Abstract
Objectives
To describe the process and feasibility of our randomised, controlled intervention study (NuAD trial) that positively affected the nutrition and quality of life, and prevented falls of home-dwelling persons with Alzheimer disease (AD).
Design, setting, participants
This qualitative study comprised 40 persons with AD and spousal caregivers of our trial. Our intervention during one year involved tailored nutritional guidance for these couples. The nutritionist's field notes (about 100 pages) and the participant feedback questionnaires (N = 28) served to analyse the feasibility of intervention, factors promoting the application of intervention and challenges hindering it. Thematic content analysis served to analyse our data with the grounded theory approach.
Results
We identified several positive elements promoting better nutrition: positive attitudes on nutrition to participants including a participant-centred approach, positive feedback, findings of food diaries and practical suggestions. Home visits by the nutritionist were convenient and participants felt that someone cares. Group meetings which included protein-rich snacks strengthened the nutritional message by enabling discussions and socialising. The oral nutritional supplements (ONS) helped participants to regain their energy and to motivate them to exercise and make changes in their diets. Obstacles to making changes in diets included participants' false ideas about nutrition, especially with regard to weight gain. Health problems and functional limitations hampered food management, and some families had inveterate eating habits. The positive feedback from participants indicated the feasibility of our tailored nutritional guidance.
Conclusions
Assessment-based, tailored nutritional guidance implemented with a personal and positive approach may inspire and empower AD families to make positive changes in their diets, leading them to improved nutrition and quality of life.
Key words: Nutritional intervention, Alzheimer disease, spousal caregivers, feasibility
Introduction
Nutrition is a key component in maintaining health and function in persons with Alzheimer disease (AD) and their spousal caregivers. Nutritional problems, such as unintentional weight loss, malnutrition, and poor nutrient intake, are common among persons with (AD) (1, 2, 3, 4, 5) and their older spousal caregivers may also be at risk for malnutrition (6). Weight loss, poor nutrition and protein intake are associated with increased infections, morbidity, sarcopenia and functional decline (7, 8, 9, 10).
Interventions among AD families have yielded in promising outcomes. A health and nutritional program targeting to caregivers and physicians not only reduced the risk for malnutrition among home-dwelling AD sufferers (11), and had a positive long-term impact on the nutritional status of those with probable or mild AD suffering from weight loss (12), but also positively affected on AD sufferer’s cognition (13). Oral nutritional supplements (ONSs) have proved effective in weight maintenance and gain among AD patients in long-term care (14, 15, 16).
Caregivers are often responsible for food management in AD families and face many challenges, such as their spouse’s modified food preferences, decreased food intake and food diversity, comorbidities, and the AD person’s decreased autonomy (17). Caregivers’ high burden has been associated with weight loss in their AD spouses (18), and our baseline data showed that male gender among caregivers was associated with poor nutrient intake in AD families (19). Therefore, home-dwelling AD families are an important target group for nutritional intervention (20). Poor nutritional status has also been associated with poorer quality of life among older adults (21, 22).
The report of our randomized, controlled trial shows that tailored nutritional guidance improved the nutrient intake and quality of life, and prevented falls of those with AD (23). The aim of this study is to describe the process, feasibility and challenges of our intervention. We use grounded theory to qualitatively explore the process of intervention from the interventionist’s field notes and the participants’ feedback.
Subjects and Methods
This study is based on a randomized controlled trial exploring the effectiveness of nutritional intervention among persons with AD living at home and their spousal caregivers. The study design, the baseline results and the effectiveness of the intervention have been described previously (23, 24, 25).
We recruited the participants, AD persons and their spousal caregivers, from the central Alzheimer drug reimbursement register of the Social Insurance Institution of Finland during 2010-2011. The participants were assessed with the Mini Nutritional Assessment (MNA) (26) and the Mini-Mental
State Examination (MMSE) (27). We instructed the caregivers to maintain food diaries for three days. After the researchers had received and recorded the food diaries, the couples were assigned to the intervention and control groups. This article focuses on the intervention couples who completed the one-year trial, and aims to describe the process of intervention and its feasibility.
Intervention
The one-year intervention was tailored and based on the participants’ nutritional status according to the MNA, their nutrient intake according to three-day food records, and personal assessments and discussions during home visits.
