Grace is a mildly confused resident, self-ambulatory, with hypertension, glaucoma and cataracts. Increasingly, she is not eating her meals. Grace had been sitting at a table by the back wall with one other person The staff requested an evaluation by a speech language pathologist, which was conducted in her office so as to not disturb the other residents in the dining room during the meal. During the meal, Grace was able to eat most of the food she was served. The evaluation indicated no swallowing difficulties, but Grace had difficulty verbally identifying food items, and required cuing to refocus her attention to the meal. After the evaluation, dining room staff moved Grace to a four person table that was more social, and along the main path that staff walked during meals. This would allow staff to more easily watch Grace, and enable them to more easily encourage her to eat more. This change did not immediately have the desired effect. One day at dinner a few days later, Grace exploded with unexplained anger, pushing her food away, spilling coffee on her table partners, screaming and eventually breaking down and crying. Staff took her back to her room, and sat with her until she calmed down, but she wouldn’t—or couldn’t—tell staff what had upset her so. For several days, she refused to go to the dining room at all. The speech language pathologist [SLP] stopped by to see her, and suggested maybe they should go to lunch together. During this meal, the SLP was able to watch Grace, and could see that being in the middle of the dining room overtaxed Grace’s capabilities. There was too much traffic walking by the table, too many conversations from near-by tables, it was near the ice machine and where the silverware and dishes were stocked (and restocked during the meal). It also seemed the area was not very bright.

Dining is more than simply a means to consume sufficient caloric nutrients to sustain life. Meals are a ritual with stable patterns generally followed on a day to day basis. Special occasions, such as holidays, birthdays, or anniversaries, often revolve around meals as a centerpiece to the celebration. The where, when, what is eaten, with whom, and with what else (TV, radio, newspaper, etc.) may be well entrenched in an individual’s daily routine, and can vary tremendously from one individual to another. Forcing changes to this routine may be emotionally and functionally disruptive.

Long-term care facilities, however, cannot realistically cater to every resident’s complete personal preferences. Group living, almost by definition, requires some level of compromise. It does not, however, suggest care providers should set policies and practices solely to suit their preferred organizational structure. Codes, in nursing homes, and market pressure in independent and assisted living make understanding and catering to your residents preferences related to dining increasingly important. This includes, at a minimum, some choice in meal time and some choice in what is served. More progressive facilities are also offering a choice of meal location, table companions, and a greater array of food options.

Let’s go back and examine the case study of Grace. In her original location, staff worried she was not eating enough. The SLP evaluation, conducted in the SLP’s office, showed no swallowing problems. The SLP began the evaluation by beginning a friendly, casual conversation with Grace as they walked to her office. Grace, delighted by the attention, and wanting to please her new friend, was happy to eat almost all the food put in front of her, although she was a little disappointed that the therapist wouldn’t share any of her food. In this situation, her mealtime abilities appeared quiet functional.

Yet, when returned to the dining room and relocated so staff could more easily observe her and encourage her to eat, Grace was clearly overwhelmed and failed to cope. An examination of the new situation will show what happened.

1) Visual Stimulation: Being in the middle of the dining room and along the main path that staff walked meant Grace was constantly surrounded by people moving briskly about. Having lived alone for many years before moving to the facility, Grace was used to eating in peace and quiet. Staff also seated her early, because it took her so long to eat. Thus, she was constantly greeting other residents as they walked in after her, or left before her. It seemed rude to Grace to simply ignore her friends and acquaintances.

2) Lighting: Although care had been taken to light the dining room evenly, when Grace sat by the wall, the fixture above her table shed light that bounced off the light colored wall, making her place setting just a bit brighter. The window behind her back also added additional light, especially during the mid-day meal. In the middle of the room, the light dissipated and did not reach the recommended foot candles (50 foot candles), except directly under one of the fixtures.

