Eating is a basic self-care activity that individuals perform in daily life for their physiological needs, and it is also psychosocially critical as a source of pleasure and enjoyment of food as well as an opportunity for social interactions.1,2 Eating ability is defined as the functional performance and capability to get food and drinks into the mouth.1,3 Mealtime behaviors are defined as verbal or nonverbal ways in which individuals express their emotions, communicate their unmet wants and needs, and/or respond to care or other stimuli during a meal. These behaviors can be positive, neutral, and challenging.1,3 Positive mealtime behaviors refer to expressions indicating help-seeking, collaboration, reception, approval, interest, attention, engagement, enjoyment, and eating independence.3, 4, 5 Challenging mealtime behaviors refer to expressions indicating distraction, disengagement, rejection, aggression, and/or disturbance during meals that communicate the need for additional care.3, 4, 5 Neutral behaviors are other expressions such as passivity or under-responsiveness to food or care, and may be deemed as either positive or negative, contingent upon contexts.3, 4, 5

Persons living with dementia (PLWD), particularly those in the mid to late stages, commonly experience decline in eating ability and changes in mealtime behaviors, resulting from decline in physical and cognitive functions, psychological states including anxiety or depression, and inadequate caregiver interactions and environmental support.6,7 The prevalence of decline in eating ability and challenging mealtime behaviors is nearly six times greater in people with advanced dementia compared to people with mild dementia.1,8 PLWD experiencing decline in eating ability and challenging mealtime behaviors have difficulties in recognizing, initiating, and/or manipulating food without assistance or exhibit a lack of attention to eating or other behavioral symptoms including resistive behaviors, pacing, forgetting to eat, wandering, and apathy. These behaviors need more attention for appropriate assessments and further assistance.7,9 Prior studies reported that 32 to 45% of PLWD in long-term care communities required partial to full mealtime assistance from care staff.1,10,11 PLWD who do not receive adequate and quality assistance may experience reduced oral intake, weight loss, poor nutritional status.12,13 The consequences of a decline in eating ability and challenging mealtime behaviors of PLWD include an increased risk of physical frailty, falls, hospitalization and mortality, low quality of life and more stress for both PLWD and caregivers, and higher care costs.7,13, 14, 15, 16

Eating ability and mealtime behaviors of PLWD are critical indicators of functional performance and behavioral symptoms as well as outcomes of interest that mealtime interventions are aimed to optimize in dementia care research and practice. Using psychometrically robust instruments to assess eating ability and mealtime behaviors will minimize measurement bias and contribute to the development and accurate evaluation of tailored mealtime care strategies.17 Despite the availability of a number of instruments assessing eating ability and mealtime behaviors, the characteristics and psychometric quality of these instruments have not been synthesized and assessed to date. Therefore, this systematic review aimed to synthesize the characteristics and psychometric quality of existing instruments designed and/or used to assess eating ability and/or mealtime behaviors of PLWD.