Telehealth Intervention Improves Nutritional Care and Caregiver Well-Being in Dementia

Can Telehealth Revolutionize Nutritional Care in Dementia?

# Telehealth Intervention Shows Promise for Improving Nutrition in Dementia Care

A novel behavioral intervention designed to address mealtime challenges in persons with dementia (PWD) may offer benefits for both patients and their caregivers, according to a recent clinical trial. The study, conducted across six Respite Care Centers in the southeastern United States, evaluated the "Partners at Meals" (PAM) intervention, which uses a train-the-trainer approach to empower caregivers in managing mealtime behaviors and improving nutritional outcomes.

Dementia care presents significant challenges related to nutrition, as patients often experience declining abilities to prepare and consume appropriate foods. These challenges include difficulty preparing food safely, selecting suitable diets, consuming balanced meals, using utensils, and as the disease progresses, even recognizing hunger or accepting assistance with eating. Behavioral and cognitive dysfunction further complicate mealtime interactions, potentially leading to agitation, food refusal, and difficulty following mealtime routines. For informal family caregivers, these nutritional challenges add to an already demanding care burden, potentially affecting their own health and well-being. Approximately 30-50% of caregivers of persons with dementia experience negative health outcomes, including clinical depression, which can impact their ability to provide effective care.

How Was This Innovative Study Designed?

The cluster randomized controlled trial, registered as NCT#03622814, compared the PAM intervention to enhanced usual care (EUC) over a six-month period. The PAM intervention was grounded in the C3P (Change the Person, Change the People, Change the Place) model and implemented through respite care center volunteers who were trained to deliver evidence-based adaptive mealtime strategies via telehealth. The volunteers conducted virtual meetings with caregivers, reviewing feeding difficulties and jointly developing meal plans with adaptive strategies to facilitate the mealtime process and reinforce caregiving skills. Caregivers and volunteers were provided with tablets and data plans to support these virtual interactions throughout the study, with at least one virtual meeting per dyad observed by the research team to monitor fidelity and assess volunteer competency.

Eligible participants included persons with Alzheimer's disease or related dementias in mild to moderate stages (FAST score of 4 or greater), who attended a participating respite care center at least once weekly and exhibited mild dysfunctional behaviors during meals. Caregivers needed to reside with or near the PWD, provide at least four hours of care daily, assist with activities of daily living including meal preparation, and demonstrate competency in using tablet devices for telehealth visits and data entry. Exclusion criteria for PWD included wasting disorders, heart or renal failure, COPD, end-stage cancer, enteral feeding, active treatment by a speech pathologist, diagnosed dysphagia, or enrollment in hospice care.

The study enrolled 53 PWD-caregiver dyads, with 27 assigned to the PAM intervention group and 26 to the enhanced usual care control group. At baseline, PWD in the PAM group were older (81.0 ± 7.7 years vs. 73.9 ± 10.5 years) and had better hearing and vision compared to the EUC group, though cognitive impairment measured by MMSE was comparable between groups (12.6 ± 6.5 vs. 12.2 ± 6.7). Caregivers in the PAM group were also older (69.4 ± 10.8 years vs. 62.9 ± 12.2 years) and reported better baseline health status than those in the EUC group.

What Outcomes Did the Trial Reveal?

The primary outcomes assessed included changes in PWD body weight, mid-upper arm circumference (MUAC), caloric intake, mealtime behaviors, and quality of life, as well as caregiver depression, burden, and health-related quality of life. While no significant differences were observed in the unadjusted mean weight or percent change from baseline between the groups, some promising trends emerged in other nutritional indicators. PWD in the PAM group showed an increase in MUAC (1.0 ± 2.0 cm) while those in the EUC group experienced a slight decrease (-0.2 ± 2.2 cm), suggesting better maintenance of nutritional status, although this difference was not statistically significant.

Caloric intake patterns also showed interesting differences. At baseline, the EUC group consumed significantly more calories than the PAM group (1575 ± 90 kcal vs. 1207 ± 91 kcal, p=0.006). However, by the end of the study, while the EUC group showed a slight decrease in caloric intake, the PAM group demonstrated an increase of approximately 87 kcals from month 1 to month 6. Regarding mealtime behaviors, PWD in the PAM group showed a decrease in dysfunctional behaviors over the study period, whereas these behaviors increased in the EUC group.

