- Email: [email protected]
Increasing food intake in nursing home residents: Efficacy of the Sorbet Increases Salivation intervention
Geriatric Nursing xx (2014) 1e4
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Increasing food intake in nursing home residents: Efficacy of the Sorbet Increases Salivation intervention Neva L. Crogan, PhD, GCNS-BC, GNP-BC, FNGNA, FAAN a, *, Aditya Simha, PhD b, Craig Morgenstern, DO a a b
Gonzaga University, 502 E. Boone Ave., Spokane, WA 99258, USA University of Wisconsin e Whitewater, 826 W Starin Road, Whitewater, WI 53190, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 January 2014 Received in revised form 27 March 2014 Accepted 31 March 2014 Available online xxx
The purpose of this study was to test the effect of the Sorbet Increases Salivation (SIS) intervention on resident food intake and body weight. Using a pre- post design, thirty-nine nursing home residents received 2 ounces of lemon-lime sorbet prior to lunch and dinner meals for 6 weeks. As a comparison and prior to the intervention, participants were offered 2 ounces of a non-citrus drink for 6 weeks prior to the lunch and dinner meals. Twenty-two residents completed both the comparison and intervention periods. Of those, 8 gained weight, 10 maintained and 4 lost weight. The amounts of food ingested during dinner increased significantly (p ¼ 0.001) from the comparison period to the intervention period (208e253 g). For liquids, the amounts ingested during dinner decreased significantly (p ¼ 0.002) from the comparison period to the intervention period (from 356 ml to 310 ml). Further study is needed to test the efficacy of the intervention with a larger sample of residents from multiple nursing homes. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Nursing home Elder Salivation Food intake Xerostomia
Introduction Up to 85% of elders living in nursing homes suffer from inadequate food intake,1 which can lead to weight loss and malnutrition. The Centers for Medicare & Medicaid Services2 defines significant weight loss as “a weight loss of 5% or more in the last month or 10% or more in the last two quarters” for those not on a providerprescribed weight-loss regimen. Malnutrition compromises quality of life and can lead to chronic disability, functional decline, increased health care utilization and health care costs, and even death.3 A multifaceted problem, weight loss can be caused by poor appetite, chronic disease, sensory loss, poor oral/dental health, polypharmacy, depression, chronic inflammation, catabolism due to severe illness, and environmental factors.4 For the average nursing home resident, weight loss may ultimately be due to inadequate food intake.5 Many of the medications taken by older adults have anticholinergic or sympathomimetic actions, causing xerostomia or dry mouth.6 The average nursing home resident uses 7e8 different medications each month, while approximately one third of resident’s use 9 or more.7
* Corresponding author. Tel.: þ1 509 313 6641. E-mail address: [email protected] (N.L. Crogan). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.03.007
Persons with xerostomia have difficulty in chewing, forming a food bolus and swallowing. They also can experience a decreased ability to taste food. Dependent upon the medication, symptoms of xerostomia can be temporary secondary to short-term antihistamine use, viral infections, dehydration, and/or anxiety, or long-standing secondary to iatrogenic causes from drugs, local radiation, or chemotherapy.8e10 In the older adult population, xerostomia is most likely drug-induced and the risk increases with greater numbers of drugs taken.10 Xerostomia can lead to poor food intake in older adults.11 In an extensive review of the literature, there was some preliminary evidence that offering sorbet prior to meals can stimulate salivation and help alleviate the effects of drug-induced xerostomia in older adults. In this 2011 pilot study,12 8 of 10 nursing home residents ate more food after consuming 2 ounces of sorbet when compared to non-sorbet meals. However, the study was underpowered and thus, not generalizable. The purpose of this study was to continue to pilot test the use of the Sorbet Increases Salivation (SIS) intervention with a larger sample of nursing home residents within two nursing homes. The aim of this pilot study was to test the effect of the intervention on resident food intake and body weight when compared to a competing treatment of 2 ounces of a non-citrus drink before meals. We hypothesized that participating residents would consume significantly more food over the treatment period in
2
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
