We appreciate Watson’s (2010) careful critique of the original review of instruments to assess behaviours that facilitate or inhibit an older adult’s ability to ingest food and fluids in various settings (Aselage 2010). The commentary clarified the history of nomenclature for the Edinburgh Feeding in Dementia (EdFED) scale, takes note of the limited number of scientists studying this problem, and the need for further testing of the scale as a direct observation tool and in other settings (Watson 2010). The manuscript on which Watson commented was written as part of the primary author’s doctoral coursework, prior to any personal use of the instrument.
When used in real-time observational research in a nursing home, one early insight was the need to define the frequency of observed behaviours; the researcher is given the option of three choices: often, sometimes and never with no direction as to what is meant by ‘sometimes’ and ‘often’ (Aselage 2010). For that study, the convention that was followed was if the behaviour was observed once during a meal, this would be scored as ‘sometimes’, and if the behaviour was seen more than once, this would be scored as ‘often’. Furthermore, if assessment data are gathered by proxy report from nursing staff or family caregivers, the issue of frequency of occurrence is raised and a convention needs to be adopted, such as more than once a week as ‘sometimes’ and every day as ‘often’. The other question arose as to the length of time to observe for these behaviours; often in observational research, a standard amount of minutes or seconds is prescribed that constitutes one observation (Phillips & Van Ort 1993). Having both of these parameters defined for the EdFED scale would be extremely helpful, so there is uniformity among observers and across studies.
Watson (2010) observed there is a ‘paucity of work by others in this field’. As our global population ages and increasing numbers of persons acquire the various forms of dementia, more caregivers and licence nursing staff will need objective ways to assess individual’s deficits and strengths so that proper management plans can be developed. The most effective clinical assessment would be one that could be used by a number of disciplines (e.g. nursing, speech pathology, dietetics) so that a comprehensive plan of care could be derived that allows a unified approach to the issues encountered at meals, which are not the domain of any one discipline. Ideally, this instrument could also be validated across settings as older adults with dementia are increasingly being managed for longer times in the home by family caregivers and in community day service programmes (Alzheimer’s Association 2011). When those individuals are hospitalised, they need even greater attention to deficits resulting from acute episodic or severe chronic illness, and for which nutritional compromise can lead to further complications. Having an instrument that is valid in acute care that then could be used other settings would be very helpful, especially with the realisation of the need for transitional care models for cognitively impaired older adults.
Finally, Watson (2010) also notes that an ecological model would be helpful in assessing mealtime, eating and feeding issues. Since Kayser-Jones (1981) seminal work 30 years ago comparing Scottish and US nursing homes, there has been a realisation that outcomes related to positive ageing are strongly influenced by caregivers and the environment in which care is given. Inclusion of the behaviours of both the caregiver toward the individual with dementia and the setting in which care is given – whether a noisy nursing unit or in a home in which there is much distraction – would generate a more comprehensive assessment that could highlight areas that might enhance individual performance.