Nutrition has long been recognized as a key element in promoting good health and recovery from illness across the lifespan; this is especially true as an individual ages.  However, the process of eating and the entire ritual of meals, which together are largely culturally determined, are given little attention when nutritional problems are identified.  This is especially notable in a time when interest in food and its presentation has become a national craze, with many claiming to be "foodies" and chefs raised to the status of media stars.  However, in institutions, restrictive diets are sometimes barely palatable, the eating environment ranges from a cluttered hospital room to a large, noisy dining room, and staff treat the meal as a task to complete rather than a process to enjoy.  

Nursing Standard of Practice Protocol: Assessment and Management of Mealtime Difficulties

Elaine J. Amella, PhD, APRN, BC, FAAN and Melissa B. Aselage, MSN, RN-BC, FNP-BC

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:

Parameters of Assessment
Nursing Interventions
Evaluation/Expected Outcomes
Follow-up Monitoring


To maintain or improve nutritional intake at meals and provide a quality mealtime experience that fosters dignity and pleasure in eating, as well as respecting cultural and personal preferences, for as long as possible.


Guiding Principles

  1. The adequate intake of nutrients is necessary to maintain physical and emotional health.
  2. Mealtime is not only an opportunity to ingest nutrients but also to maintain physical and emotional health.
  3. The social components of meals will be observed, including mealtime rituals, cultural norms, and food preferences.
  4. Persons will be encouraged and assisted to self-feed for as long as possible.
  5. Persons dependent in eating will be assisted with dignity.
  6. End-of-life decisions by the individual or his or her proxy regarding the provision or termination of food and fluid will be respected.
  7. The quality of mealtime is an indicator of quality of life and care of an individual.
  1. Definitions
    1. Feeding is "the process of getting the food from the plate to the mouth. It is a primitive sense without concern for social niceties" 1
    2. Eating is "the ability to transfer food from plate to stomach through the mouth" 1. Eating involves the ability to recognize food, the ability to transfer food to the mouth, and the phases of swallowing.
    3. Anorexia is characterized by a refusal to maintain a minimally normal body weight, and has a physiological basis in the older adults. (Ref 2)
    4. Dehydration is "a fluid imbalance caused by too little fluid taken in or too much fluid lost or both."
    5. Dysphagia is "an abnormality in the transfer of a bolus from the mouth to the stomach." (Ref 3)
    6. Apraxia is an inability to carry out voluntary muscular activities related to neuromuscular damage. As it relates to eating and feeding, it involves loss of the voluntary stages of swallowing or the manipulation of eating utensils.
    7. Agnosia is the inability to recognize familiar items when sensory cuing is limited.
  2. Etiology

Mealtime difficulties can have multiple causes from both physiological and psychological origins. Health professionals need to consider multiple etiologies and not assume that difficulties are related only to increased confusion from a cognitive decline.

    1. Cognitive/neurological: Parkinson's disease; amyotrophic lateral sclerosis; dementia, especially Alzheimer's disease; stroke
    2. Psychological: depression
    3. Iatrogenic: lack of adaptive equipment; use of physical restraints that limit ability to move, position, or self-feed; improper chair or table surface or discrepancy of chair to table height; use of wheelchair in lieu of table chair; use of disposable dinnerware, especially for patients with cognitive or neuromuscular impairments

