A 6 week feasibility study was conducted between October and early December 2017 in a nursing home for elderly with dementia in the North of the Netherlands. Two different group homes within the nursing home participated in this study with a pre-test post-test design, in which dose received, fidelity and appreciation were measured as indicators of feasibility (28,29). This study was exempted from METC approval by the METC-WU. Written informed consent was signed by family as legal guardians of participants in this study, since the mental state of the participants (elderly with advanced dementia) made them unable to provide appropriate informed consent.
Two group homes of one nursing home participated in this study. Patients living in these group homes were elderly with advanced dementia. Exclusion criteria for participation to the study were having a special diet or receiving enteral tube feeding which does not allow to eat fingerfoods, unable to eat solid food due to chewing and/or swallowing difficulties, and severe illness which makes consumption of fingerfoods impossible for ≥ 2 days. From all 16 patients living in the two group homes within the nursing home, 15 patients were included in the study after their family member signing informed consent.
Residents received all their meals from the nursing home including morning and afternoon snacks. In addition, during the intervention period fingerfoods were served daily around 4 pm as snacks, on top of their regular meals and snacks. The fingerfoods were provided by the general kitchen of the nursing home.
Before the start of the study, a wide array of different types of fruit and vegetable rich fingerfoods were pretested in a tasting session among the residents, including fresh fruit and vegetables presented, such as cherry tomatoes and paprika sticks, and fruit and vegetable rich baked goods. The fresh fruit and vegetable fingerfoods were poorly recognized by the residents and they often refused to taste them. Also, the kitchen staff indicated an unacceptable amount of preparation time related to fresh fruit and vegetables snacks. Another consideration to not continue with the fresh fruit and vegetables were the chewing and/or swallowing difficulties most residents had. The baked goods, however, were well accepted during the pretest despite their larger than normal amount of fruit and vegetables added. For the caregivers it was easy to offer the baked goods as it fit into the daily routine of the residents as they were used to receiving cake slices with their coffee and tea moments. Lastly, the baked goods fit with the residents’ increased preference for sweet. Therefore, we further developed and tested nutritious and fruit and vegetables rich baked goods in this study.
The researchers, dietician, and cooks of the nursing home developed four types of cake and three types quiche recipes based on the pretest; one type of fingerfood for each day of the week. The kitchen made these cakes and quiches in large batches and delivered them frozen to the group homes which improved cost efficiency and was compliant with the food safety regulation. To account for the chewing and/or swallowing difficulties the fingerfoods were free of nuts, bits and grits and large chunks of vegetables. The development and production the cost of the fingerfoods was €1,00 to €1,50 per piece during the pilot phase. The kitchen staff estimated to bring these prices down when embedding the process into a routine, using more seasonal ingredients and making larger batches.
To calculate nutritional contents of the fingerfoods, recipes of the seven types of fingerfoods were imported in the dietary assessment software Compl-eat (Version 1.0, Wageningen University, Wageningen) which is developed for the Dutch diet. Compl-eat is suitable for calculating nutritional contents based on food recipes: weights and amounts of ingredients can be imported and specific food characteristics, for example shrinkage of vegetables due to the cooking process can be taken into account. According to the calculations in Compl-eat, fruit and vegetable contents of all fingerfoods were around 50% (Table 1).
To ensure fidelity a clear serving protocol was provided as described in the intervention and showcased in plain view of all the caregivers. The serving protocol instructions were: the caregivers provide the fingerfoods daily in a piece of circa 5x5 cm for each resident, warmed in the oven and served on small plates. The warming in the oven was to give the sensory aspect of filling the group home with the smell of fresh baked cake or quiche. If the first piece was consumed without protest a second piece was to be offered. The caregivers were asked to encourage the consumption of the fingerfoods, but not emphasize the health aspects; the fingerfoods were promoted as ‘tasty snack’ instead as they resembled a slice of cake or quiche.
Dose received by the residents
Consumption of the fingerfoods
The caregivers were asked to record consumption of fingerfoods during the whole intervention period (every day of the week for six weeks long) using a checklist. On this checklist, caregivers could indicate how much of the offered fingerfoods was consumed by the resident (0, 0.5, 1, 1.5, 2 or more than 2 pieces) and provide optional remarks. All types of fingerfoods were weighed during both the first and last week of the intervention using a calibrated scale. The average of these measurements was used to indicate portion sizes. Based on the recipes and weight, nutritional contents were calculated using the dietary assessment software Compl-eat (Version 1.0, Wageningen University, Wageningen; 30).
Fruit and vegetable consumption and food intake during dinner
Three-day food diaries were completed by the researchers to measure nutritional intake between 2.00 and 8.00 pm before and at the end of the intervention period (t0 and t6), to assess fruit and vegetable consumption and compensation behaviour of total intake during dinner. The focus of this measurement was on the afternoon fruit snack, tea time biscuit and the main evening meal (served between 5.30 and 6.30 pm), since this was the only meal where possible compensation for the fingerfoods was expected. The residents were randomly divided over three independent weekdays, thus the food record was registered for three days at t0 and t6 per resident. From the food diaries, energy intake and total fruit and vegetable consumption in the afternoon and evening were calculated using the dietary assessment software Compl-eat (Version 1.0, Wageningen University, Wageningen; 30).
Fidelity and appreciation by the caregivers
During the intervention period a researcher was present one day of the week to observe introduction of the fingerfoods, collect forms and offer assistance. A feedback form was provided in week 6 of the intervention to caregivers who had been involved in the distribution of the fingerfoods. This feedback form consisted of three open questions (positive and negative experiences with serving the fingerfoods and remarks for improvement about the individual fingerfoods) and three multiple-choice questions: (1) How did you experience serving the fingerfoods (easy, same as a regular snack, difficult), (2) What kind of atmosphere was created by (the eating of) fingerfoods (restful, restless, unchanged) and (3) How much time did the serving of fingerfoods take (it took little time, similar time as a regular snack, it took more time than regular snacks but this was no problem, it took too much time).
Baseline information (gender, age, dementia type, use of psychotropic medication, and use of other medication) of the residents was derived from patient information files and recorded anonymously. Nutritional status was measured at baseline by means of the Short Nutritional Assessment Questionnaire for Residential Care (SNAQrc) (31), body weight, and body mass index (BMI). Body weight in kilograms was measured using a wheelchair scale. Body height was derived from patient information dossiers. BMI was calculated as weight (kg) divided by squared height (m) (32).
SPSS (version 22, IBM SPSS Statistics, NY, USA) was used to analyse all data and for all tests, statistical significance was set at P < 0.05. Background characteristics and outcome variables were analysed. Normally distributed continuous variables were presented as means and standard deviations, non-normally distributed variables were presented as medians and interquartile ranges (IQRs). Categorical variables were presented as numbers and percentages. The differences in consumption between the types of fingerfoods were assessed with paired t-tests. Besides, energy intake and fruit and vegetable consumption between 2.00 and 8.00 pm was compared at t0 and t6 with paired t-tests.