ORIGINAL ARTICLE

Effects of a feeding intervention in patients with Alzheimer’s disease

and dysphagia
Li-Li Chen, Hong Li, Rong Lin, Jian-Huang Zheng, Yan-Ping Wei, Jing Li, Ping Chen and
Hui-Ying Chen

Aims and objectives. This study aimed to investigate the effects of a feeding inter-
vention in patients with Alzheimer’s disease with dysphagia. What does this paper contribute
Background. In patients with Alzheimer’s disease, inadequate food and fluid to the wider global clinical
intake can result in malnutrition, dehydration and increased morbidity and mor- community?
tality. Patients may lose self-care abilities such as self-feeding. • A feeding intervention among
Design. A prospective cohort study. Alzheimer’s disease patients with
Methods. A three-month self-control feeding intervention was conducted prospec- dysphagia significantly improved
patients’ food intake, increased
tively in 30 nursing home residents with Alzheimer’s disease with dysphagia. Pre-
eating and swallowing ability
and post-intervention measures included the Kubota water swallow test, type and and improved eating compliance.
amount of food intake and assessment of nutritional status by triceps skinfold thick- • Nutritional status improvement
ness, upper arm circumference, serum albumin and haemoglobin. We used the Edin- was shown by significant
burgh Feeding Evaluation in Dementia scale to evaluate eating compliance and the increases between pre- and post-
Mini- Mental State Examination to evaluate cognitive function. Pre- and post-inter- intervention values of upper arm
circumference, skinfold thickness,
vention results were compared to evaluate the effects of nursing intervention.
serum albumin and haemoglobin.
Results. Patients’ eating/feeding abilities improved overall, including significantly • Our results can be applied to
increased food intake (p < 0
001), decreased levels on the Kubota water swallow improve both the eating/feeding
test (p < 0
001) and significant differences in skinfold thickness, arm circumfer- care by nursing staff and the eat-
ence, serum albumin and haemoglobin (all p < 0
01), indicating improved nutri- ing/feeding abilities and nutri-
tional status of AD patients.
tional status. Edinburgh Feeding Evaluation in Dementia scale scores decreased
significantly, showing improved eating compliance. No changes were noted in
cognition post-intervention. Among 22 patients who initially required feeding, five
patients resumed self-feeding after the intervention (p = 0
06).
Conclusions. Results of this study show that a feeding intervention can improve
food intake, eating compliance and nutritional status in patients with Alzheimer’s
disease with dysphagia and prevent further decline in swallowing function.

Authors: Li-Li Chen, MD, MS, Associate Professor of Nursing,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Hong Li, MD, PhD, Professor of Nursing,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Rong Lin, MD, MS, Nurse Practitioner,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Jian-Huang Zheng, MD, MS, Nurse-in-
charge, Fujian Medical University 2nd Affiliated Hospital, Quanz-
hou, Fujian Province; Yan-Ping Wei, MD, MS, Nurse-in-charge,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Jing Li, MD, MS, Nurse Practitioner,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Ping Chen, MD, MS, Nurse Practitioner,
Fujian Medical University Affiliated Clinical Medical Institute,
Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City; Hui-Ying Chen, MD, MS, Nurse Practi-
tioner, Fujian Medical University Affiliated Clinical Medical Insti-
tute, Fujian Provincial Hospital, Nursing School of Fujian Medical
University, Fuzhou City, China
Correspondence: Hong Li, Professor of Nursing, Fujian Provincial
Hospital, No 134, East street, Fuzhou City, Fujian Province 35001,
China. Telephone: +86-0591-88216007.
E-mail: leehong99@126.com