The main elements of the intervention are listed in Table 1. Those with weight loss (1, 5) were instructed to increase their food intake with energy-dense food items. Those with medium or high BMI were advised to maintain their weight and increase their exercise. Those with insufficient energy, protein or nutrient intake received tailor-made instructions for improving their diet (8, 9, 10, 20), ONS were given to those who had low energy or protein intake (16) and were unable to change their diet with normal food items. The participants with low energy or nutrient intake received guidance to increase the number of meals and their consumption of energy-, protein-, and nutrient-rich snacks (28). We ensured their consumption of vitamin D supplements (20 µg) (29), recommended exercise (30), and offered advice on their housekeeping and cooking.
Table 1.
Key elements of intervention and the means by which they were implemented
| Main Elements of Intervention | Means to Implement Intervention |
|---|---|
| • Tailored guidance on weight or unintentional weight loss | • Home visits |
| • Tailored nutritional care plan | |
| • Sufficient energy, protein and other nutrient intake | • Personal discussions |
| • Booklet of good nutrition for older adults | |
| • Vitamin D supplementation | |
| • Use of oral nutritional supplements (ONS) | • Brochures about sources of protein, calcium and vitamin D |
| • Exercise | • ONS when needed |
| • Housekeeping and cooking |
The means to implement the guidelines appear in Table 1. The interventionist (nutritionist, TMP) visited each couple between four and eight times in a year. During the first visit, the nutritionist discussed the findings from their food diaries and other food-related issues such as grocery shopping, cooking, appetite, and possible eating-related problems. The guidance was participant-centred, and the nutritionist offered the instructions based on an assessment of the participant’s nutrient intake, discussions and own wishes. The guidance focused on the caregivers, as they were in most cases responsible for the meals in their families. In cases of weight loss, acute illness, fatigue, surgery, or when the nutritionist noticed that the couples could not make the needed changes in their diets, the nutritionist offered ONSs for the necessary period of time to ensure sufficient nutrient intake. We used protein-rich ONSs, containing 300 kcal, 20 g protein and other nutrients, as well as energy-dense ONSs containing 300 kcal, 12 g protein and other nutrients.
The tailored nutritional care plan (NCP) was a short, one-page written plan that included positive feedback on their diet, information and practical suggestions. We tried to find some positive things to say about each couple’s housekeeping, nutrition, diet or exercise habits. The aim was to raise the participants’ active agency, to empower them to express their own ideas, and to strengthen their feelings of self-efficacy and mastery according to the principles of self-management (31). The NCP consisted of the participants’ nutrient intakes compared to recommendations and practical suggestions for how to improve one’s diet. For protein intake, we based our recommendation on at least 1 g per body-kg of protein daily (9, 10). Our suggestions in the NCPs focused on the most important issues for each participant and limited our guidance to a few key messages (32). The NCPs were mailed to every participant shortly after the first visit, and the interventionist discussed the themes written in the NCP during the following home visits. Participants were encouraged to express their opinions about the NCPs.
We used several booklets and brochures to clarify our guidelines (Table 1). Participants had the opportunity to call the nutritionist and participate in a group meeting once or twice during the intervention year. Of the couples, 26 participated in the group meeting once, and one couple twice. Each meeting comprised of 12-25 participants. The aim was to enhance peer support and to strengthen the nutrition message (32).
Data collection and analyses
The nutritionist wrote field notes on each home visit throughout the entire intervention. She wrote down her observations on the participants’ housekeeping habits, appetite, eating habits, symptoms and signs, current relevant life events, and opinions about nutritional issues. Field notes also included the participants’ responses to the NCPs and the intervention, as well as problems related to following the NCPs.
At the end of the intervention, we invited the participants to provide anonymous feedback on the intervention through a questionnaire (“Feedback form”) containing both structured items and open-ended questions that encouraged the participants to express their opinions (“How did you benefit from the intervention?” and “Please, share with us free comments about the intervention”).
We used grounded theory (33) and an inductive coding process. First, we collected data with several methods, namely field notes (FN) (about 100 pages) and the participants’ feedback forms (FF) (n = 28). Second, two researchers (TMP, MHS) read through the data several times independently and systematically examined them to identify emergent themes. The key points were marked as a series of codes. The codes were further grouped into categories, and each item was compared to the rest of the data to establish analytical categories (constant comparison) (34). The coding was performed independently by two authors (TP, MHS) to ensure reliability. In a few cases, all the authors (TMP, MHS, KHP) held discussions in order to reach a consensus on various concepts. Attention also focused on deviant phenomena. In this article, we report our findings related to the positive elements which improved the nutrition among the participants as well as obstacles in the intervention process that hinder nutritional changes.