contrast to a comparison period leading to increased body weight post intervention. Methods Study design and intervention Using a pre- post design, thirty-nine nursing home residents (n ¼ 20 from Nursing Home A, n ¼ 19 from Nursing Home B) received 2 ounces of lime sorbet prior to lunch and dinner meals for 6 weeks. As a comparison and prior to the intervention, participants were offered 2 ounces of a non-citrus drink for 6 weeks prior to the lunch and dinner meals. The breakfast meal was not a part of the intervention because older adults typically eat the most food at breakfast. Setting Two nursing homes (110 & 160 beds) located in Spokane, Washington agreed to participate in the study. Both facilities are for profit and offer subacute, skilled, custodial and dementia care. Sample recruitment Facility nursing staff identified all residents who met inclusion/ exclusion criteria. Inclusion criteria included residents age 65 years or older, a Mini Mental State Examination (MMSE) score of 12e30 indicating moderate/mild or normal cognition, residents that consume meals in the main dining room, residents who screened positive for drug-induced xerostomia (dry mouth), and residents who can feed themselves unassisted in w1 h or less. Residents excluded were those that were actively dying e receiving palliative or hospice care, those that had a history of head/neck radiation, salivary gland surgery, or Sjogrens disease, residents with a diagnosis of dysphagia or major depression, and those receiving a pureed diet. A nurse known to the resident introduced the Principal Investigator (PI) or Research Associate (RA) to each qualified resident. The PI or RA explained the study, invited participation, and if agreeable, obtained written informed consent, administered the Mini Mental State Examination (MMSE), and screened for xerostomia. If the resident had a guardian and met study criteria, facility staff contacted the guardian. After the guardian verbally agreed, the PI or RA made contact to obtain written consent. In this case, assent was obtained from the resident. Residents that did not score 12e30 on the MMSE, or did not screen positive for xerostomia were not included in the study. After informed consent was obtained, the RA obtained demographic data (age, gender, diagnoses) and diet information (type of diet, consistency) from the subject’s medical record. If a resident (or their guardian) refused to participate, did not score 12e30 on the MMSE, or did not screen positive for xerostomia, another resident was invited to participate until an N of 20 was obtained at each nursing home. Human subjects (IRB) approval was obtained through Gonzaga University’s Human Subjects Protection Program prior to initiation of the study. Measures Pre-study screening The Mini Mental State Examination (MMSE) is a valid and reliable 11-item tool for measuring 5 areas of cognitive function in diverse populations.13 Scores of 12e23 indicate mild-moderate impairment; 24e30 indicates normal cognition.14 Residents that scored 12e30 were screened for xerostomia.
The PI (a Geriatric Nurse Practitioner) screened each potential subject for xerostomia using a three-step process: Drug Review, Oral Inspection, and Subjective Evaluation. Oral inspection (step 2) and subjective evaluation (step 3) are described in Table 1. Residents that took two or more xerogenic drugs, displayed 3 of 5 visual indicators of xerostomia, and reported 3 of 6 subjective symptoms were identified as suffering from xerostomia (a positive screen). Procedures: measuring the effects of sorbet on resident food intake A plate waste protocol was used to determine actual food intake for each resident during lunch and dinner meals during the last 7 days of both comparison and intervention periods. This accurate procedure uses a gram food scale to weigh and compare weights of original food servings to weights of the same foods left ‘on the plate’ after meals.15 Research assistants weighed filled food plates as they were served and then reweighed the plates at the end of each meal (after residents were finished eating). The two ounces of sorbet was not included in the amount of food consumed. Fluid intake was calculated at each meal by measuring the amount of fluids left in the glass/cup at the end of the meal. Procedures: measuring the effects of the intervention on body weight Body weight was determined by weighing each participant at the same time of day, at baseline and post comparison and intervention periods, wearing approximately the same amount of clothing each time. The research assistant documented the time of day and amount of clothing worn by each resident so that this process could be accurately replicated on each occasion. Data analysis Before embarking on analyses related to the study aims, summary statistics (means, standard deviations, proportions) were determined to describe the study sample. The methods used were repeated measures ANOVA to measure the effects of sorbet on resident food intake and resident body weight and Bonferroni pair wise comparison tests. Results A total of 39 residents met study inclusion/exclusion criteria and participated in the study. Of those, 22 residents (11 from each site)
Table 1 Steps for screening xerostomia. Step one e Drug review Step two e Oral inspection Positive indicators of xerostomia: Dry, cracked lips Oral mucosa dry or shiny Tongue furrowed, dry or sticky Food debris stuck to teeth or soft tissue Normal pooling of saliva in mouth absent Step three e Subjective evaluation 1. Do you have difficulties swallowing any foods? 2. Does your mouth feel dry while eating a meal? 3. Do you sip liquids to aid in swallowing dry foods? 4. Does the amount of saliva in your mouth seem to be too little? 5. Do your lips feel dry? 6. Does your mouth feel dry?