© 2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 25, 699–707, doi: 10.1111/jocn.13013 699
L-L Chen et al.
Relevance to clinical practice. The significant improvement in eating/feeding mea-
sures suggest that this feeding intervention model could be developed as a feeding
skills programme to improve both the eating/feeding care by nursing staff and the
eating/feeding abilities and nutritional status of Alzheimer’s disease patients.
Key words: Alzheimer’s disease, dysphagia, eating compliance, elderly, feeding
intervention
Accepted for publication: 3 August 2015
Introduction
Alzheimer’s disease (AD) is a primary degenerative disease
of the central nervous system, manifest as progressive mem-
ory impairment, large-scale deterioration in mental func-
tion, personality changes and abnormal psychological
behaviour (Li 2011). The World Health Organization’s
2012 statistical report showed an increase in the number of
AD patients to about 7
7 million persons per year globally;
this is equivalent to one new case every four-seconds
(World Health Organization 2012). In China, the preva-
lence of dementia increased from 3
7 million in 1990 to 9
2
million in 2010 (Chan et al. 2013), making AD a serious
national concern.
Background
Because of the advanced age, impaired cognitive function
and attention deficits together result in reduced interest in
food, poor eating coordination and reduced self-feeding.
Alzheimer’s disease patients commonly have poor nutrition
and an increased risk of aspiration leading to aspiration
pneumonia (Priefer & Robbins 1997, Kalia 2003, Hanson
et al. 2011). In a study of 323 nursing home residents with
advanced dementia, 85
8% had eating disorders, and the
six-month mortality rate for these patients was 38
6%
(Mitchell et al. 2009). A health/nutrition training interven-
tion conducted for 946 home-living AD patients had no
effect on functional decline but reduced the risk of malnutri-
tion (Salva et al. 2011) Dysphagia is an important clinical
issue in the care of AD patients, and may have a significant
influence on the effectiveness of feeding interventions for
AD patients. We hypothesised that the eating behaviours
and nutritional status of nursing home patients with AD
and dysphagia may benefit from a feeding intervention
focused on the dining environment, interactions between
nursing staff and residents and feeding strategies to improve
both the feeding skills of nurses and the eating behaviours
700
of patients. This study conducted a feeding intervention in
AD patients with dysphagia to investigate the effects of
intervention on patients’ swallowing ability, nutritional and
cognitive status and degree of eating compliance.
Patients and methods
A cohort of 30 patients with Alzheimer’s disease and dys-
phagia who met the inclusion criteria were selected from
residents of a nursing home in Fuzhou, China, between
October and December 2013. The patients included 17
men and 13 women with an average age of
82
40  6
79 years. Inclusion criteria were: (1) Diagnosis
of dementia consistent with the International Statistical
Classification of Diseases and Related Health Problems
(ICD-10) issued by the World Health Organization; (2)
Clinical manifestations, including different degrees of gag-
ging, dysphagia or difficulty moving muscles of the soft
palate or tongue during screening using the Kubota water
swallow test (Priefer & Robbins 1997, Hanson et al. 2011)
to verify the presence of dysphagia; (3) Able to take food
orally; (4) No lung diseases; (5) Age greater than 60 years;
and (6) Informed consent provided by the patient or family
members. Exclusion criteria were: (1) severe pathologies of
the liver, kidneys or blood, or primary disease of the endo-
crine system; (2) other past or current diseases that may
have affected swallowing function, such as tumours of the
head or neck, tumours of the oesophagus or cranial injury;
(3) dependent on gastric tube or feeding tube for nutrition;
and 4) unstable vital signs.
Ethical approval
The institutional review board of Fujian Medical Univer-
sity, School of Nursing approved the study protocol (IRB
No.: K2014-LW-011). All enrolled patients or their family
members provided signed informed consent to participate
in the study.
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
Original article
Study design
This prospective study employed a before/after self-control
design, and performed a three-month feeding intervention
of AD patients with dysphagia. Observations and assess-
ments of the patients were performed pre- and post-inter-
vention.
All nurses who participated in this study had graduated
from the School of Nursing of the affiliated university,
passed their qualifying examinations and were certified as
registered nurses. Prior to the start of the study, they
attended lectures about the study protocol, received a copy
of the procedures in decision-tree format and had hands-
on supervision in provision of a uniform feeding interven-
tion.
Feeding intervention model
Preparation of patients
Patients were instructed to empty their bowels or bladders
and wash their hands and were gathered in a cafeteria 30-
minutes prior to meals. Preparations for the meal included
setting out utensils and putting aprons on patients. The
patients were helped to their places, and maintained in an
upright seated position as much as possible. Pillows were
placed behind patients’ backs as needed to maintain com-
fort. Those confined to bed had the upper bed raised so
they could assume a semi-reclining position. Patients’
wishes were respected, and efforts were made to avoid dis-
turbing their eating environment and habits. Patients’ status
prior to meals was observed and assessed, and efforts were
made to ensure that they took food while in a stable,
focused state.
Preparation of environment
Patients ate meals together as much as possible, and the
dining environment was kept warm, with comfortable
humidity and good ventilation. While AD patients ate,
nurses were instructed to avoid sudden noises, such as
shouting loudly at patients or loudly opening or closing
doors. Radio broadcasts, music and movies/videos were
played for patients to ensure a good mood while taking
food.
Preparation of food
Food was cooked and seasoned for easy swallowing. Foods
