By: Margaret Calkins, PhD and Jennifer Brush, MA, CCC/SLP
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
wouldntor couldnttell 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 Graces 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 individuals 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 residents 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.
Lets 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 SLPs 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 wouldnt share
any of her food. In this situation, her mealtime abilities appeared
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
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 Alzheimers 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 Alzheimers disease read
more quickly and easily when contrast is increased (Koss and Gilmore,
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 didnt 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 Graces 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 didnt 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 Graces 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 wasnt 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 didnt distract
her while she was concentrating. The nurse, having reviewed the
chart, indicated that with both glaucoma and cataracts, Graces
vision was quite poor. Cataract surgery had been discussed, but
Grace, at 87, didnt feel she wanted to undergo surgery at
her age. John, from dietary, commented that breakfast was Graces
worst meal, from a consumption perspective. Her plate
almost always came back with almost 100% of her food still on it.
Graces daughter said her mother had never been much of a breakfast
eatera 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
shed 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 shed rather be seated early or late in the meal.
Grace said shed 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 wasnt until she sat there for 10 minutes just looking
and listening and thinking about it from Graces 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 kitchentoo 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 wouldnt 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. Graces
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) LightingThere 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) AcousticsPay attention to both people generated and environmental
sources of noise. Some are easier to address than others. Since
dining rooms seldom are carpeted, its 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 EnvironmentIn 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
Brush, J. (2001) Improving dining for people with dementia. Milwaukee,
WI: Center for Architecture and Urban Planning Research, University
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 Alzhheimers
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.
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