Present Present Present Present Present
Absent Absent Absent Absent Absent
Yes Yes Yes Yes
No No No No
Yes Yes
No No
Adapted from Gupta A, Epstein JB, & Stroussi H. Hypo salivation in elderly patients. JCDA, 2006;72:841e846.
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
completed both the control and treatment periods. All were 65 years of age and older, 13 of 22 (59%) were female. Mini Mental State Examination Scores ranged from 12 to 29 (average of 20.56). All residents screened positive for xerostomia. The number of medications prescribed that potentially could cause xerostomia ranged from 2 to 6 (average 3.32 medications per resident). Major drug categories included antidepressants, opioid pain medications, diuretics, axiolytics, benzodiazepines, beta-blockers, and H2 blockers/protein pump inhibitors. Participant attrition was problematic, in that 17 of 39 participants, or 43% of the original sample did not complete the study. Attrition was attributed to residents going home, or a change in condition leading to hospitalization or transfer to another facility. Two participants voluntarily withdrew from the study. Of the 22 residents who completed the study (Table 2), 8-gained weight, 10 maintained their weight, and 4 lost weight. Of those who gained weight, all were taking 3 or more xerogenic medications. Measuring the effects of sorbet on resident food intake and body weight A repeated measures ANOVA was conducted to measure the effects of sorbet on resident food intake and resident body weight. The measures were observed the last 7 days of comparison and intervention periods. Amount of food and amount of liquid were each tabulated separately, and compared at the different time points, for both lunch and dinner. Differences in the amounts of food eaten at dinner pre- and post are reported in Table 3. Table 4 reports the differences in liquids consumed at dinner pre- and post. As shown in Table 5, the amount of food ingested during dinner increased significantly (p ¼ 0.001) from the comparison period to the Intervention measurement point (208e253 g). At the same time the amount of liquids ingested during dinner reduced significantly (p ¼ 0.002) from the comparison period to the intervention measurement point (from 356 ml to 310 ml). There were no significant changes in weight during the different time periods. Discussion The aim of this pilot study was to test the effect of the intervention on resident food intake and body weight when compared
3
Table 3 Differences in amounts of food eaten at dinner pre- and post-sorbet (measured in grams). ID
Pre-sorbet
Post-sorbet
% change
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
241 280 137 205 168 351 247 377 303 249 256 118 182 613 279 267 217 129 121 182 122 73
253 313 226 226 162 316 380 299 308 60 216 92 160 218 449 319 316 148 186 227 104 206
5 12 65 10 3.5 9 54 21 2 76 16 22 12 64 38 19.5 46 15 54 25 15 182
to a competing treatment of 2 ounces of a non-citrus drink before meals. Participants did eat more food while consuming less fluid during treatment periods in comparison to non-treatment periods possibly implying that residents needed less fluid (sorbet was effective in increasing salivation) thereby eating more food. However, this finding needs to be considered cautiously in that dehydration is common in older adults and any decrease in fluid intake should be assessed to determine if this reduction impacts the elder’s overall health status. Challenges within our study included the ordering of comparable sorbet at both sites. After much discussion and exploration of options, the research team and nursing home dietary managers agreed to use Blue Bunny Lime Sherbet. It was accessible, inexpensive and came in large containers. The sherbet was stored in each nursing home’s walk-in freezer and pre-scooped into small 3-ounce dishes and covered for use later in the day. The sherbet
Table 4 Differences in amounts of liquids consumed at dinner pre- and post-sorbet (measured in milliliters).