were classified as liquid, semi-liquid, soft and solid. (1) Liq-
uid foods included rice soup, meat soup and milk; (2) semi-
liquid foods consisted of various foods processed together
in a blender until of paste-like consistency; (3) soft foods
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
Feeding intervention in Alzheimer patients
included rice gruel, vermicelli noodles and cake; and (4)
solid foods included rice, fish balls and ravioli/dumplings.
Appropriate types of food were chosen depending on
patients’ degree of dysphagia. To increase patients’ appe-
tites, food colours, aromas and tastes were adjusted with
the help of nutritionists. The diet was generally low salt,
low fat, high protein and rich in vitamins for optimum
nutrition. Certain nonbeneficial foods including fatty, exces-
sively sweet, oily and spicy foods were restricted. Although
AD patients were not particularly sensitive to food temper-
ature, foods were kept at a suitable temperature to prevent
digestive discomfort from food that was too cold or burns
from excessively hot food.
Preparation of utensils
Appropriate utensils were selected to reflect the degree to
which patients could use their limbs. Utensils included
forks, spoons with curved handles and spoons with large
handles; utensils were coloured to distinguish them from
food and the tables.
Feeding intervention
Appropriate assistance
Foods and dining implements were placed in convenient
positions on the tables. Emphasis was placed on patients’
autonomous eating during the process of taking food, and
patients were encouraged to eat on their own using uten-
sils, with nurses on hand to provide encouragement and
assistance. The patients were not rushed, and given suffi-
cient time to chew and swallow food. They were reminded
of the different types of food, and advised to eat them in
turns. Patients were allowed to take short rests while eat-
ing. For those who refused to continue eating, the reason
was sought and problems resolved promptly whenever pos-
sible. When necessary, patients were fed to ensure sufficient
food intake. Nurses were advised to help those persons
who could not feed themselves to obtain food as much as
possible. Feeding approaches were as follows: (1) Actions
were performed gently, and the amount of food provided
at any one time was not too large (approximately 3/4 of a
spoonful). (2) Feeding speed was slow to moderate and
patients were given adequate time for eating; nurses
observed the patients’ eating and fed them a mouthful after
they had swallowed the previous mouthful. (3) For patients
with poor eyesight, food was pressed to their lips to stimu-
late awareness and encourage them to allow feeding. (4) If
a patient’s mouth could not be shut tightly and cheek mus-
cles were contracted and lacked muscle tone, food was sim-
ply placed near the root of the tongue, and the back of a
701
L-L Chen et al.
spoon used to lightly press on the tongue and stimulate the
swallowing reflex, enabling food to pass through the
throat. (5) Lethargic patients were awakened to receive
food. (6) Suitable verbal communication was used during
the feeding process to increase patients’ active participation
in eating.
Patient monitoring
Patients’ compliance, swallowing and chewing were
observed during the eating process, and patients with dys-
phagia were observed closely to prevent accidents such as
gagging or aspiration. Care was taken to ensure that
patients swallowed small mouthfuls slowly, and ate the
next mouthful only after completely swallowing the previ-
ous mouthful. Whenever gagging occurred, the nurses
immediately propped up the patients and caused them to
bend forward at the waist and lower their heads, so that
their chins approached their chests. The nurses then gave
quick, continuous pats between the patients’ shoulder
blades to cause them to cough out the food residue. Alter-
nately, nurses would perform the Heimlich manoeuvre,
standing behind the patient’s back, reaching their arms
around the patient’s chest, clasping their fingers together
and applying a strong upward force to the patient’s dia-
phragm. Airflow passing through the epiglottis caused
patients to eject the congested matter.
Psychological care
Nurses observed the manifestation of AD patients’ person-
alities and preferences in their eating behaviour and habits,
and selected appropriate methods of reassurance consistent
with patients’ preferences and interests; they made correct
assessments of patients’ abnormal eating behaviour, and
treated patients with understanding, tolerance and sincerity,
used reassurance, encouragement and suggestions to guide
patients, and provided acknowledgement, encouragement
and praise for each accomplishment. Nurses communicated
frequently with the patients, maintaining a friendly attitude,
speaking slowly and quietly using brief, clear language and
avoiding shouting.
Nursing care after eating
After each meal, the nurses helped patients to wash their
hands and rinse their mouths, straightened their clothing
and ensured that their posture was comfortable. They also
provided oral care to patients with dysphagia, and kept a
record of the amount of food intake, eating speed, food
preferences and whether incidents such as gagging
occurred.
702
Assessment measures
Kubota water swallow test
The Kubota water swallow test (Onishi & Sun 1997, Jia
2002) was used to assess subjects’ swallowing ability, and
conducted specifically as follows: While in a seated posi-
tion, the patient was given a teaspoon of water to drink; if
the patient drank that with no problem, a cup containing
30 ml of warm water was given to the seated patient, who
was asked to ‘drink it in your usual way.’ The patient’s
drinking process was then observed and scored as follows:
(1) Grade I (normal): the patient drank water in one
mouthful within five seconds without gagging. (2) Grade II
(doubtful): the patient drank water in one mouthful in over
five seconds without gagging or drank water in two mouth-
fuls without gagging. (3) Grade III (mild abnormality): the
patient drank water in one mouthful with gagging. (4)
Grade IV (moderate abnormality): the patient drank water
in two or more mouthfuls with gagging. (5) Grade V (sev-
ere abnormality): the patient experienced constant gagging
and found it difficult to drink all the water.