Feedback on structured items with multiple choice questions (Table 2) appears as frequencies and percentages.
Table 2.
Baseline characteristics of the intervention couples
| Characteristic | AD persons N=40 | Spousal caregivers N=40 |
|---|---|---|
| Mean age, (SD) | 78 (6) | 77 (6) |
| Males, % | 76 | 24 |
| Mean MMSE, (SD) | 19 (6) | 27 (2) |
| MNA, % | ||
| < 17 points, malnourished | ||
| 17-23.5 points, at risk | 42 | 30 |
| >23.5 points, well-nourished | 58 | 70 |
| BMI, % | ||
| <24 | 22.5 | 35 |
| 24-29 | 55 | 40 |
| >29 | 22.5 | 25 |
| Own opinion of nutrition, % | ||
| severe nutritional problems | .. | .. |
| insecure of own nutrition | 3 | 8 |
| no nutritional problems | 97 | 92 |
| Education < 8 years, (%) |
34 |
32 |
The Ethics Committee of the Helsinki University Central Hospital approved our study, and each participant provided his or her written informed consent. In cases where the participant with dementia had poor judgment, the AD sufferer’s spouse provided the informed consent for both.
Results
Altogether 40 couples completed the intervention and their baseline characteristics appear in Table 1. According to the MNA, 43% of AD persons and 30% of spousal caregivers were at risk for malnutrition, but 98% and 93% estimated that they themselves had no nutritional problems, respectively.
Positive elements promoting improved nutrition
We identified in our intervention several positive elements promoting improved nutrition and quality of life.
Positive attitudes on nutrition was provided for all participants. Firstly, the participants found the findings of food diaries interesting, which was a good way to spark a discussion about their nutrition. The participants realised the possible shortcomings of their diets when viewing the findings of their food diaries, especially the graphics of their nutrient intakes compared to recommendations.
Positive feedback, provided both orally and in written form in the NPC, encouraged participants to discuss their nutrition more freely and to express their own opinions and wishes. Comments stating that participants’ own nutrition was good and balanced were important. Some caregivers were concerned about their nutrition and felt they could not keep up with the conflicting nutritional information. Some had also received conflicting nutritional guidance from other health care professionals.
“It was a relief to know that our diet was balanced; it is impossible to understand the nutritional information in the media.”
Practical suggestions tailored to participants motivated them to make changes in their diet, as they understood the reasons for certain suggestions. The participant-centred approach sparked in increased interest in nutrition and empowered participants to take care of themselves. Our recommendation to refrain from losing weight was also a relief for many participants:
“It’s so reliving that I don’t have to lose weight anymore! That [weight loss] has been the only nutrition-related advice I have ever received.”
Home visits were a convenient way to carry out the intervention. Firstly, transportation for the participants was a non-issue. Secondly, visiting couples at their homes enabled us to see the actual environment in which the participants lived and how they handled their food-related activities. This information enabled the implementation of our guidance to meet the participants’ needs. Home visits also seemed to be important events that left participants with a feeling that someone cares:
“The guidance cheers us up; we are thankful for the guidance and home visits.”
“It is good to know that someone cares about us.”
Group meetings were socialising events for participants, whose social lives had declined, but the meetings also reinforced the nutritional message. Participants were served healthy protein-rich snacks at the meetings. In this way, they became familiar and interested in them and later on found similar snacks from at the grocery store. Lectures about nutrition given in the group meetings sparked up lively discussions revealing interest in nutrition issues. We offered taxi transportation to help participants get at the meetings so that all could participate. Even though each couple participated in the group meeting only once, and one couple twice, the participants valued the meeting.
When couples were unable to change their food habits, we used ONS. The nutritionist tried mainly to support the couples’ diets with food items. Altogether 28 of the AD sufferers and 20 of the caregivers received ONSs. Some participants regained energy substantially after receiving ONS. ONSs helped them to gain weight or for some to stop their weight loss, which proved feasible; only two participants thought that the ONSs were too sweet. The nutritionist noticed that, after taking ONSs some participants succeeded and were sufficiently motivated to make changes in their diets. The ONSs also motivated some participants to exercise, as we advised them to combine their ONSs with daily exercise.