Table 2 Participant pre- and post sorbet body weight (in pounds). ID
Pre-sorbet
Post-sorbet
ID
Pre-sorbet
Post-sorbet
% difference
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
219 151 150 163 176 194 170 336 141 165 87 77 107 241 249 162 189 120 165 165 180 86
221 152 148 154 171 203 178 340 142 152 94 77 106 246 260 162 182 128 166 165 181 87
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
390 111 109 193 398 201 391 587 330 324 306 500 316 285 441 163 260 285 257 440 570 103
430 120 116 66 162 561 364 973 345 187 150 360 220 345 343 163 305 180 206 662 463 101
10 8 6 66 59 179 7 65 4.5 42 51 28 30 21 22 0 17 37 20 50 15 2
4
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
Table 5 Mean amounts of food eaten and differences pre- and post sorbet. Outcome
Food intake (grams) Fluid intake (milliliters) Body weight (pounds)
Pre-sorbet
Post-sorbet
F (p)
Mean
SD
Mean
SD
208 356 167
98 134 52
253 310 168
96 214 60
0.001 0.002 NS
was served 5 min prior to the beginning of the meal service (the delivery of plates to tables). Our study was not free of difficulties. The original power analysis was based on an N of 30 (15 from each site). However, participant attrition was problematic. Thus the results, even though encouraging, may not be applicable to other settings or populations. Prior to initiating the next study, over-sampling of the targeted population by at least 40% should be considered so that loss of participants does not affect the power of the study. Another potential limitation was fidelity. Even though research assistants assigned to deliver the sorbet also were asked to ensure each participant consumed it, this was not well documented. Future studies should consider gathering fidelity data to help the researchers fully understand study findings. The process used to measure food intake could be viewed as a limitation. Even though accurate, the process does not take into account the types of food consumed rather than just the amount (in grams) of food consumed. Future studies also should consider measuring serum pre-albumin levels pre- post to further correlate participant nutrition status with weight gain or loss. Conclusion This innovative and novel approach to alleviating elder dry mouth utilized a simple, easy-to-implement intervention that has the potential of increasing food intake in this at-risk population. The intervention offers a tasty, stimulating dessert prior to the meal thereby tantalizing the elder to eat more food (most elders enjoy dessert). The product is inexpensive and the SIS protocol requires
very little staff training or time to initiate. Further study is needed to test the efficacy of the intervention with a larger sample of residents from multiple nursing homes. Acknowledgment Study funded by the American Nurses Foundation (ANF). References 1. Suominen M, Muurinen S, Roautasalo P, et al. Malnutrition and associated factors among aged residents in all nursing homes in Helsinki. Eur J Clin Nutr. 2005;54:578e583. 2. Center for Medicare and Medicaid Services. MDS 3.0 Quality Measures User’s Manual. RTI International; 2012. 3. Reed PS, Zimmerman S, Sloane PD, Williams CS, Boustani M. Characteristics associated with low food and fluid intake in long-term care residents with dementia. Gerontologist. 2005;45:74e80. 4. Morley JE. Undernutrition: a major problem in nursing homes. J Am Med Dir Assoc. 2011;12:243e246. 5. Aoyama L, Weintraub N, Reuben DB. Is weight loss in the nursing home a reversible problem? J Am Med Dir Assoc. 2006;7:S66eS72. 6. Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol. 2004;97:28e46. 7. Doshi JA, Shaffer T, Briesacher BA. National estimates of medication use in nursing homes: findings from the 1997 medicare current beneficiary survey and the 1996 medical expenditure survey. J Am Geriatr Soc. 2005;53:438. 8. Glore RJ, Spiteri-Staines K, Paleri V. A patient with dry mouth. Clin Otolaryngol. 2009;34:358e363. 9. Gupta A, Epstein JB, Sroussi H. Hypo salivation in elderly patients. J Can Diet Assoc. 2006;72:841e846. 10. Lingstrom P, Moynihan P. Nutrition, saliva, and oral health. Nutrition. 2003;19: 567e569. 