Parameters of Assessment
  1. Assessment of Older Adult and Caregivers
    1. Rituals used before meals (e.g., handwashing and toilet use); dressing for dinner.
    2. Blessings of food or grace, if appropriate.
    3. Religious rites or prohibitions observed in preparation of food or before meal begins (e.g., Muslim, Jewish, and Seventh-Day Adventist; consult with pastoral counselor, if available).
    4. Cultural or special cues: family history, especially rituals surrounding meals.
    5. Preferences as to end-of-life decisions regarding withdrawal or administration of food and fluid in the face of incapacity, or request of designated health proxy; ethicist or social worker may facilitate process.
  2. Assessment Instruments:
    1. EdFED-Q for persons with moderate to late-stage dementia. (Ref 4)
    2. Katz Index of ADL for functional status. 1
    3. Food diary/meal portion method. (Ref 5)
Nursing Interventions
  1. Environment
    1. Dining or patient room: encourage older adult to eat in dining room to increase intake, personalize dining room, no treatments or other activities occurring during meals, no distractions.
    2. Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer, flatware, tablecloth, napkin) versus disposable tableware and bibs.
    3. Furniture: older adult seated in stable arm chair; table-appropriate height versus eating in wheelchair or in bed.
    4. Noise level: environmental noise from music, caregivers, and television is minimal; personal conversation between patient and caregiver is encouraged.
    5. Music: pleasant, preferred by patient.
    6. Light: adequate and nonglare-producing versus dark, shadowy, or glaring.
    7. Contrasting background/foreground: use contrasting background and foreground colors with minimal design to aid persons with decreased vision.
    8. Odor: food prepared in area adjacent to or in dining area to stimulate appetite.
    9. Adaptive equipment: available, appropriate, and clean; caregivers and/or older adult knowledgeable in use; occupational therapist assists in evaluation.
  2. Caregiver/Staffing
    1. Provide an adequate number of well-trained staff.
    2. Deliver an individualized approach to meals including choice of food, tempo of assistance.
    3. Position of caregiver relative to elder: eye contact; seating so caregiver faces elder patient in same plane.
    4. Cueing: caregiver cues elder whenever possible with words or gestures.
    5. Self-feeding: encouragement to self-feed with multiple methods versus assisted feeding to minimize time.
    6. Mealtime rounds: interdisciplinary team to examine multifaceted process of meal service, environment, and individual preferences.
Evaluation/Expected Outcomes
  1. Individual
    1. Corrective and supportive strategies reflected in plan of care.
    2. Quality of life issues emphasized in maintaining social aspects of dining.
    3. Culture, personal preferences, and end-of-life decisions regarding nutrition respected.
  2. Health Care Provider
    1. System disruptions at mealtimes minimized.
    2. Family and staff informed and educated to patient's special needs to promote safe and effective meals.
    3. Maintenance of normal meals and adequate intake for the patient reflected in care plan.
    4. Competence in diet assessment; knowledge of and sensitivity to cultural norms and preferences for mealtimes reflected in care plan.
  3. Institution
    1. Documentation of nutritional status and eating and feeding behavior meets expected standard.
    2. Alterations in nutritional status, eating and feeding behaviors assessed and addressed in a timely manner.
    3. Involvement of interdisciplinary team (geriatrician, advanced practice nurse [NP/CNS], dietitian, speech therapist, dentist, occupational therapist, social worker, pastoral counselor, ethicist) appropriate and timely.
    4. Nutritional, eating, and/or feeding problems modified to respect individual preferences and cultural norms.
    5. Adequate number of well-trained staff who are committed to delivering knowledgeable and individualized care.
Follow-up Monitoring
  1. Providers' competency to monitor eating and feeding behaviors.
  2. Documentation of eating and feeding behaviors.
  3. Documentation of care strategies and follow-up of alterations in nutritional status and eating and feeding behaviors.
  4. Documentation of staffing and staff education; availability of supportive interdisciplinary team.

From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.


1. Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development of the Index of ADL. The Gerontologist, 10(1), 20–30. Evidence Level IV: Quasi-experimental Study.

2. Wilson, M.M. (2007). Assessment of appetite and weight loss syndromes in nursing home residents. Missouri Medicine, 104(1), 46-51. Evidence Level VI.

3. Groher, M. E. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston: Butterworth-Heinemann.

4. Watson, R. (1996). The Mokken Scaling Procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia. International Journal of Nursing Studies, 33, 385–393. Evidence Level III: Quasi-experimental Study.

5. Berrut, G., Favreau, A. M., Dizo, E., Tharreau, B., Poupin, C., & Gueringuili, M. (2002). Estimation of calorie and protein intake in aged patients: Validation of a method based on meal portions consumed. Journals of Gerontology: Medical Science, 57(1), M52–M56. Evidence Level III: Quasi-experimental Study.

Last updated - July 2012

Journal Articles

Althus, D. E., Engelman, K. K., & Mathews, R. M. (2002). Using family-style dining to increase participation and communication in person with dementia. Journal of Gerontological Nursing, 28(9), 47-53.

Amella, E. J. (in press). Feeding and hydration issues for older adults with dementia. Nursing Clinics of North America.

Bennett, J. A., Thomas, V., & Riegel B. (in press). Chronic dehydration is common in elders who visit the emergency department. Journal of Gerontological Nursing.

Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development of the Index of ADL. The Gerontologist, 10, 22.

Kayser-Jones, J. (2002). Malnutrition, dehydration and starvation in the midst of plenty: The political impact of qualitative inquiry. Qualitative Health Research, 12,1391-1405.

Mathys, M. L., & Finin, M. L. (2002). Treatment of obesity in the elderly patient.Clinical Geriatrics, 10(7), 44-50.

Mentes, J. C., & Iowa-Veterans Affairs Research Consortium. (2000). Hydration management protocol. Journal of Gerontological Nursing, 26(10), 6-15.

Mitchell, S. L., Teno, J. M., Roy, J., Kabumoto, G., & Mor, V. (2003). Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. Journal of the American Medical Association, 290, 73-80.

Morley, J. B. (2002). Pathophysiology of anorexia. Clinics of Geriatric Medicine,18, 661-673.

Siebens, H., Trupe, E., Siebens, A., Cook, F., Anshen, S., Hanauer, R., & Oster, G. (1986). Correlates and consequences of eating dependency in institutionalized elderly. Journal of the American Geriatrics Society, 34, 193.

White, J., Ham, R., & Lipschitz, D. (1991). Consensus of the Nutrition Screening Initiative: Risk factors and indicators of poor nutritional status in older Americans. Journal of the American Dietetic Association, 91, 783-787.

Zembruski, C. D. (1997). A three-dimensional approach to hydration of elders: Administration, clinical staff, and in-service education. Geriatric Nursing, 18(1), 20-26.

Last updated - January 2005