Challenges during the intervention process that hindered nutritional improvements
Some false ideas regarding what is good nutrition persisted. The idealisation of weight control prevented some couples from increasing their food intake as they were used to thinking that they should avoid becoming overweight.
“The less you eat the better”
“You should weigh the same [now] as when you were young.”
Some male caregivers had to be strongly convinced that weight gain would benefit their wives with a BMI under 20. Some participants expressed concerns about weight gain, and had even received conflicting guidance from health care professionals to lose weight. One male caregiver had preconceptions of home-delivered meals; as a biologist he was skeptical of the hygienic preparation of these meals. We encouraged him to use convenience foods and to add some fresh salads and vegetables to the meals. Some participants felt that the food was too expensive.
In some families, health problems were challenges to intervention. Celiac disease, swallowing or chewing problems caused extra work and stress for caregivers, because they had to prepare two different meals. For those with AD, the nutrition-related challenges included poor appetite, which in some cases was due to the medication.
In one family, the female caregiver’s impaired physical functioning resulted in her husband with AD handling the grocery shopping. He refused to use a checklist, however, and purchased whatever, so the couples’ diet ended up being unbalanced most of the time. Some male caregivers found cooking to be an overwhelming task. Of these, some had managed to organise a home-delivered meal service. The Inability to go out due to functional disabilities may in some cases have also contributed to low food intake.
Some families had inveterate eating habits, such as refusing to eat any fruit or vegetables. In addition, a few were obsessed with avoiding fat.
Participants’ opinions about the intervention
Most (93%) of the participants estimated that the nutritionist’s home visits and guidance were useful for them, while 4% found that visits to be somewhat useful. The participants were able to choose two things they considered were the most useful ways to receive guidance; they found the discussions with the nutritionist (42%) to be the most useful way, though they also appreciated the booklet on good nutrition for older adults (35%) and brochures of good sources of protein and calcium (23%), and NCP (16%). Most (80%) of the participants felt that they benefited from their participation (Table 3).
Table 3.
Feedback from the participants who completed the intervention
| Question | % |
|---|---|
| 1. Your opinion about the nutritionist’s home visits | |
| a. They were useful | 93 |
| b. They were partly useful | 4 |
| c. They were not useful | 0 |
| d. Other comments | 0 |
| 2. Your opinion about the nutritionist’s guidance | |
| a. Guidance was useful | 93 |
| b. Guidance was not useful | 0 |
| c. Guidance was hard to understand | 0 |
| b. Other comments | 0 |
| 3. What were the most useful ways to receive nutritional guidance? | |
| (you may choose 2) | |
| a. Booklet about good nutrition for older adults | 21 |
| b. Nutritional care plan | 16 |
| c. Discussions with the nutritionist | 42 |
| d. Phone discussions with the nutritionist | 0 |
| e. Booklet about good sources of protein | 23 |
| 4. Did you participate in the group meeting? If so, what is your opinion of it? | |
| a. We did not participate | 46 |
| b. We participated and liked it. | 32 |
| c. We participated, but did not like it. | 7 |
| d. Other comments | 0 |
| 5. Do you think that participating was useful for you? | |
| a. No | 4 |
| b. We don’t know | 18 |
| c. Yes. If so, how? |
71 |
Maintaining the food diaries, which one couple find tiring, generated some negative feedback.
Discussion
We identified several positive elements in our intervention that promoted better nutrition. Beneficial elements of constructive feedback included a participant-centred approach, positive feedback, findings from the food diaries and practical suggestions. Home visits were convenient for participants and left them with the feeling that someone cares. Participants viewed group meetings positively for their socialising elements. In addition, group meetings strengthened the nutritional message and introduced participants to examples of protein-rich snacks. The use of ONSs helped some participants to regain their energy, and motivated them to exercise and make changes in their diets. The challenges our intervention faced included participants’ false ideas of nutrition, especially their concerns about weight gain. Participants suffered from health problems and functional limitations that hampered with their diets. Some families had inveterate eating habits. The positive feedback from participants indicated the feasibility of our tailored nutritional guidance.
Figure 1.