11. Gerdin EW, Einarson S, Jonsson M, Aronsson K, Johansson I. Impact of dry mouth conditions on oral health-related quality of life in older people. Gerontologist. 2005;22:219e226. 12. Crogan NL. Managing xerostomia in nursing homes: pilot testing of the Sorbet Increases Salivation Intervention. J Am Med Dir Assoc. 2011;12:212e216. 13. Folstein M, Folstein SE, McHugh PR. “Mini-Mental State” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12: 189e198. 14. Kane RL, Kane RA. Assessing Older Persons. New York: Oxford University Press; 2000. 15. Hayes J, Kendrick OW. Plate waste and perception of quality of food prepared in conventional vs. commissary systems in the Nutrition Program for the elderly. J Am Diet Assoc. 1995;95:565.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Increasing food intake in nursing home residents: Efficacy of the Sorbet Increases Salivation intervention Neva L. Crogan, PhD, GCNS-BC, GNP-BC, FNGNA, FAAN a, *, Aditya Simha, PhD b, Craig Morgenstern, DO a a b
Gonzaga University, 502 E. Boone Ave., Spokane, WA 99258, USA University of Wisconsin e Whitewater, 826 W Starin Road, Whitewater, WI 53190, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 January 2014 Received in revised form 27 March 2014 Accepted 31 March 2014 Available online xxx
The purpose of this study was to test the effect of the Sorbet Increases Salivation (SIS) intervention on resident food intake and body weight. Using a pre- post design, thirty-nine nursing home residents received 2 ounces of lemon-lime sorbet prior to lunch and dinner meals for 6 weeks. As a comparison and prior to the intervention, participants were offered 2 ounces of a non-citrus drink for 6 weeks prior to the lunch and dinner meals. Twenty-two residents completed both the comparison and intervention periods. Of those, 8 gained weight, 10 maintained and 4 lost weight. The amounts of food ingested during dinner increased significantly (p ¼ 0.001) from the comparison period to the intervention period (208e253 g). For liquids, the amounts ingested during dinner decreased significantly (p ¼ 0.002) from the comparison period to the intervention period (from 356 ml to 310 ml). Further study is needed to test the efficacy of the intervention with a larger sample of residents from multiple nursing homes. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Nursing home Elder Salivation Food intake Xerostomia
Introduction Up to 85% of elders living in nursing homes suffer from inadequate food intake,1 which can lead to weight loss and malnutrition. The Centers for Medicare & Medicaid Services2 defines significant weight loss as “a weight loss of 5% or more in the last month or 10% or more in the last two quarters” for those not on a providerprescribed weight-loss regimen. Malnutrition compromises quality of life and can lead to chronic disability, functional decline, increased health care utilization and health care costs, and even death.3 A multifaceted problem, weight loss can be caused by poor appetite, chronic disease, sensory loss, poor oral/dental health, polypharmacy, depression, chronic inflammation, catabolism due to severe illness, and environmental factors.4 For the average nursing home resident, weight loss may ultimately be due to inadequate food intake.5 Many of the medications taken by older adults have anticholinergic or sympathomimetic actions, causing xerostomia or dry mouth.6 The average nursing home resident uses 7e8 different medications each month, while approximately one third of resident’s use 9 or more.7
* Corresponding author. Tel.: þ1 509 313 6641. E-mail address: [email protected] (N.L. Crogan). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.03.007
