The resident-caregiver relationship at meals

By Dale Mayerson and Karen Thompson

The ability to feed ourselves is a skill learned early in childhood; loss of this ability for aged persons has significant emotional and physical effects.  Long-term care residents should be encouraged to maintain their independence and eat by themselves whenever possible. There are, however, many reasons why a resident may require help. Physical and/or cognitive problems can result in a need for assistance with eating. Even those who can eat independently may require help with setting-up their meal and getting started. Supports can range from cueing, partial assistance, adaptive utensils and dishware, up to total assistance. Proper identification of these problems is a key factor so that appropriate interventions can be started promptly, in order to increase nutrient intake and therefore the overall health and well-being of residents.

Signs that a resident needs assistance with eating may include poor meal intake, refusal to come to the dining room or lack of interest or focus on meals. Cognitive impairment may result in confusion and behaviors that prevent a resident from eating, or a resident may simply forget how to use utensils, chew and/or swallow. Physical issues such as stroke, severe arthritis or Parkinson’s disease may be related to difficulty with chewing, swallowing, poor vision, or the inability to use one’s arms and hands. Sometimes tremors or physically being unable to be properly positioned to eat may interfere with the ability to eat.

The type and level of assistance required to support and maintain a resident is determined by the care team and will change as the resident’s condition progresses. A resident’s abilities can vary from day to day or time of day. This should be considered when individualizing strategies to assist with eating.  While it is important to maintain the resident’s self-feeding skills as much as possible, this must be weighed against the resident’s need for adequate nutrition and hydration intake. Often the agreed upon strategies will include a combination of support with eating and direct assistance with eating. Involving the resident in planning is essential.

The Caregiver assisting a resident with eating is a very intimate interaction and should be performed with dignity and respect at all times.  A positive eating experience can improve the resident’s physical as well as emotional health.   Caregivers at meals can include staff, volunteers and family members.  Caregivers must be trained in proper techniques.  Some ‘best practices’ include being seated next to the resident and not assisting the resident while standing.  Both eye contact and pleasant conversation with the resident may encourage better food and fluid intake.  Using a small, metal teaspoon to feed residents, especially when portioning pureed textured foods, is the safest method, so that swallowing is easy for the resident.  Caregivers should be mindful of the swallow actually taking place, so that food is not pocketed in the cheeks, or remaining in the mouth.  If the meal assistant is not sure what to do, then asking a trained staff member is the safest option, so that the resident does not have a coughing or choking incident.

The caregiver must thoroughly understand the individual goals and strategies in place and to focus on the resident by being attentive, listening well and by providing for the resident by anticipating individual needs. Describing a resident’s meal choices and providing opportunity to choose foods and beverages gives some control back to the resident. Asking permission from the resident to begin assisting, or, if they would prefer a specific food first, also helps make mealtime a more resident-centered experience.  This must be done in a fashion that encourages the resident’s independence and eating skills and is not in any way obtrusive.  Dining room conversation should be directed to the resident by engaging in appropriate conversation, always refraining from engaging in staff to staff conversation that excludes the resident.  Assisting at a comfortable pace is critical for safety and in helping the resident enjoy the meal.

Long term care homes must establish and maintain a culture of respect around providing assistance with eating.  A good place to start would be to avoid use of demeaning terminology such as ‘feeders’ and ‘bibs’ and instead use terminology such as ‘residents that require assistance with eating’ and ‘aprons’ or ‘clothing protectors’.  Family members and volunteers provide a great deal of this type of assistance in the Long Term Care setting.  Homes need to provide these helping hands with the knowledge and skills to perform the task effectively and safely. Processes should be in place to identify high risk situations and determine how to maintain safety.

Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care.  They are coauthors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians of Canada.