3) Visual Contrast: In addition, Grace had a hard time seeing her plate clearly. The tables were set with white tablecloths, so it was hard to see the white china and silverware. This may have been due to her glaucoma and cataracts. The problems she faced may also have been exacerbated by her early dementia. Research has shown that people with Alzheimer’s disease have decreased ability to perceive color contrasts and have impaired depth perception. This means that when objects that are close together or on top of each are close in color or value (the lightness or darkness of an object on a gray scale), it is harder to see the edges of those objects. This is why, for instance, some facilities paint door frames a contrasting color so the doorways are more visible. This same research has shown that people with Alzheimer’s disease read more quickly and easily when contrast is increased (Koss and Gilmore, 1998).

4) Auditory Stimulation: By sitting near the main path, Grace heard a lot of pieces of conversation as people walked past. Sometimes Grace found it hard to keep the conversations separate as they seemed to run into each other; but then they didn’t make sense any more. Her new table companions, while quite friendly, spoke in loud voices to each other, since Harriet was a little hard of hearing but still not ready to wear hearing aids. Compounding the problem was the background noise of the ice machine discharging ice cubes into the plastic pitchers, and the metallic clanging of silverware as the drawer was restocked during the meal. Being used to eating alone, Grace found it hard to cope with the noise.

Designing the Solution
After the second evaluation, a care plan meeting was scheduled with the SLP, dietician, nurse, personal care assistant who routinely helps Grace in her apartment, and Grace’s daughter. They wanted to brainstorm how to best help Grace be more functional and enjoy her meals more. They started by listing what was different about her new location in the dining room from her old one. Debbie, the personal care assistant, said she had been thinking about the meeting, but since she typically didn’t help Grace with meals, she had been unsure how she would be able to help. But then she thought that maybe if she sat where Grace sat, she might learn something. So one day, for 5 minutes she sat at Grace’s old table, and then pulled up a chair to sit at her new table. Debbie said what struck her immediately was how busier and noisier the new table was. Even she had trouble oncentrating, and she wasn’t trying to focus on a meal. Debbie said in her experience with Grace, things worked best if you did one task at a time, and didn’t distract her while she was concentrating. The nurse, having reviewed the chart, indicated that with both glaucoma and cataracts, Grace’s vision was quite poor. Cataract surgery had been discussed, but Grace, at 87, didn’t feel she wanted to undergo surgery at her age. John, from dietary, commented that breakfast was Grace’s “worst” meal, from a consumption perspective. Her plate almost always came back with almost 100% of her food still on it. Grace’s daughter said her mother had never been much of a breakfast eater—a banana or a bowl of cold cereal and a cup of coffee was almost all she ever had, and that was usually around 10:00 or so. Traditionally, dinner had been her big meal of the day, but she’d noticed recently that her mother had been tired in the later afternoons, sometimes saying she was too tired to go to dinner.

Armed with this information, they brainstormed some ideas for how to help Grace. They wanted to come up with some ideas to present to Grace, and ask her which ideas she thought she would like. First, they thought they would move Grace back to her quiet corner, and add an additional light on the wall above her table. They also decided to put a dark blue tablecloth on her table, so the white plate, napkins and cups would stand out and be easier to see. They asked her whether she’d rather be seated early or late in the meal. Grace said she’d rather have breakfast later, “something light please”, but would rather go into the dining room earlier for dinner. In the evening, she thought getting there early would give her plenty of time to eat, since she liked to eat slowly.

Staff were still concerned about the general noise level of the dining room. Debbie said she had been in the dining rooms a lot, but it wasn’t until she sat there for 10 minutes just looking and listening and thinking about it from Grace’s perspective, that she realized how noisy the dining room was. Some of the noise they could address immediately. For instance, several staff members had a tendency to treat the dining room like a fast food restaurant, calling loudly to other staff when they wanted or needed something. An in-service training session was scheduled to work on this. But some of the other noise was harder to manage, such as the ice maker. It was handy having it in the dining room so staff could quickly and easily fill pitchers to serve residents water. They looked for a new location, but the only place that had access to water and a drain was in the far corner of the kitchen—too far away. John asked about buying extra plastic pitchers, since they are not very expensive, and filling them all up before the meal. That way the staff wouldn’t have to get more ice from the machine during meals. They also looked into adding a few movable wall partitions covered with highly rated acoustic materials to block the entrance to the kitchen a little. This way, the noise from the kitchen would not seep into the dining room.