Persons with xerostomia have difficulty in chewing, forming a food bolus and swallowing. They also can experience a decreased ability to taste food. Dependent upon the medication, symptoms of xerostomia can be temporary secondary to short-term antihistamine use, viral infections, dehydration, and/or anxiety, or long-standing secondary to iatrogenic causes from drugs, local radiation, or chemotherapy.8e10 In the older adult population, xerostomia is most likely drug-induced and the risk increases with greater numbers of drugs taken.10 Xerostomia can lead to poor food intake in older adults.11 In an extensive review of the literature, there was some preliminary evidence that offering sorbet prior to meals can stimulate salivation and help alleviate the effects of drug-induced xerostomia in older adults. In this 2011 pilot study,12 8 of 10 nursing home residents ate more food after consuming 2 ounces of sorbet when compared to non-sorbet meals. However, the study was underpowered and thus, not generalizable. The purpose of this study was to continue to pilot test the use of the Sorbet Increases Salivation (SIS) intervention with a larger sample of nursing home residents within two nursing homes. The aim of this pilot study was to test the effect of the intervention on resident food intake and body weight when compared to a competing treatment of 2 ounces of a non-citrus drink before meals. We hypothesized that participating residents would consume significantly more food over the treatment period in
2
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
contrast to a comparison period leading to increased body weight post intervention. Methods Study design and intervention Using a pre- post design, thirty-nine nursing home residents (n ¼ 20 from Nursing Home A, n ¼ 19 from Nursing Home B) received 2 ounces of lime sorbet prior to lunch and dinner meals for 6 weeks. As a comparison and prior to the intervention, participants were offered 2 ounces of a non-citrus drink for 6 weeks prior to the lunch and dinner meals. The breakfast meal was not a part of the intervention because older adults typically eat the most food at breakfast. Setting Two nursing homes (110 & 160 beds) located in Spokane, Washington agreed to participate in the study. Both facilities are for profit and offer subacute, skilled, custodial and dementia care. Sample recruitment Facility nursing staff identified all residents who met inclusion/ exclusion criteria. Inclusion criteria included residents age 65 years or older, a Mini Mental State Examination (MMSE) score of 12e30 indicating moderate/mild or normal cognition, residents that consume meals in the main dining room, residents who screened positive for drug-induced xerostomia (dry mouth), and residents who can feed themselves unassisted in w1 h or less. Residents excluded were those that were actively dying e receiving palliative or hospice care, those that had a history of head/neck radiation, salivary gland surgery, or Sjogrens disease, residents with a diagnosis of dysphagia or major depression, and those receiving a pureed diet. A nurse known to the resident introduced the Principal Investigator (PI) or Research Associate (RA) to each qualified resident. The PI or RA explained the study, invited participation, and if agreeable, obtained written informed consent, administered the Mini Mental State Examination (MMSE), and screened for xerostomia. If the resident had a guardian and met study criteria, facility staff contacted the guardian. After the guardian verbally agreed, the PI or RA made contact to obtain written consent. In this case, assent was obtained from the resident. Residents that did not score 12e30 on the MMSE, or did not screen positive for xerostomia were not included in the study. After informed consent was obtained, the RA obtained demographic data (age, gender, diagnoses) and diet information (type of diet, consistency) from the subject’s medical record. If a resident (or their guardian) refused to participate, did not score 12e30 on the MMSE, or did not screen positive for xerostomia, another resident was invited to participate until an N of 20 was obtained at each nursing home. Human subjects (IRB) approval was obtained through Gonzaga University’s Human Subjects Protection Program prior to initiation of the study. Measures Pre-study screening The Mini Mental State Examination (MMSE) is a valid and reliable 11-item tool for measuring 5 areas of cognitive function in diverse populations.13 Scores of 12e23 indicate mild-moderate impairment; 24e30 indicates normal cognition.14 Residents that scored 12e30 were screened for xerostomia.