Nutrition indicators
Triceps skinfold thickness, upper arm circumference, serum
albumin and haemoglobin were used to assess patients’
nutritional status. Skinfold thickness measurements were
performed simultaneously by the researcher and another
research personnel; measurements were performed twice
and the average was taken. Upper arm circumference can
accurately reflect protein storage and level of consumption,
as well as caloric intake, and can further indicate whether a
patient’s nutrition has improved or deteriorated. Serum
albumin chiefly reflects chronic protein abnormalities, while
haemoglobin determines whether patients have anaemia.
Food intake
The Nutrition Society of Taiwan recommends that older
adults who engage in light work should receive a daily
caloric intake of 2000–2200 kcal for men and 1800–
1900 kcal for women; 2000 kcal of food can therefore be
represented as 1 unit. This study employed fractions of
this unit to calculate patients’ food intake during their
three daily meals, and intake was recorded as 0, 1/4, 1/2,
3/4 and 1.
Eating compliance
The Edinburgh Feeding Evaluation in Dementia scale
(EdFED) has 11 items encompassing eating behaviour,
nursing intervention and eating difficulties (Watson 1994).
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
Original article
It is suitable for AD patients of all types at any disease
stage. The validated Chinese version of EdFED has a
Cronbach’s a of 0
90, a coefficient of inter-rater reliability
of 0
81, and a retest correlation coefficient of 0
89 (Lin
et al. 2008). The EdFED was administered pre- and post-
intervention to assess subjects’ eating compliance.
Cognitive function
The Mini-Mental State Examination (MMSE) is a brief 30-
item questionnaire used to assess cognitive function
(Folstein et al. 1975). It is currently the most commonly
used dementia screening instrument in Taiwan and abroad.
Sensitivity of the scale is 0
66, specificity 0
90, with an
overall correct classification rate of 89% in detecting
dementia and a 90% confidence level in measuring changes
(O’Bryant et al. 2008). The 30 items address temporal and
spatial orientation ability, memory, attention and computa-
tion ability, recall ability, language skills and structural
copying. Each correct response counts as one point, while
each error or failure to answer counts as zero points. A per-
fect score is 30 points, with higher scores indicating milder
cognitive impairment. All subjects completed the MMSE
pre- and post-intervention to assess cognitive function.
Statistical analyses
Categorical and ordinal variables are presented as counts
and percentages. Due to the small sample size and possible
violation of the assumption of normality, continuous vari-
ables are described as median and interquartile range
(IQR). All variables were measured for each patient pre-
and post-intervention. Nonparametric tests for paired
samples were performed to compare differences between
pre- and post-intervention values. The Wilcoxon signed
rank test was used for continuous and ordinal variables
while the McNemar test was used for categorical variables.
All statistical analyses were carried out with IBM SPSS statis-
tical software version 22 for Windows (IBM Corp., New
York, NY, USA). Statistical significance was defined as
p-value < 0
05.
Results
A total of 30 elderly AD patients with dysphagia were
enrolled, including 17 (54
8%) males and 13 (45
2%)
females with a mean age of 82
4  6
8 years. Table 1
shows the results of comparisons between patients’ pre-
and post-intervention eating/feeding abilities, anthropomet-
ric and physiologic measurements. Overall improvement
was found in patients’ post-intervention eating/feeding abili-
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
Feeding intervention in Alzheimer patients
ties, including significantly increased food intake
(p < 0
001), decreased levels on the Kubota water swallow
test (63
4% of subjects were grade III to V pre-intervention,
decreasing to 23
3% post-intervention; p < 0
001). Among
22 patients who required feeding pre-intervention, five
patients resumed self-feeding after the intervention,
although borderline significance was found (p = 0
06).
EdFED scores decreased significantly (p < 0
001), indicating
improved eating compliance. Significant increases were
found in upper arm circumference, skinfold thickness,
serum albumin and haemoglobin (all p < 0
001), indicating
improved nutritional status. No post-intervention changes
were noted in cognitive function assessed by the MMSE.
Discussion
Results of this study show that a feeding intervention
among AD patients with dysphagia significantly improved
patients’ food intake, increased eating and swallowing abil-
ity and improved eating compliance. Nutritional status
improvement was shown by significant increases between
pre- and post-intervention values for upper arm circumfer-
ence, skinfold thickness, serum albumin and haemoglobin.
Our results can be attributed to an intervention model
involving general training as well as feeding training. A pre-
vious study (Simmons & Schnelle 2006) showed that when
AD patients with eating-swallowing impediments receive
training in oral functioning, they should also receive a gen-
eral training regimen that includes muscular strength train-
ing, functional training of the arms to assist with eating,
selection and the use of auxiliary implements, preparation
of foods, maintenance of oral hygiene before and after food
intake and assistance and care from helpers (Simmons &
Schnelle 2006).
Consequently, our intervention employed comprehensive
feeding training involving environmental engineering, thor-
ough meal preparation, selection of suitable utensils, the
maintenance of suitable posture, individualised feeding
assistance and emphasis on psychological care.
Feeding intervention slows deterioration of swallowing
function in AD patients
Normal swallowing involves a series of complex, coordi-
nated muscular movements, which are directed by the brain
and require participation of the mouth, throat and oesopha-
gus. Pathologies of any of these areas may induce func-
tional impairment and lead to aspiration (Liu et al. 2004).
The mucous membranes of the laryngeal cavity in AD
patients atrophy and thin with age, the throat becomes
703
L-L Chen et al.