After several weeks, it was clear the changes were working. Grace’s caloric intake was up, and she was clearly enjoying her meals more. Occasionally she would invite someone to share her small table, while at other times she seemed to enjoy the peace and quiet of eating alone. She was no longer overwhelmed by too-large breakfasts, eating her cold cereal or banana quite happily. Other residents also commented on how pleasant the dining room was, now that it was not so noisy.

How well does your dining room stack up? There are several common problems that can make meals more of a challenge and less of a pleasurable event for your residents:

1) Lighting—There is often insufficient lighting in dining rooms (as well as other areas of care facilities). If you do not have access to a light meter, try wearing a pare of sunglasses smeared with a little petroleum jelly or lip balm. If after 15 minutes or so you find your eyes are tired, or you are subconsciously taking the glasses off, then the dining room probably does not have enough light. Older individuals require three times the amount of light as do younger individuals. So a dining room that is well lit for residents may seem overly bright to younger caregivers. Corners and areas around the perimeter of the room are often not a well lit as the center of the room. Try adding lights and directing the light so it bounces off the walls.

2) Acoustics—Pay attention to both people generated and environmental sources of noise. Some are easier to address than others. Since dining rooms seldom are carpeted, it’s important to look to other surfaces to absorb noise. If there are many windows, which is a hard surface that bounces noise instead of absorbing it, use full drapes or curtains around them. The folds of the fabric will help absorb some noise. If the ceiling is high enough (usually 10 feet or more) fabric covered acoustic panels that hang down several feet will both absorb noise and keep it from reverberating around the room. If ceiling panels are not feasible, add acoustic panels to the wall. They can be given an old-fashioned, elegant paneled effect if they are frames in with a little wood trim.

3) Visual Environment—In addition to lighting, consider other aspects of the visual environment. Be sure to provide high contrast between the plate and the table or place setting. Research projects have shown that this, along with increasing light levels, can be effective in increasing independence and caloric intake (Brush, 2001; Koss and Gilmore, 1998). Also consider how the food is served. Some people will do better if they are given one course at a time. Too many choices may be overwhelming. You also need to consider the visual acuity of each resident. Someone with a stroke may not be able to see one side of the plate as well as the other.

Thinking back on your life, how many memorable occasions involved a meal? So you treasure a quiet meal at the end of a long day, either alone or with your family? Or are your meals full of fun and laughter, a chance to renew your balance.

Think about your residents, and ask about their preferences. Find creative ways to help them continue to find meals more than just an opportunity to eat.

Margaret P. Calkins, Ph.D, and Jennifer A. Brush, CCC/SLP

References:
Brush, J. (2001) Improving dining for people with dementia. Milwaukee, WI: Center for Architecture and Urban Planning Research, University of Wisconsin-Milwaukee.

Koss, E. & Gilmore, C.G. (1998). Environmental interventions and functional abilities of AD patients. In B. Vellas, J. Filten & G. Frisoni (Eds.), Research and practice in Alzhheimer’s disease, 185-191. Paris/New York: Serdi/Springer.

IESNA (1998). Recommended practice for lighting and the visual environment for senior living. New York: Illuminating Engineering Society of North America.

Other resources:
Briller, S., Proffitt, M., Perez, K., Calkins, M. & Marsden, J. (2001). Minimizing Congitive and Functional Abilities. In Calkins, M.P. (Producer) Creating Successful Dementia Care Settings. Baltimore MD: Health Professions Press.

Brush, J.A., Meehan, R.A. & Calkins, M.P. (under review) Using the environment to improve intake for people with dementia. Journal of Communication Disorders.

Gross-Figueiro, M. (2001) Lighting the way: A key to independence. Troy, New York: Rensselaer Polytechnic Institute.

Zgola, J. & Bordillon, G. (2001). Bon Appetit!: The joy of dining in long-term care. Baltimore: Health Professions Press.

Reprinted with permission: Journal of Dementia Care, Vol 10, No. 2. Hawker Publications, 2nd floor, Culvert House, Culvert Road, London, SW11 5DH. 020-7720-2108