The PI (a Geriatric Nurse Practitioner) screened each potential subject for xerostomia using a three-step process: Drug Review, Oral Inspection, and Subjective Evaluation. Oral inspection (step 2) and subjective evaluation (step 3) are described in Table 1. Residents that took two or more xerogenic drugs, displayed 3 of 5 visual indicators of xerostomia, and reported 3 of 6 subjective symptoms were identified as suffering from xerostomia (a positive screen). Procedures: measuring the effects of sorbet on resident food intake A plate waste protocol was used to determine actual food intake for each resident during lunch and dinner meals during the last 7 days of both comparison and intervention periods. This accurate procedure uses a gram food scale to weigh and compare weights of original food servings to weights of the same foods left ‘on the plate’ after meals.15 Research assistants weighed filled food plates as they were served and then reweighed the plates at the end of each meal (after residents were finished eating). The two ounces of sorbet was not included in the amount of food consumed. Fluid intake was calculated at each meal by measuring the amount of fluids left in the glass/cup at the end of the meal. Procedures: measuring the effects of the intervention on body weight Body weight was determined by weighing each participant at the same time of day, at baseline and post comparison and intervention periods, wearing approximately the same amount of clothing each time. The research assistant documented the time of day and amount of clothing worn by each resident so that this process could be accurately replicated on each occasion. Data analysis Before embarking on analyses related to the study aims, summary statistics (means, standard deviations, proportions) were determined to describe the study sample. The methods used were repeated measures ANOVA to measure the effects of sorbet on resident food intake and resident body weight and Bonferroni pair wise comparison tests. Results A total of 39 residents met study inclusion/exclusion criteria and participated in the study. Of those, 22 residents (11 from each site)
Table 1 Steps for screening xerostomia. Step one e Drug review Step two e Oral inspection Positive indicators of xerostomia: Dry, cracked lips Oral mucosa dry or shiny Tongue furrowed, dry or sticky Food debris stuck to teeth or soft tissue Normal pooling of saliva in mouth absent Step three e Subjective evaluation 1. Do you have difficulties swallowing any foods? 2. Does your mouth feel dry while eating a meal? 3. Do you sip liquids to aid in swallowing dry foods? 4. Does the amount of saliva in your mouth seem to be too little? 5. Do your lips feel dry? 6. Does your mouth feel dry?
Present Present Present Present Present
Absent Absent Absent Absent Absent
Yes Yes Yes Yes
No No No No
Yes Yes
No No
Adapted from Gupta A, Epstein JB, & Stroussi H. Hypo salivation in elderly patients. JCDA, 2006;72:841e846.
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
completed both the control and treatment periods. All were 65 years of age and older, 13 of 22 (59%) were female. Mini Mental State Examination Scores ranged from 12 to 29 (average of 20.56). All residents screened positive for xerostomia. The number of medications prescribed that potentially could cause xerostomia ranged from 2 to 6 (average 3.32 medications per resident). Major drug categories included antidepressants, opioid pain medications, diuretics, axiolytics, benzodiazepines, beta-blockers, and H2 blockers/protein pump inhibitors. Participant attrition was problematic, in that 17 of 39 participants, or 43% of the original sample did not complete the study. Attrition was attributed to residents going home, or a change in condition leading to hospitalization or transfer to another facility. Two participants voluntarily withdrew from the study. Of the 22 residents who completed the study (Table 2), 8-gained weight, 10 maintained their weight, and 4 lost weight. Of those who gained weight, all were taking 3 or more xerogenic medications. Measuring the effects of sorbet on resident food intake and body weight A repeated measures ANOVA was conducted to measure the effects of sorbet on resident food intake and resident body weight. The measures were observed the last 7 days of comparison and intervention periods. Amount of food and amount of liquid were each tabulated separately, and compared at the different time points, for both lunch and dinner. Differences in the amounts of food eaten at dinner pre- and post are reported in Table 3. Table 4 reports the differences in liquids consumed at dinner pre- and post. As shown in Table 5, the amount of food ingested during dinner increased significantly (p ¼ 0.001) from the comparison period to the Intervention measurement point (208e253 g). At the same time the amount of liquids ingested during dinner reduced significantly (p ¼ 0.002) from the comparison period to the intervention measurement point (from 356 ml to 310 ml). There were no significant changes in weight during the different time periods. Discussion The aim of this pilot study was to test the effect of the intervention on resident food intake and body weight when compared