Key elements of the intervention that promoted improved nutrition, and challenges that hindered nutritional changes
An important aspect of our intervention was how we implemented our guidance. Besides the content, we also tailored the way we implemented it according to participants’ ability to absorb information. The intervention was a process that began with each couples’ own nutrition and living situation. We took advantage of constructive learning theory (35, 36) to view participants as active learners who were invited to present their own ideas and wishes. In addition, we made sure not to increase the caregivers’ stress levels by offering them advice on what they could not achieve at the moment. We applied Kolb’s reflective learning model (37) when participants received feedback and information on their diet along with an invitation to taste protein-rich snacks and ONS (active experimentation). They saw that these changes in their diet helped them to regain their energy and to exercise (concrete experience). Further, this convinced the participants that the new ideas they learnt actually work (reflective observation). This resulted in concrete learning (conceptualisation), which led to positive, long-term changes in their diet, such as the inclusion of protein-rich milk products.
Some nutritional interventions have used methods similar to ours, such as home visits (38, 39), nutritional care plans (20) and brochures (40). Home visits seemed to be a feasible way to carry out the intervention for these families because of the convenience. In addition, the personal contact among this group of people proved important, and a review of Bandarayel & Wong (41) concluded that nutrition interventions that involve active participation were promising. ONSs have been served mainly for weight among malnourished AD patients (14, 15, 16). However, we also used them to improve diet if changes proved impossible with food items. We were positively surprised that ONSs motivated our participants to exercise and, after raising their energy levels, to make changes in their diets also. Our guidance emphasised positive feedback. In contrast, before our intervention our participants had received mainly negative nutritional guidance, such as orders to lose weight and to avoid certain foods. Many participants were surprised by our positive approach. They became more interested in taking care of themselves, and were encouraged to discuss their nutrition more openly and to seek solutions to their nutritional problems.
The strength of this study is that we collected the detailed qualitative data from our field notes and the participants’ feedback about the process, feasibility and challenges of our intervention. Even when the nutritional challenges among AD families are well known (17), little information is available about how to manage these challenges and to implement tailored nutritional guidance. Our intervention with several home visits enabled us to observe these families pervasively and to acquire information that is difficult to obtain in the studies.
Our study also has several limitations. We analysed data from the nutritionist’s field notes and feedback questionnaires, but because the field notes came from by only one nutritionist, misconceptions may result. The authors, therefore, analysed the data separately and widely discussed the issues that arose. Our study participants were well-educated volunteers, interested in nutrition (25), and thus a good target group for nutritional intervention, as previous studies among older adults suggest (32, 38). Our study population was heterogeneous, however, and some couples faced multiple nutritional challenges; the number of these challenged couples may be underestimated in the real life situations. Our intervention was suitable for persons with severe AD, but with the caregivers.
The challenges that hindered nutritional changes were diverse, so the means to influence them varied. In some cases, such as those suffering from poor appetite or weight loss, we were able to use the ONS. Further, the use of brochures with pictures to teach participants to increase their protein intake and, later with practical suggestions succeeded. Changing participants’ attitudes that hindered nutritional changes, however, was not so simple. Rather than judge our participants, we supported them in their learning process with the discussions. If our suggestions were unsuitable, we found new ideas that were suitable for participants’ current daily living situation.
Conclusions
Assessment-based, tailored nutritional guidance that uses a personal, positive approach and learner-centred adult education may empower AD families to make positive changes in their diets, and thus lead them to improved nutrition and quality of life.
Conflict of interest: Puranen and Pitkala has no conflict of interest, Suominen has received lecture and conference fees from Nutricia Medical.
Etical standards: The Ethics Committee of the Helsinki University Central Hospital approved our study, and each participant provided his or her written informed consent.