Pre-intervention Post-intervention Table 1 Comparisons between pre- and

post- feeding intervention in eating/feeding
Variables Median IQR Median IQR p* abilities, anthropometrics and physiologic
†
measurements among patients with Alzhei-
Amount of food intake 0
7 0
5–1
0 1
0 0
7–1
0 <0
001
mer’s disease with dysphagia
Self-feeding‡,§
No 22 73
3 17 56
7 0
06
Yes 8 26
7 13 43
3
Kubota water swallow test§,¶
I 0 0
0 4 13
3 <0
001
II 11 36
7 19 63
3
III 6 20
0 1 3
3
IV 8 26
7 4 13
3
V 5 16
7 2 6
7
EdFED** 4
0 1
8–6
0 2
0 1
0–4
3 <0
001
Upper arm circumference 24
0 22
0–26
0 24
5 22
5–26
0 <0
001
Skinfold thickness 11
8 9
5–14
0 12
0 9
9–14
6 <0
001
Serum albumin 37
0 35
8–40
0 40
0 37
8–41
3 <0
001
Haemoglobin 115
0 102
0–130
8 118
5 104
8–135
0 <0
001
MMSE 12
0 3
0–15
0 12
0 3
0–15
0 1
00

IQR, Interquartile range; EdFED, Edingburgh Feeding Evaluation in Dementia Scale; MMSE,
Minimal Mental State Examination.
*Wilcoxon signed rank test was performed.
†
One unit equals to 2000 kcal.
‡
McNemar test was performed.
§
Shown as number and percentage.
¶
Grade I indicates normal and Grade V indicates severe.
**Higher score indicates higher levels of eating and feeding problems.