3
Table 3 Differences in amounts of food eaten at dinner pre- and post-sorbet (measured in grams). ID
Pre-sorbet
Post-sorbet
% change
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
241 280 137 205 168 351 247 377 303 249 256 118 182 613 279 267 217 129 121 182 122 73
253 313 226 226 162 316 380 299 308 60 216 92 160 218 449 319 316 148 186 227 104 206
5 12 65 10 3.5 9 54 21 2 76 16 22 12 64 38 19.5 46 15 54 25 15 182
to a competing treatment of 2 ounces of a non-citrus drink before meals. Participants did eat more food while consuming less fluid during treatment periods in comparison to non-treatment periods possibly implying that residents needed less fluid (sorbet was effective in increasing salivation) thereby eating more food. However, this finding needs to be considered cautiously in that dehydration is common in older adults and any decrease in fluid intake should be assessed to determine if this reduction impacts the elder’s overall health status. Challenges within our study included the ordering of comparable sorbet at both sites. After much discussion and exploration of options, the research team and nursing home dietary managers agreed to use Blue Bunny Lime Sherbet. It was accessible, inexpensive and came in large containers. The sherbet was stored in each nursing home’s walk-in freezer and pre-scooped into small 3-ounce dishes and covered for use later in the day. The sherbet
Table 4 Differences in amounts of liquids consumed at dinner pre- and post-sorbet (measured in milliliters).
Table 2 Participant pre- and post sorbet body weight (in pounds). ID
Pre-sorbet
Post-sorbet
ID
Pre-sorbet
Post-sorbet
% difference
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
219 151 150 163 176 194 170 336 141 165 87 77 107 241 249 162 189 120 165 165 180 86
221 152 148 154 171 203 178 340 142 152 94 77 106 246 260 162 182 128 166 165 181 87
101 102 104 107 108 110 115 117 118 119 120 201 202 203 206 207 208 210 211 213 214 215
390 111 109 193 398 201 391 587 330 324 306 500 316 285 441 163 260 285 257 440 570 103
430 120 116 66 162 561 364 973 345 187 150 360 220 345 343 163 305 180 206 662 463 101
10 8 6 66 59 179 7 65 4.5 42 51 28 30 21 22 0 17 37 20 50 15 2
4
N.L. Crogan et al. / Geriatric Nursing xx (2014) 1e4
Table 5 Mean amounts of food eaten and differences pre- and post sorbet. Outcome
Food intake (grams) Fluid intake (milliliters) Body weight (pounds)
Pre-sorbet
Post-sorbet
F (p)
Mean
SD
Mean
SD
208 356 167
98 134 52
253 310 168
96 214 60
0.001 0.002 NS
was served 5 min prior to the beginning of the meal service (the delivery of plates to tables). Our study was not free of difficulties. The original power analysis was based on an N of 30 (15 from each site). However, participant attrition was problematic. Thus the results, even though encouraging, may not be applicable to other settings or populations. Prior to initiating the next study, over-sampling of the targeted population by at least 40% should be considered so that loss of participants does not affect the power of the study. Another potential limitation was fidelity. Even though research assistants assigned to deliver the sorbet also were asked to ensure each participant consumed it, this was not well documented. Future studies should consider gathering fidelity data to help the researchers fully understand study findings. The process used to measure food intake could be viewed as a limitation. Even though accurate, the process does not take into account the types of food consumed rather than just the amount (in grams) of food consumed. Future studies also should consider measuring serum pre-albumin levels pre- post to further correlate participant nutrition status with weight gain or loss. Conclusion This innovative and novel approach to alleviating elder dry mouth utilized a simple, easy-to-implement intervention that has the potential of increasing food intake in this at-risk population. The intervention offers a tasty, stimulating dessert prior to the meal thereby tantalizing the elder to eat more food (most elders enjoy dessert). The product is inexpensive and the SIS protocol requires
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