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BMC Health Serv Res. 2019 Oct 30;19(1):775. doi: 10.1186/s12913-019-4667-z.

A path analysis on the direct and indirect effects of the unit environment on eating dependence among cognitively impaired nursing home residents.

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Department of Medical Sciences, Udine University, Viale Ungheria, 20, 33100, Udine, Italy.
Department of Economics and Statistics, Udine University, Via Francesco Tomadini, 30, 33100, Udine, Italy.
Department of Medical Sciences, Udine University, Viale Ungheria, 20, 33100, Udine, Italy.
Faculty of Health Sciences, Hull University, Hull, HU6 7RX, UK.



This study aims to estimate the direct and indirect effects of the unit environment alongside individual and nursing care variables on eating dependence among residents who are cognitively impaired and living in a nursing home.


A multicentre observational study was carried out in 2017: 13 Italian nursing homes were involved in data collection. Included residents were aged > 65 at baseline, living in the considered facility for the last 6 months and during the entire study period and having received at least one comprehensive assessment. Data were collected (a) at the individual level: eating dependence using the Edinburgh Feeding Evaluation in Dementia Scale and other clinical variables; (b) at the nursing care level with daily interventions to maintain eating independence assessed with a checklist; and (c) at the nursing home level, using the Therapeutic Environment Screening Survey for Nursing Homes.


One thousand twenty-seven residents were included with an average age of 85.32 years old (95% CI: 84.74-85.89), mainly female (781; 76%). The path analysis explained the 57.7% variance in eating dependence. Factors preventing eating dependence were: (a) at the individual level, increased functional dependence measured with the Barthel Index (β - 2.374); eating in the dining room surrounded by residents (β - 1.802) as compared to eating alone in bed; and having a close relationship with family relatives (β - 0.854), (b) at the nursing care level, the increased number of interventions aimed at promoting independence (β - 0.524); and (c) at the NH level, high scores in 'Space setting' (β - 4.446), 'Safety' (β - 3.053), 'Lighting' (β - 2.848) and 'Outdoor access' (β - 1.225). However, environmental factors at the unit level were found to have also indirect effects by influencing the degree of functional dependence, the occurrence of night restlessness and the number of daily interventions performed by the nursing staff.


Eating dependence is a complex phenomenon requiring interventions targeting individual, nursing care, and environmental levels. The NH environment had the largest direct and indirect effect on residents' eating dependence, thus suggesting that at this level appropriate interventions should be designed and implemented.


Cognitive decline; Dementia; Eating dependence; Feeding difficulties; Mealtime difficulties; Nursing home; Path analysis

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