loose and lax and patients cannot fully raise their heads. In
addition, sensation in the throat deteriorates, the muscles of
the throat weaken and risk of developing impediments to
swallowing increases. AD patients may readily inhale food
and saliva into their respiratory tracts, causing gagging and
suffocation. Long-term dysphagia also puts elderly AD
patients at high risk for weight loss (Inelmen et al. 2010)
and poor nutrition (McDonald 2008) due to lack of suffi-
cient food and fluid intake. It may also induce ulcers, aspi-
ration and pneumonia (Sue Eisenstadt 2010). Swallowing
training in elderly AD patients has been shown to improve
the flexibility and coordination of the muscles of the
mouth, throat and neck, reflexively stimulate the central
nervous system, promote reorganisation of nerve networks,
accelerate establishment of collateral circulation, expand
the sensorimotor cortex, prevent atrophy of the tongue,
throat and neck muscles through disuse, and improve and
slow impairment of swallowing function (Qiang 2012). In
this study, results of the Kubota water swallow test sug-
gested that the feeding intervention may effectively delay
deterioration of the swallowing function in AD patients.
The absence of complications of dysphasia such as aspira-
tion and pneumonia also suggested that improving swal-
lowing may help to reduce the incidence of such
complications.
Feeding intervention can improve nutrition in AD
patients
In this study, biological and biochemical (serum albumin,
haemoglobin) indicators of nutrition, including triceps skin-
fold thickness, upper arm circumference, serum albumin
and haemoglobin, all exhibited significant improvement
compared with pre-intervention values. This result was con-
sistent with previous findings (Jia 2002) that biochemical
indicators of nutrition improved significantly after AD
patients received 42 days of dietary intervention. The inci-
dence of poor nutrition among elderly AD patients is about
70% (Li et al. 2005). Long-term poor nutrition reduces
patients’ ability to respond to stress, impairs immune func-
tion, promotes disease progression and increases mortality
(Hong et al. 2005). Feeding and eating skills regress gradu-
ally with physical and cognitive degeneration and weight
loss is inevitable despite quality care (Claggett 1989). A
case–control study in AD patients showed that an integrity-
promoting training programme focused on the eating envi-
ronment and encouraging individual eating preferences
resulted in significant weight gains in patients vs. controls
(Mamhidir et al. 2007). The authors concluded that ensur-
ing good meal situations is a high priority for AD patients.
Patients with dysphagia require safe foods that are easy to

© 2015 John Wiley & Sons Ltd

704 Journal of Clinical Nursing, 25, 699–707
Original article
swallow and tend not to induce aspiration. Although once
considered ‘life sustaining’, the use of tube feeding is now
discouraged in dementia patients (Lacey 2004). In this
study, while considering patients’ preferences, we scientifi-
cally selected foods with appropriate forms, and adjusted
the food colours, aromas and tastes with the help of nutri-
tionists. This gave patients greater eating confidence,
ensured adequate nutritional intake and helped to restore
swallowing function, enhancing patients’ quality of life.
Feeding intervention can enhance feeding compliance
among AD patients
Among the 17 patients requiring feeding in this study, five
began eating on their own after the feeding intervention,
which certainly supports more efforts to promote self-feed-
ing in elderly AD patients with dysphagia who can still take
in food orally. The nutritional status of elderly hospitalised
patients with at least basic self-care ability is significantly
better than that of patients who require assisted living or
are significantly or completely dependent on others for daily
living needs (Li et al. 2013). Patients should be encouraged
to resume self-feeding using utensils. This may help to slow
the deterioration of autonomous eating ability, enhance
their degree of feeding compliance and their nutritional sta-
tus. Nurses in this study were instructed to not only provide
assistance and encouragement, but also to observe AD
patients’ food intake closely to prevent accidents.
Importance of psychological care in feeding intervention
Approximately 45% of elderly AD patients in nursing
homes and in the community are estimated to suffer from
depression (Fernandez et al. 2010). As their disease pro-
gresses and self-care ability deteriorates, they may feel alone
and have a severe sense of inferiority, which can intensify
mood swings, making them irritable and volatile when
encountering minor issues. Changes in functional or psy-
chological status and reports of pain may foretell the occur-
rence of depression (Kverno et al. 2008), and these patients
may refuse food or feeding assistance, ultimately becoming
isolated and paranoid. Nurses in this study were encour-
aged to discern changes in patients’ memory, thinking and
emotions from their words and actions. If nurses establish
good relationships with AD patients during everyday care
and observe the patients’ personalities and preferences, then
they can give praise and acknowledgement to patients who
make progress, no matter how minor. This can motivate
patients and provide a basis for eating regularly. Because
psychological factors are closely related to dementia in
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
Feeding intervention in Alzheimer patients
elderly AD patients, psychological care must be emphasised
as well as feeding training, which may help to slow disease
progression and improve patients’ quality of life in addition
to improving eating/feeding ability and nutrition.
Comprehensive feeding intervention supports nurses and
AD patients
Throughout the intervention, nurses were supported by
having a defined plan to follow while caring for AD
patients with dysphagia. Research has shown that decision
aids about feeding options in AD increased the knowledge
of nurses and reduced uncertainty and decisional conflict
(Hanson et al. 2011). Advance care planning is often
neglected in caring for AD patients who cannot participate
in developing a plan, but research shows that having a care
plan may benefit end-of-life care for patients with dementia
and help improve their quality of life (Sampson et al.
2011). A report of another comprehensive feeding skills
training programme showed that nurses’ knowledge, atti-
tudes and behaviour related to feeding dementia patients
improved as a result of on-the-job training (Chang & Lin
2005). Similarly, the consistent application of the
approaches outlined in our comprehensive feeding interven-
tion contributed directly to the improved eating/feeding
situation of the AD patients.
Limitations
Results of this study are limited by the small sample and
short evaluation period. Results may thus not apply to all
Alzheimer patients with dysphagia in different areas of
China or other populations. Patients were also from a sin-
gle institution, which may cause site bias. Although our
results suggest the effectiveness of this feeding intervention
programme in improving eating compliance and nutritional
status in Alzheimer patients, larger prospective multicenter
studies with longer application of the intervention are
needed to confirm our results.
Conclusions
Results of this study showed that a comprehensive feeding
intervention can improve food intake, eating compliance
and nutritional status in patients with Alzheimer’s disease
with dysphagia and prevent further decline in swallowing
function. The significant improvement in eating/feeding
measures suggested that this feeding intervention model
could be developed as a feeding skills programme to
improve both the eating/feeding care by nursing staff and
705
L-L Chen et al.

