Thinking back on your life, how many memorable occasions involved a meal? Do 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?
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 of the celebration. The details of 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. For individuals with dementia who live in long-term care facilities, enforced changes to this routine may be emotionally and functionally disruptive.
Research has shown that the physical and social environments are important but often untapped resources that can have a significant impact on quality of life (Brush, Meehan, & Calkins, 2002). Rutledge (1987, p. 42) considers the environment "as a collection of tools used to support its inhabitants. Forcing the inhabitants to adapt to a poorly designed set of tools means that the tasks of daily living cannot be successfully completed."
Pleasurable mealtimes can enhance the quality of life of many nursing-home residents with dementia. Modifications in the environment can improve the dining experience, support the rehabilitation process, and enhance overall nutrition. The dining environment should ultimately help compensate for cognitive impairments, thus acting as a facilitator, and be easily modifiable to compensate for future impairments as residents' needs change.
Assessing environmental stimuli, lighting, noise levels, staff care practices, and other aspects of the dining environment are not part of routine clinical practice for most speech-language pathologists. There are many situations in long-term care, however, in which residents with dementia who do not perform to their maximum potential or exhibit "behavior problems" may simply be responding to something in the environment that is not supportive.
The Environment as a Barrier
An example of an unsupportive environment can be seen in many long-term care dining rooms. The literature describes most nursing-home dining rooms as noisy places where residents are seated long before meals are served, with companions chosen for comparable level of dependence rather than social compatibility (Griffin, 1995). In this situation, the environment should be viewed as a barrier that inhibits one's ability to function at one's highest potential.
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. Regulations in nursing homes, and market pressure in independent and assisted living, increase the importance of understanding and catering to residents' preferences related to dining. Responding to preferences 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.
Several common environmental barriers are found in the dining areas of long-term care settings.
- Visual overstimulation. Being seated in the middle of a dining room near the main path used by staff means being surrounded by noise and motion. Most people, having lived at home for many years before moving to a care facility, are accustomed to eating in peace and quiet. In addition, staff often seat residents early because there are many people to "gather" and bring to the dining room. Thus residents, especially if they are seated based on assistance levels and not on affinity or friendship, are often sitting for long periods of time with nothing to do and become distracted. Some may lose interest in eating before the meal arrives.
- Poor lighting. When a resident sits by a wall or window, the fixture above the table sheds light that bounces off the wall, making the place setting a bit brighter. The window next to the person also adds additional light, especially during the mid-day meal, but may cause glare as it reflects off of a polished floor and table. However, for residents in the middle of the room, the light dissipates and often does not reach the recommended light intensity for a dining room (50 foot-candles) unless a fixture is directly overhead.
- Lack of visual contrast. Residents often have difficulty seeing their plates clearly. In facilities trying to be "upscale," tables are often set with white tablecloths, so it is hard to see the white china and silverware. This difficulty is exacerbated for people with glaucoma, cataracts, or dementia. Research has shown that people with Alzheimer's disease have decreased ability to perceive color contrasts and impaired depth perception. When objects close together or on top of each other are also similar in color or value—the lightness or darkness on a gray scale—residents with these conditions find it harder to see the edges of those objects. This difficulty 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).
- Auditory confusion. Residents sitting near the main serving path hear fragments of conversation as staff walk past. Sometimes residents find it hard to keep the conversations separate as they seem to run into each other and don't make sense. Table companions speak in loud voices to one another because many have hearing loss but do not wear hearing aids. Compounding the problem are the background noises of ice machines, the metallic clanging of silverware, announcements on the public-address system, and a radio or boom box playing "dinner" music. Being used to eating quietly and alone, many residents find it hard to cope with the stimulation associated with group dining.
Designing a Solution
How does your dining room measure up? The following environmental adjustments can make meals more enjoyable for residents.
Turn Up the Lights
Often there is insufficient lighting in dining rooms (as well as in other areas of care facilities). If you do not have access to a light meter, try wearing a pair of sunglasses smeared with a little petroleum jelly or lip balm (to simulate vision with cataracts). If after about 15 minutes your eyes are fatigued and you feel the need to remove the glasses, then the dining room probably does not have enough light. Older individuals require three times the amount of light as younger individuals. Therefore, a dining room that is well-lit for residents may seem overly bright to younger caregivers. Corners are often not as well lit as other areas of the room. Try adding lights and directing the light so it bounces off the walls. Make sure not to point lights directly at shiny surfaces such as polished floors or tables, as older adult eyes are much less tolerant of glare than younger eyes.
Increase Visual Contrast
In addition to lighting, consider other aspects of the visual environment. Provide high contrast between the plate and the table or place setting. Research projects have shown that this change, along with increased light levels, can be effective in increasing independence and caloric intake (Brush, Threats, & Calkins, 2003; Koss & Gilmore, 1998; Brush, 2001). 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.
The authors completed a pilot study that examined the effect of improved lighting and table-setting contrast on residents' meal consumption, communicative interaction, independence, and behaviors during meals in both assisted living and long-term care environments serving people with dementia (Brush, Meehan, & Calkins, 2002). After an intervention to improve lighting and contrast, significant improvements were observed in oral intake and functional abilities at both facilities.
Study results showed statistically significant increases from baseline to post-test in the frequency with which the residents initiated and engaged in conversations with staff and answered questions with on-topic responses.
Other research has shown an increase in intake with the use of primary-colored china (red or blue). This research suggests that nursing home staff and designers should consider modifying dining environment barriers, such as dim lighting and poor contrast, to increase clients' ability to participate in meals. These environmental changes—which support residents' independence—will facilitate favorable therapeutic outcomes.
Improve the Acoustics
Pay attention to both people-generated and environmental sources of noise. Some are easier to address than others. Dining rooms seldom are carpeted, so it's important to look to other surfaces to absorb noise. If there are many windows (a hard surface that bounces noise instead of absorbing it), use full drapes or curtains around them to 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 prevent reverberation. If ceiling panels are not feasible, add acoustic panels to the wall. Wood trim gives them an old-fashioned, elegant paneled effect.
As speech-language pathologists, we have a great opportunity to make a real difference in residents' lives by looking at and listening to what the physical environment is telling us. After observing the environment, talk with the residents and ask about their preferences. Find creative ways to help them continue to find meals as more than just an opportunity to eat.