Dysfunctional eating behaviors were measured using the Edinburgh Feeding in Dementia Scale (EdFED) with additional study-specific items (XL) developed by the researchers. Quality of life for PWD was assessed using the 13-item Alzheimer's Disease Quality of Life (QOL-AD) scale, which evaluates physical condition, mood, memory, functional abilities, interpersonal relationships, and participation in meaningful activities. For caregivers, depression was assessed with the 10-item Center for Epidemiological Studies-Depression scale (CES-D), burden with the 12-item Zarit Burden Scale, and quality of life with the European Quality of Life (Euro-QOL-5D).

Perhaps most notably, caregivers in the PAM intervention group reported consistently higher health-related quality of life scores throughout the study. After adjusting for relevant covariables, the mean Euro-Qol health state score among caregivers in the PAM group (81.2 ± 3.4) was significantly higher at study end compared to the EUC group (68.9 ± 3.7), indicating better general health state (p=0.014). This finding suggests that the support provided through the PAM intervention may have positively impacted caregivers' perceived well-being, even if other measures of depression and burden did not show significant differences.

How Did the Control Group Compare?

The study's control group received what the researchers termed "Enhanced Usual Care" (EUC), which included educational materials but no volunteer-facilitated intervention. Caregivers in the control group were provided with a tablet device, study manual containing basic health and nutrition information, and selected materials adapted from The Savvy Caregiver Program covering topics such as dementia caregiving strategies, self-care, communication, and managing challenging behaviors. These caregivers completed the same assessments and data uploads as the intervention group but did not receive the structured telehealth component.

What Are the Study's Limitations?

The researchers acknowledge several limitations, including the relatively small sample size, regional focus limiting generalizability, and challenges with recruitment during the COVID-19 pandemic. The study did not reach its targeted enrollment of 30 dyads per group due to persistent respite care center operational challenges during the pandemic. Additionally, the study did not account for the quality or quantity of nutritional supplements, and there may have been variability in volunteer training and implementation fidelity that could have influenced outcomes.

Despite these limitations, the findings suggest that the telehealth-delivered, volunteer-supported PAM intervention shows promise in improving nutritional outcomes for persons with dementia and enhancing quality of life for caregivers. The train-the-trainer model demonstrates the feasibility of leveraging respite care center volunteers to deliver evidence-based strategies in community settings, potentially extending the reach of interventions to support the growing population of dementia caregivers.

How Can These Findings Shape Future Practice?

These results raise important questions for future research and clinical practice. How might telehealth-based interventions be further optimized to address the specific needs of diverse caregiver populations? Could more objective measures of nutritional status help clarify the intervention's impact on PWD health outcomes? What modifications to the training approach might enhance volunteer effectiveness and intervention fidelity? As the prevalence of dementia continues to rise globally, innovative approaches like PAM that address both patient nutrition and caregiver well-being will be increasingly valuable components of comprehensive dementia care.

Summary

A cluster randomized controlled trial evaluated the "Partners at Meals" (PAM) intervention, a telehealth-delivered behavioral program designed to address mealtime challenges in persons with dementia. The study enrolled 53 patient-caregiver dyads across six respite care centers in the southeastern United States, comparing PAM to enhanced usual care over six months. The intervention used a train-the-trainer approach, with trained volunteers conducting virtual meetings with caregivers to develop adaptive mealtime strategies based on the C3P model. While no significant differences were observed in body weight changes, the PAM group showed trends toward better nutritional maintenance, with increased mid-upper arm circumference and caloric intake over the study period, alongside decreased dysfunctional mealtime behaviors. Most notably, caregivers in the PAM group reported significantly higher health-related quality of life scores compared to the control group, with adjusted mean Euro-Qol health state scores of 81.2 versus 68.9 at study end. The findings suggest that volunteer-supported telehealth interventions can feasibly deliver evidence-based nutritional strategies in community settings, potentially improving outcomes for both persons with dementia and their caregivers, though the study's limitations include small sample size and regional focus.