Chapter 4 Maintaining Independent Dining Skills

BOX 4.2 Other Interventions to Address Cognitive Deficits

●

Accommodate prior eating habits, food preferences, and cultural considerations. Family and friends can be an invaluable resource in identifying daily food pleasures, preferences for foods, mealtimes, and dining habits.

● Limit, but provide choices. ● Serve one food at a time.

● Provide only one utensil at a time. ●

●

Avoid plastic utensils, as these can be easily bitten or broken.

Provide color contrast between the plate and the table and the plate and its contents.

● Provide foods with the appropriate texture. ●

● ●

Serve pureed foods in bowls, as this may be more familiar than a divided plate.

Offer finger foods when appropriate or incorporate foods into a sandwich.

Experiment with alternating between warm and cold items to increase interest, or providing one tempera- ture or texture at a time to decrease stress.

●

If weight loss is a problem, provide extra servings at breakfast, as appetite may be enhanced and there may be less stress at this meal.

●

Minimize all stimuli that distract focus from eating. This includes excess noise from TV, radio, staff conversation, and dishwashing equipment as well as visual stimuli from windows, doorways, and movement within the dining room.

● Keep conversation focused on the meal. ●

Provide a calm, quiet environment. Large rooms and “unending spaces” can be overstimulating and increase stress.

●

Provide a calm, consistent routine to decrease stress. Repetition does not become boring for the person with dementia.

●

Allow adequate time for the meal to be eaten. Keep in mind the 90-second response delay that may occur in end-stage dementia.

● ●

Follow the prompt hierarchy when providing assistance.

If the person must be assisted, use bridging, a technique to focus attention by having the person hold the same utensil or object the caregiver is using.

● ●

Plan a rest period in a calm, quiet area before each meal to alternate between low- and high-stress events.

Use verbal prompts, praise, touch, and positive reinforcement.

● Observe for problems with swallowing (dysphagia). ● Stroke the person’s arm gently while he or she eats.

BOX 4.3 Prompt Hierarchy

1. Stimulus control—present the activity of daily living item, such as the utensil or cup, in front of the person.

2. Verbal support—make positive statements that give no indication of what or how to do the task (“thank you,” “good job”).

3. Verbal directive—give one-step directives (“take a drink,” “scoop”). It is important that these directives be short and specific.

4. Gesture (alone or paired with a verbal cue)— attempt to direct attention through motion or by reference to a specific object (point to the spoon, point to the cup, and say, “Take a drink”).

5. Modeling with verbal guidance—prompt a response through imitation (staff lifts the cup and says, “Like this” or “This way”).

6. Manual guidance—use a light touch to initiate or support movement (gentle pressure under the hand to cue the older adult to lift the spoon).

7. Manual response block—use a light touch to stop repetitive or inappropriate action (placing the hand over the person’s hand to prevent placing more food into the mouth before swal- lowing current contents).

8. Hand-over-hand assistance—guide the older adult through the motion by placing the hand over their hand and performing the task with them.

9. Physical assistance—perform the task for the older adult (scooping food onto the spoon, then placing the utensil into his or her hand and prompting the older adult to independently complete the remaining steps).

Chaining

Chaining is a useful technique in retraining cognitively impaired individuals to perform familiar tasks. When using the chaining technique, the caregiver begins a task by providing hand-over-hand assistance through each step, until a point is reached where the older adult can complete the task independently (22). The task of independent dining can be broken down into individual steps, such as grasp utensil, scoop, lift, place in mouth. In backward chaining, staff assists the older adult with all steps up to the last step. When the older adult can perform that step, staff decrease their assistance one step at a time, until the older adult has mastered the

43