he hadn't really stopped to think about her weight loss over time and that her physician hadn't seemed too worried, saying that she wanted Ms. Kyle to "keep her weight down."

The nurse discusses these concerns with the interdisciplinary team. The physician orders a laboratory workup to evaluate her serum albumin and prealbumin levels, lymphocyte count, transferrin level, and hemoglobin level and hematocrit. Ms. Kyle's morning weight is 102 lbs. (46.27 kg) and her height is 63 in. (160 cm); the team calculates a body mass index of 18.1 (less than 18.5 is considered underweight). Her ideal body weight is 115 pounds (52.4 kg). The physician orders a dietary consultation to evaluate Ms. Kyle's three-day caloric intake and to make recommendations for greater intake of protein, calories, and fluids. Findings will allow the physician to discuss these recommendations with Mr. Kyle. Realizing that Ms. Kyle's dementia may be contributing to her inability to eat adequately, the nurse administers the Edinburgh Feeding Evaluation in Dementia (EdFED) scale.

read it | watch it | try it

Web Video

Get more information on why it's important for nurses to screen for nutritional deficits in patients with dementia, as well as why this scale is a good approach for doing so.

The Edinburgh Feeding Evaluation in Dementia Questionnaire

This is the scale in its original form. See page 51.

THE EDINBURGH FEEDING EVALUATION IN DEMENTIA SCALE

The EdFED scale contains 11 items developed to help clinicians look for eating and feeding problems in people with late-stage dementia. Although it is not a screening or diagnostic tool, it can establish a baseline of behaviors and define the level of assistance the patient needs. It can take as little as five minutes to complete, and results can be used to predict needs and build a care plan.

The first 10 items in the scale are questions addressing 10 mealtime behaviors; each is scored according to how often it occurs during a meal. A score of 0 is given if the behavior "never" happens, a 1 if it happens "sometimes," and a 2 if it happens "often." The first four behaviors indicate that assistance is already required or that it might be required:

* needs close supervision

* requires physical help

* spills food

* leaves food on plate

* refuses to eat

* turns head away

* refuses to open mouth

* spits out food

* leaves mouth open

* refuses to swallow

Finally, an 11th item asks the rater to indicate the level of support the patient requires during the meal: supportive-educative assistance (needs cuing or help with plate setup or refocusing), partly compensatory assistance (is involved with meals but requires physical assistance), or wholly compensatory assistance (requires hand-feeding).

The EdFED scale can be administered either by watching the patient eat a meal or by asking caregivers to report mealtime behaviors (the latter is more frequently done in community or primary care settings). Observation should be as unobtrusive as possible. For example, the nurse completing the assessment should not assist with the meal and should avoid conversation with the patient and caregivers, which could distract the observer. To gain better insight into mealtime patterns, the observed meal should take place where the person usually eats.

The observer will note how often (if at all) the specific behaviors occur during the meal. Afterward, the observer talks with the regular caregiver to find out how often and under what circumstances the observed behaviors occur. (Caregiver input is only necessary to complete the baseline assessment.) For example, if the observer notes that the patient turns his head away, the observer might ask, "I noticed that Mr. Smith turned his head away when you lifted up the cup of coffee. Has this ever happened before?" If so, the observer should ask further questions, such as, "Is there anything specific that seems to cause this? Perhaps certain types of food? When does this occur-at the end of the meal when he seems to be tired? Does he ever cough, clear his throat, or need more time to swallow?" With such probing, a more complex picture will emerge.

Ms. Kyle is observed during the evening meal, during which she is supervised by her husband. For the need for close supervision, the nurse gives Ms. Kyle a score of 2. She also requires significant help with tasks such as cutting her food and receives a score of 2 in the physical assistance category. Frequently during the meal she refuses to eat and in the end leaves more than half of the food on her plate; therefore, the nurse assigns a score of 2 for each of these behaviors. She did not spill any food, turn her head away, refuse to open her mouth, spit out food, leave her mouth open and allow food to drop out, or refuse to swallow, therefore earning a score of 0 in each of those categories. Answering the 11th item, the nurse notes that Ms. Kyle requires partial assistance with the meal.

The nurse asks Mr. Kyle to describe mealtimes at home: are the behaviors noted during observation common there as well? "I make all of the food. I try to make her favorites," he replies, "and we usually eat in front of the television." Mealtimes last between 30 to 45 minutes, and she requires constant prompting to focus on her food. "If I don't remind her to eat, she'll only take a few bites." He always cuts her food, and when possible he serves finger foods, such as sandwiches and cheese cubes, that don't require utensils. During meals Ms. Kyle often complains of having no appetite and says she's full after eating a small amount. With constant encouragement, she usually eats about half what's served. Although Mr. Kyle tries to keep her on a low-fat diet because of her history of cerebrovascular disease, he notes that "she always cleans her plate when I serve dessert."

Challenges that may arise. Because Watson never quantified the terms "sometimes" or "often" in the EdFED scale, the determination of frequency is somewhat subjective. If deciding to adopt the EdFED scale, an institution or unit should define frequency; for example, "sometimes" could be defined as observed at least once during a meal.

SCORING AND INTERPRETING THE RESULTS

The rater will assign a score (ranging from 0 to 2) to each of the 10 behaviors according to whether it is observed never, sometimes, or often. These 10 scores are summed, with final scores ranging from 0 to 20. A higher score indicates greater dysfunction. Any behavior that receives a score of 1 or 2 should be addressed in a new plan of care.

Ms. Kyle receives a score of 8, which indicates a need for assistance. The nurse and the case manager arrange for her to be transferred to the hospital's acute-care-of-the-elderly (ACE) unit. The results of the EdFED scale are shared with the new team, which generates further assessments. A dental consultation is arranged; improperly fitting dentures, loose or missing teeth, and poor dental hygiene can all diminish a person's ability and desire to eat. The speech-language pathologist verifies that Ms. Kyle is not aspirating her food but recommends a mealtime environment as free of distractions as possible. The occupational therapist provides a lightweight, sturdy covered cup to improve Ms. Kyle's grip and reduce the likelihood of spilled liquids.

The dietician cancels Ms. Kyle's low-fat diet and recommends a dense calorie diet (with a high calorie-to-quantity ratio), suggesting more protein and fat and fewer simple carbohydrates. Commercial nutritional drinks are ordered for between-meal snacks. Because Ms. Kyle enjoys dessert, ice cream is added to the nutritional drink. The dietician also orders a three-day calorie count to be conducted while Ms. Kyle is hospitalized.

To provide insight into which of the modifications are helping Ms. Kyle, she is reassessed with the EdFED scale during each evening meal. As it's determined which interventions work and which do not, the information is shared with her family.

OTHER CONSIDERATIONS

Following up with team members about findings is an important nursing role. For example, dietary changes may need to be accommodated by providing the appropriate implements (such as no-spill cups with straws); oral care techniques should be discussed with family members and other health care professionals.

Ms. Kyle, continued. The acute care nurse explains the results of the EdFED scale to Mr. and Ms. Kyle and to their son and daughter-in-law, who occasionally help with meals. Clear communication with all caregivers about the kind of assistance a patient needs and the type of behaviors to watch for is ideal: it supports consistency in the interventions used. For example, in this case, the nurse explains that the plan is to encourage Ms. Kyle's independence, but if her caregivers find that she needs more help or her abilities decline, a referral to a member of the team will be necessary.

This population is at particular risk for malnutrition.