References
- 1.Guerin O, Andrieu S, Schneider SM, Milano M, Boulahssass R, Brocker B, Vellas B. Different modes of weight loss in Alzheimer disease: a prospective study of 395 patients. Am J Clin Nutr. 2005;82:435–441. doi: 10.1093/ajcn.82.2.435. PubMed PMID: 16087990. [DOI] [PubMed] [Google Scholar]
- 2.Guigoz Y. The Mini Nutritional assessment (MNA®) review of the literature — what does it tell us. J Nutr Health Aging. 2006;10:466–485. PubMed PMID: 17183419. [PubMed] [Google Scholar]
- 3.Shatenstein B, Kergoat MJ, Reid I. Poor nutrient intakes during 1-year follow-up with community-dwelling older adults with early-stage Alzheimer dementia compared to cognitively intact matched controls. J Am Diet Assoc. 2007;107:2091–2099. doi: 10.1016/j.jada.2007.09.008. 10.1016/j.jada.2007.09.008 PubMed PMID: 18060894. [DOI] [PubMed] [Google Scholar]
- 4.Isaia G, Mondino S, Germinara C, Cappa G, Aimonido-Ricauda N, Bo M, Isaia GC, Nobili G, Massaia M. Malnutrition in an elderly demented population living at home. Arch Gerontol Geriatr. 2011;53:249–251. doi: 10.1016/j.archger.2010.12.015. 10.1016/j.archger.2010.12.015 PubMed PMID: 21236503. [DOI] [PubMed] [Google Scholar]
- 5.Rogue M, Salva A, Vellas B. Malnutrition in community-dwelling adults with dementia (Nutrialz trial) J Nutr Health Aging. 2013;4:295–299. doi: 10.1007/s12603-012-0401-9. 10.1007/s12603-012-0401-9 [DOI] [PubMed] [Google Scholar]
- 6.Rullier L, Lagarde A, Bouisson J, Bergua V, Barberger-Gateau P. Nutritional status of community-dwelling older people with dementia: associations with individual and family caregivers' characteristics. Int J Geriatr Psychiatry. 2013;28:580–588. doi: 10.1002/gps.3862. 10.1002/gps.3862 PubMed PMID: 22821728. [DOI] [PubMed] [Google Scholar]
- 7.White H, Pieper C, Schmader K. The association of weight change in Alzheimer's disease with severity of disease and mortality: a longitudinal analysis. J Am Geriatr Soc. 1998;46:1232–1234. doi: 10.1111/j.1532-5415.1998.tb04537.x. [DOI] [PubMed] [Google Scholar]
- 8.Lesourd B. Nutritional factors and immunological ageing. Proc Nutr Soc. 2006;65:319–325. doi: 10.1079/pns2006507. 10.1079/PNS2006507 PubMed PMID: 16923315. [DOI] [PubMed] [Google Scholar]
- 9.Morley JE, Argiles JM, Evans JW, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010;11:391–396. doi: 10.1016/j.jamda.2010.04.014. 10.1016/j.jamda.2010.04.014 PubMed PMID: 20627179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14:542–559. doi: 10.1016/j.jamda.2013.05.021. 10.1016/j.jamda.2013.05.021 PubMed PMID: 23867520. [DOI] [PubMed] [Google Scholar]
- 11.Salvà A, Andrieu S, Fernandez E, et al. Health and nutrition promotion program for patients with dementia (NutriAlz): cluster randomized trial. J Nutr Health Aging. 2011;15:822–830. doi: 10.1007/s12603-011-0363-3. 10.1007/s12603-011-0363-3 PubMed PMID: 22159768. [DOI] [PubMed] [Google Scholar]
- 12.de Sousa OLV, Amaral TF. Three-week nutritional supplementation effect on long term nutritional status of patients with mild Alzheimer disease. Am Dis Assoc Disord. 2012;26:119–123. doi: 10.1097/WAD.0b013e31822c5bb3. 10.1097/WAD.0b013e31822c5bb3 [DOI] [PubMed] [Google Scholar]
- 13.Rivière S, Gillette-Guyonnet S, Voisin T, Reynish E, Andrieu S, Lauque S, Salva A, Frisoni G, Nourhashemi F, Micas M, Vellas B. A nutritional education program could prevent weight loss and slow cognitive decline in Alzheimer´s disease. J Nutr Health Aging. 2001;5:295–299. PubMed PMID: 11753499. [PubMed] [Google Scholar]
- 14.Lauque S, Arnaud-Battandier F, Gillette S, Plaze JM, Andrieu S, Cantet C, Vellas B. Improvement of Weight and Fat-Free Mass with Oral Nutritional Supplementation in Patients with Alzheimer's Disease at Risk of Malnutrition: A Prospective Randomized Study. J Am Geriatr Soc. 2004;52:1702–1707. doi: 10.1111/j.1532-5415.2004.52464.x. 10.1111/j.1532-5415.2004.52464.x PubMed PMID: 15450048. [DOI] [PubMed] [Google Scholar]
