TrEat: Supporting community-dwelling people with dementia to maintain a healthy diet: development and evaluation of a multidisciplinary intervention to prevent and treat undernutrition.

The Dutch Health Council estimated that approximately 20.000 Dutch community-dwelling persons with dementia (CD-PwD) are undernourished. Undernourished CD-PwD are found to decline faster, are more prone to other diseases and more often admitted to a hospital or nursing home. The estimated costs related to undernutrition in Dutch CD-PwD were over 10 million Euros in 2009. Difficulties in eating and drinking and related tasks such as doing groceries and preparing a meal (nutrition related difficulties; NRD) are common in CD-PwD and can lead to insufficient food intake and undernutrition. The causes are multifactorial and relate to practical (e.g. inability to cook), nutritional (e.g. appetite loss) and psychosocial aspects (e.g. eating alone or together). Current (dietary) guidelines are not dementia specific and lack guidance about how to deal with these multifactorial causes of NRD in CD-PwD. Recent systematic reviews show that there is a serious lack of studies investigating interventions aimed at NRD in CD-PwD or studies describing a multidisciplinary approach although combining dietary treatment with occupational therapy as a strategy to treat both nutritional and practical problems is recommended by the Alzheimer’s Disease International. The Radboud Alzheimer Center has developed an evidence-based occupational therapy intervention that supports CD-PwD in the self-management of practical difficulties in everyday life (COTiD). The aim of this project is to develop and evaluate an intervention for NRD in CD-PwD that combines the best evidence and practice from dietetics with this occupational therapy intervention. This includes addressing psychosocial aspects of eating and drinking and promoting the self-management and self-reliance of CD-PwD. As these are the essence of the new concept of positive health, combining the 6 aspects of positive health with the best evidence and practice from occupational therapy and dietetics could be a possible effective method to treat NRD in CD-PwD. As such, NRD would not only be approached from the aspect of physical functioning (the body needs nutrients) but also from the aspects of giving meaning, quality of life, social and societal participation, daily functioning, and mental functions and perception. This project is the first step in developing such a multidisciplinary intervention. Within the projects time frame the objectives are: - To develop a theoretical framework including best evidence and key elements from occupational therapy, dietetics and the concept of positive health. - To develop a draft guideline/protocol based that offers a diagnostic tool, guidance and directions about tailoring support and interventions and monitoring outcomes for NRD in CD-PwD. - To identify the characteristics of CD-PwD and informal carers that influence successful application of intervention elements. - To identify barriers and facilitators for implementing intervention elements into dementia care practice. We hypothesize that the multidisciplinary intervention is efficacious in supporting CD-PwD and their carers in the (self-)management of NRD and results in more CD-PwD meeting protein and energy needs, less decrease of weight in CD-PwD, lower risk of undernutrition, better self-management skills, better quality of life of CD-PwD and informal carers, decreased burden of informal carers. We do not in- or exclude specific subgroups of CD-PwD on beforehand but decide about the exact intervention outcomes and target groups as part of the process of development. The multidisciplinary intervention is both a complex and psychosocial intervention in dementia care. As method of its development we will use the MRC-framework for developing complex interventions and incorporate factors related to implementation in an early phase as suggested for the development of psychosocial dementia care interventions. The project’s duration is 48 months, within this time frame we go through the developmental and feasibility/piloting stages of the framework. The results should provide sufficient input for writing a protocol for the conduct of an explanatory trial, which would be the first step of the evaluation stage after completion of this project. Our project team includes the Malnutrition Steering Group, dietitians, occupational therapists, a home care organization, a hospital, HAN University of Applied Science, and researchers and implementation scientists from Radboudumc. They will share their expertise and collaborate with each other within this project. Furthermore, CD-PwD and their informal carers will participate in meetings, focus groups and interviews to gain insights in their needs, wishes and expectations regarding the multidisciplinary intervention. During and after this project, project partners contribute to inform care professionals, CD-PwD and their carers, the scienfitic field and students about the findings, results and possible effective intervention tools.