the eating/feeding abilities and nutritional status of AD
patients.
Relevance to clinical practice
The significant improvement in eating/feeding measures sug-
gest that this feeding intervention model could be developed
as a feeding skills programme to improve both the eating/
feeding care by nursing staff and the eating/feeding abilities
and nutritional status of AD patients.
Contributions
LLC carried out the study design, collected the data and
performed statistical analysis and also drafted the manu-
script. HL participated in the study design and help
performed the statistical analysis. RL is responsible for the
data collection and analysis and help prepared the manu-
script. JHZ, YPW, JL, PC and HYC all help with data col-
lection and statistical analysis. All authors read and
approved the final manuscript.
Funding
Youth Scientific Research Subject of Fujian Provincial
Health Bureau, P.R.C. No. 2011-1-3. Key Project of Fujian
Provincial Department of Science and Technology, P.R.C.
No. 2012Y0013.
Conflict of interest
The authors declare that no conflict of interest exists.

References
Chan KY, Wang W, Wu JJ, Liu L,
Theodoratou E, Car J, Middleton L,
Russ TC, Deary IJ, Campbell H,
Wang W & Rudan I (2013) Epidemi-
ology of Alzheimer’s disease and other
forms of dementia in China, 1990–
2010: a systematic review and analy-
sis. Lancet 381, 2016–2023.
Chang CC & Lin LC (2005) Effects of a
feeding skills training programme on
nursing assistants and dementia
patients. Journal of Clinical Nursing
14, 1185–1192.
Claggett MS (1989) Nutritional factors rel-
evant to Alzheimer’s disease. Journal
of the American Dietetic Association
89, 392–396.
Fernandez M, Gobartt AL, Balana M &
COOPERA Study Group (2010) Be-
havioural symptoms in patients with
Alzheimer’s disease and their associa-
tion with cognitive impairment.
BioMed Central Neurology 10, 87.
Folstein MF, Folstein SE & McHugh PR
(1975) “Mini-mental state”. A practi-
cal method for grading the cognitive
state of patients for the clinician. Jour-
nal of Psychiatric Research 12, 189–
198.
Hanson LC, Carey TS, Caprio AJ, Lee TJ,
Ersek M, Garrett J, Jackman A, Gil-
liam R, Wessell K & Mitchell SL
(2011) Improving decision-making for
feeding options in advanced dementia:
a randomized, controlled trial. Journal
of the American Geriatrics Society 59,
2009–2016.
Hong Z, Zhou F, Huang MS, Zeng J, Ding
D & Jin MH (2005) Death rate
among urban and rural elderly Alzhei-
mer’s disease patients in the Shanghai
area: death rate and factors predicting
survival. Chinese Journal of Epidemi-
ology 26, 404–407.
Inelmen EM, Sergi G, Coin A, Girardi A
& Manzato E (2010) An open-ended
question: Alzheimer’s disease and
involuntary weight loss: which comes
first? Aging Clinical and Experimental
Research 22, 192–197.
Jia HY (2002) Nursing diagnosis of swal-
lowing functional impairment and
advances in rehabilitation care. Nurs-
ing Foreign Medical Sciences 21, 12–
14.
Kalia M (2003) Dysphagia and aspiration
pneumonia in patients with Alzhei-
mer’s disease. Metabolism 52, 36–
38.
Kverno KS, Rabins PV, Blass DM, Hicks
KL & Black BS (2008) Prevalence and
treatment of neuropsychiatric symp-
toms in advanced dementia. Journal of
Gerontological Nursing 34, 8–15; quiz
16-17.
Lacey D (2004) Tube feeding in advanced
Alzheimer’s disease: when language
misleads. American Journal of Alzhei-
mers Disease and Other Dementias
19, 125–127.
Li Z (2011) Analysis of concepts connected
with dementia in the elderly. Chinese
Journal of Nursing 46, 1045.
Li YM, Deng YP, Huang SK, Peng BW &
Cheng LP (2005) Nutritional status of
elderly Alzheimer’s disease patients.
Chinese Journal of Gerontology 25,
502–503.
Li XW, Chen Y & Yang QB (2013)
Assessment and analysis of the nutri-
tional status of elderly hospitalized
patients. Food and Nutrition in China
19, 82–86.
Lin LC, Watson R, Lee YC, Chou YC &
Wu SC (2008) Edinburgh Feeding
Evaluation in Dementia (EdFED)
scale: cross-cultural validation of the
Chinese version. Journal of Advanced
Nursing 62, 116–123.
Liu YC, Ku HA, Zhao YX, Cui BY, Yang
XP & Yu SF (2004) Survey of elderly
persons’ cognitive risk factors and
awareness of misaspiration. Chinese
Journal of Nursing 39, 26–27.
Mamhidir AG, Karlsson I, Norberg A &
Mona K (2007) Weight increase in
patients with dementia, and alteration
in meal routines and meal environ-
ment after integrity promoting care.
Journal of Clinical Nursing 16, 987–
996.
McDonald P (2008) Making the connec-
tion between diet and nutrition and
cardiovascular and Alzheimer’s dis-
eases. Explore 4, 148–153.