- 15.Salas-Salvado J, Torres M, Planas M, Altimir S, Pagan C, Gonzales ME, Johnston S, Puiggros C, Bonada A, Garcia-Lorda P. Effect of oral administration of a whole formula diet on nutritional and cognitive status in patients with Alzheimer disease. Clin Nutr. 2005;24:390–397. doi: 10.1016/j.clnu.2004.12.006. 10.1016/j.clnu.2004.12.006 PubMed PMID: 15896425. [DOI] [PubMed] [Google Scholar]
- 16.Hanson LC, Ersek M, Gilliam R, Carey T. Oral Feeding Options for patients with Dementia: A systematic review. J Am Geriatric Soc. 2011;59:463–472. doi: 10.1111/j.1532-5415.2011.03320.x. 10.1111/j.1532-5415.2011.03320.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Silva P, Kergoat MJ, Shatenstein B. Challenges in managing the diet of older adults with early stage Alzheimer dementia: A caregiver perspective. J Nutr Health Aging. 2013;17:142–147. doi: 10.1007/s12603-012-0385-5. 10.1007/s12603-012-0385-5 PubMed PMID: 23364492. [DOI] [PubMed] [Google Scholar]
- 18.Bilotta C, Bergamaschini L, Arienti R, Spreafico S, Vergani C. Caregiver burden as a short time predictor of weight loss in older outpatients suffering from mild to moderate Alzheimer's disease: A thee months follow-up study. Aging and mental health. 2010;14:481–488. doi: 10.1080/13607860903586128. 10.1080/13607860903586128 PubMed PMID: 20455124. [DOI] [PubMed] [Google Scholar]
- 19.Puranen TM, Pietilä S, Pitkala KH, Kautiainen H, Raivio MM, Eloniemi-Sulkava U, Jyvakorpi SK, Suominen MH. Caregivers' male gender is associated with poor nutrient intake in AD families. J Nutr Health Aging. 2014:2014. doi: 10.1007/s12603-014-0499-z. [DOI] [PubMed] [Google Scholar]
- 20.Shatenstein B, Kergoat MJ, Reid I, Chicoine ME. Dietary intervention on older adults with early-stage Alzheimer dementia: early lessons learned. J Nutr Health Aging. 2008;12:461–469. doi: 10.1007/BF02982707. 10.1007/BF02982707 PubMed PMID: 18615228. [DOI] [PubMed] [Google Scholar]
- 21.Alfonso-Rosa RM, Del Pozo-Cruz B, Del Pozo-Cruz J, Del Pozo-Cruz JT, Sañudo B. The relationship between nutritional status, functional capacity, and health-related quality of life in older adults with type 2 diabetes: a pilot explanatory study. J Nutr Health Aging. 2013;17:315–321. doi: 10.1007/s12603-013-0028-5. 10.1007/s12603-013-0028-5 PubMed PMID: 23538652. [DOI] [PubMed] [Google Scholar]
- 22.Artacho R, Lujano C, Sanchez-Vico AB, Vargas Sánchez C, González Calvo J, Bouzas PR, Ruiz-López MD. Nutritional status in chronically-ill elderly patients. Is it related to quality of life. J Nutr Health Aging. 2014;18:192–197. doi: 10.1007/s12603-013-0385-0. 10.1007/s12603-013-0385-0 PubMed PMID: 24522473. [DOI] [PubMed] [Google Scholar]
- 23.Suominen MH, Puranen TM, Eloniemi-Sulkava U, Jyvakorpi SK, Kautiainen H, Pitkala KH. Tailored nutrition intervention improves nutrient intake and quality of life of aged persons with Alzheimer disease living at home with their spouses. A randomized, controlled trial. (submitted)
- 24.Jyvakorpi S, Puranen T, Pitkala KH, Suominen MH. Nutritional treatment of aged individuals with Alzheimer disease living at home with their spouses — a randomized controlled intervention trial. Trials. 2012;24:13–66. doi: 10.1186/1745-6215-13-66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Puranen TM, Jyvakorpi SK, Pitkala KH, Eloniemi-Sulkava U, Poysti MM, Suominen MH. Nutritional intervention of patients with Alzheimer's disease living at home with their spouse: A randomized controlled trial. Baseline findings and feasibility. J Aging Res Clin Practice. 2013;2:236–241. [Google Scholar]
- 26.Guigoz Y, Launque S, Vellas BJ. Identifying the elderly at risk for malnutrition the Mini Nutritional Assessment. Clin Geriatr. 2002;18:737–757. doi: 10.1016/s0749-0690(02)00059-9. 10.1016/S0749-0690(02)00059-9 [DOI] [PubMed] [Google Scholar]