© 2015 John Wiley & Sons Ltd

706 Journal of Clinical Nursing, 25, 699–707
Original article
Mitchell SL, Teno JM, Kiely DK, Shaffer
ML, Jones RN, Prigerson HG, Volicer
L, Givens JL & Hamel MB (2009)
The clinical course of advanced
dementia. The New England Journal
of Medicine 361, 1529–1538.
O’Bryant SE, Humphreys JD, Smith GE,
Ivnik RJ, Graff-Radford NR, Petersen
RC & Lucas JA (2008) Detecting
dementia with the mini-mental state
examination in highly educated indi-
viduals. Archives of Neurology 65,
963–967.
Onishi S & Sun QL (1997) Assessment of
feeding-swallowing impediments in
stroke patients and training. Chinese
Journal of Rehabilitation Medicine 12,
141–142.
Priefer BA & Robbins J (1997) Eating
changes in mild-stage Alzheimer’s dis-
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 699–707
ease: a pilot study. Dysphagia 12,
212–221.
Qiang YY (2012) Effect of evidence-based
care on rehabilitation of dysphagia
following stroke. Chinese Journal of
Medical Guidance 14, 1076–1077.
Salva A, Andrieu S, Fernandez E, Schiffrin
EJ, Moulin J, Decarli B, Rojano-i-
Luque X, Guigoz Y & Vellas B
(2011) Health and nutrition promo-
tion program for patients with demen-
tia (NutriAlz): cluster randomized
trial. Journal of Nutrition Health &
Aging 15, 822–830.
Sampson EL, Jones L, Thune-Boyle IC,
Kukkastenvehmas R, King M, Leur-
ent B, Tookman A & Blanchard MR
(2011) Palliative assessment and
advance care planning in severe
dementia: an exploratory randomized
Feeding intervention in Alzheimer patients
controlled trial of a complex inter-
vention. Palliative Medicine 25, 197–
209.
Simmons SF & Schnelle JF (2006) Feed-
ing assistance needs of long-stay
nursing home residents and staff time
to provide care. Journal of the
American Geriatrics Society 54, 919–
924.
Sue Eisenstadt E (2010) Dysphagia and
aspiration pneumonia in older adults.
Journal of the American Academy of
Nurse Practitioners 22, 17–22.
Watson R (1994) Measuring feeding diffi-
culty in patients with dementia: devel-
oping a scale. Journal of Advanced
Nursing 19, 257–263.
World Health Organization (2012) De-
mentia: A Public Health Priority.
World Health Organization, Geneva.
707