- 27.Folstein MF, Folstein SE, Mchugh PR. ”Mini-mental-state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198. doi: 10.1016/0022-3956(75)90026-6. 10.1016/0022-3956(75)90026-6 PubMed PMID: 1202204. [DOI] [PubMed] [Google Scholar]
- 28.Zizza CA, Tayie FA, Lino M. Benefits of snacking in older Americans. J Am Diet Assoc. 2007;107:800–806. doi: 10.1016/j.jada.2007.02.002. 10.1016/j.jada.2007.02.002 PubMed PMID: 17467375. [DOI] [PubMed] [Google Scholar]
- 29.Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP, Henschkowski J. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. Br Med J Oct. 2009;1(339):3692. doi: 10.1136/bmj.b3692. 10.1136/bmj.b3692 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Pitkälä KH, Pöysti MM, Laakkonen ML, Tilvis RS, Savikko N, Kautiainen H, Strandberg TE. Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial. JAMA Intern Med. 2013;173:894–901. doi: 10.1001/jamainternmed.2013.359. 10.1001/jamainternmed.2013.359 PubMed PMID: 23589097. [DOI] [PubMed] [Google Scholar]
- 31.Laakkonen ML, Hölttä EH, Savikko N, Strandberg TE, Suominen M, Pitkälä KH. Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial. Trials. 2012;13:133. doi: 10.1186/1745-6215-13-133. 10.1186/1745-6215-13-133 PMCID 3492198; PubMed PMID: 22871107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Sahyoun NR, Pratt CA, Anderson A. Evaluation of nutrition education interventions for older adults: a proposed framework. J Am Diet Assoc. 2004;104:58–69. doi: 10.1016/j.jada.2003.10.013. 10.1016/j.jada.2003.10.013 PubMed PMID: 14702585. [DOI] [PubMed] [Google Scholar]
- 33.Birks M, Mills J. Grounded theory: a practical guide. Sage Publications; Thousand Oaks (Calif.): 2011. [Google Scholar]
- 34.Silverman D. Doing qualitative research. A practical handbook. 2000 [Google Scholar]
- 35.Spencer JA, Jordan RK. Learner centered approaches in medical education. Br Med J. 1999;318:1280–1283. doi: 10.1136/bmj.318.7193.1280. 10.1136/bmj.318.7193.1280 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Dolmans DH, De Grave W, Wolfhagen IH, van der Vleuten CP. Problem-based learning: future challenges for educational practice and research. Med Educ. 2005;39:732–741. doi: 10.1111/j.1365-2929.2005.02205.x. 10.1111/j.1365-2929.2005.02205.x PubMed PMID: 15960794. [DOI] [PubMed] [Google Scholar]
- 37.Kolb DA. Experimental learning. Experience as the source of learning and development. Prentice Hall Inc.; Englewood Cliffs NJ: 1984. [Google Scholar]
- 38.Pogge EK, Eddings L. Effect of a 12-week nutritional and wellness program in Independent living seniors. J Nutr Educ Behav. 2013;45:471–472. doi: 10.1016/j.jneb.2013.01.014. 10.1016/j.jneb.2013.01.014 PubMed PMID: 23478170. [DOI] [PubMed] [Google Scholar]
- 39.Bernstein MA, Nelson ME, Tucker KL, Layne J, Johnson E, Nuernberger A, Castaneda C, Judge J, Buchner D, Fiatarone Singh M. A home-based nutrition intervention to increase the consumption of fruit, vegetables, and calcium-rich foods in community dwelling elders. J Am Diet Assoc. 2002;102:1421–1422. doi: 10.1016/s0002-8223(02)90315-9. 10.1016/S0002-8223(02)90315-9 PubMed PMID: 12396159. [DOI] [PubMed] [Google Scholar]
- 40.Taylor-Davis S, Smiciklas-Wrigth H, Warland R, Achterberg C, Jensen G, Sayer A, Shannon B. Responses of older adults to theory-based nutrition newsletters. J Am Diet Assoc. 2000;100:656–664. doi: 10.1016/s0002-8223(00)00193-0. 10.1016/S0002-8223(00)00193-0 PubMed PMID: 10863568. [DOI] [PubMed] [Google Scholar]
- 41.Bandayrel K, Wong S. Systematic literature review of randomized control trials assessing the effectiveness of nutrition interventions in community dwelling older adults. J Nutr Behav. 2011;43:251–262. doi: 10.1016/j.jneb.2010.01.004. 10.1016/j.jneb.2010.01.004 [DOI] [PubMed] [Google Scholar]