FAGFELLEVURDERT

MALNUTRITION AMONG PATIENTS IN NURSING HOMES

Malnutrition among patients in nursing homes and its association with dementia

TEKST Rosanna Echano Major, RNa, Maria Krogseth, MD, PhD b,c,d. a Tjølling Nursing Home, Municipality of , b Oslo Delirium Research Group, Geriatric Department, . Norway. c Old Age Psychiatry Research Network, and Hospital Trust, 3710 Skien, Norway. d University of South-Eastern Norway.

Abstract Aim: To reveal the prevalence of malnutrition of risk for malnutrition was 68%, 28% and 35% among patients in nursing facilities using the scree- using MNA, MUST and NJ respectively. Using three ning tools Mini Nutritional Assessment (MNA), categories, the prevalence of high risk for malnutri- Malnutrition Universal Screening Tool (MUST), tion was 13%, 11% and 16% using MNA, MUST, and Nutritional Journal (NJ). The agreement bet- and NJ respectively. There was a positive associa- ween the tools, and the correlation between mal- tion between dementia severity and worse nutritio- nutrition and severity of dementia, were explored. nal status using MNA (p<0.001). This association was not significant using NJ (p=0.223), nor MUST Methods: 97 patients living in nursing facilities were (p=0.303). included. The patients’ nutritional status was assessed using MNA, MUST, and NJ. Severity of dementia was Conclusion: The prevalence of malnutrition among determined using Clinical Dementia Rating Scale patients living in nursing facilities varies according (CDR). to screening tool applied, and how the result is pre- sented. Risk of malnutrition increases parallel to the Result: When classifying patients’ nutritional status severity of dementia regardless of the screening into two categories (normal vs. risk), the prevalence tool, but intensity is more apparent with MNA.

14 Malnutrition among patients in nursing homes

Introduction tion is associated with dementia as alternative tools (12, 13). Malnutrition or undernutrition (1) severity (8). However, there is also Despite the recognized impor- refers to a lack of intake or uptake of evidence that obesity exists among tance of malnutrition among patients nutrition leading to altered body patients with dementia (9). Today, living in nursing institutions, only a composition and body cell mass. Its more than 70 000 people in Nor- limited number of studies present consequence is diminished physical way are living with dementia (10). updated statistics on nutritional sta- and mental function, and impaired Most of these patients are old and tus among patients with dementia in clinical outcome from diseases (2). suffer from multiple diseases. In Norwegian nursing facilities. Previo- Older people are prone to malnutri- nursing homes, about 80% of the usly presented prevalence estimates tion due to both biological aging patients suffer from dementia (11). of malnutrition in this setting vary (3), and to chronic conditions asso- The Norwegian Directorate of from 33 to 69% depending on nutri- ciated with malnutrition such as Health, through the National Pro- tional screening tool used and group lung and heart diseases, gastrointe- fessional Guidelines for Prevention studied (14-16). stinal disorders, dental and oral pro- and Treatment of Malnutrition, Accordingly, the aim of our blems, polypharmacy, depression, recommends that all patients admit- study was to present the prevalence and dementia (4). Malnutrition has ted to health facilities, should of malnutrition among patients always been the focus among old undergo nutritional screening upon living in nursing facilities using the patients, although obesity also admission and regularly thereafter three commonly used nutritional occurs in this age group (5). Over- (12). The guideline recommends screening tools MNA, MUST, and weight and obesity are defined as several nutritional screening tools. NJ. We also explored the agree- abnormal or excessive fat accumula- For older patients, the tools Mini ment between these three instru- tion that may impair health (2). Nutritional Assessment (MNA) and ments, as well as whether the People with dementia are parti- the Malnutrition Universal Scree- prevalence of malnutrition varied cularly vulnerable to malnutrition ning Tool (MUST) are recommen- with severity of dementia. due to a variety of reasons such as ded. The Nutritional Journal (NJ)1, difficulty in procurement and pre- Subjective Global Assessment Methods paration of food, feeding difficulties, (SGA), and Nutritional Risk Scree- Population / Sample increased Figurerisk of infections1: Patient (6), flow and illustrating ning (NRS-2002) patient inclusion. are recommended Using a cross-sectional design, we changes in appetite (7). Previous included patients living in nursing CRPD (Communal residences for people with dementia) studies have found that malnutri- homes and communal residences 1 Ernæringsjournal

Figure 1. Patient flow illustrating patient inclusion

CRPD (Communal residences for people with dementia)

Nursing home in Larvik CRPD in Larvik Nursing home in CRPD in Sandefjord

n=16 n=25 n=25 n=48

Short term residents, n=4 Short term residents, n=3 Physical restlessness, n=1 Acute illness, n=1

No height measurement, n=2 Incomplete data, n=3

Patients included

n=97

15

Malnutrition among patients in nursing homes

for people with dementia, collecti- NJ. Weight, height, and circumfe- from the sum of these scores. A vely termed nursing facilities. Inclu- rence of arm and leg, measured total added score of 0 indicates low sion was conducted from December within the last four weeks before risk, 1 indicates medium risk, and 2016 to March 2017, and took place the registration was used. Weight 2 indicate high risk. in the two adjacent municipalities of was measured using weighing NJ identifies the patient’s BMI and Sandefjord and Larvik, Norway. chair. Height was measured with weight changes over time, as well as Inclusion criteria were perma- the patient in standing or lying other nutritionally related data such nent residence or three months position. Height measurement as decrease in appetite, dental pro- continuous residence in one or from medical record was used if blems, chewing or swallowing pro- more nursing facilities. Patients height measurement was difficult. blems, sore or dry mouth, nausea were included regardless of age. The original form of the MNA and vomiting, diarrhoea or constipa- Patients with short-term resi- with 18 parameters was used in this tion, oedema, grabbing or movement dence, patients who were acutely ill, study. MNA assesses patients’ weight problem, independence during patients who did not cooperate changes over time, body mass index mealtime, and vision. The assess- when measuring height and weight, (BMI) measured as kg/m2, mobility, ment is graded as good nutritional and patients who had missing and possible neuropsychological status, risk of malnutrition, and height measurement, were exclu- disorders. It also provides informa- severe malnutrition (19) ded. The sample size was determi- tion about the patient’s living situat- ned by practical considerations. ion, number of regular medications, Dementia Diagnosis and presence of wounds or skin sores, Severity Data collection number of meals daily, daily con- Dementia diagnoses registered in Nurses responsible for the regular sumption of nutrients and fluids, the patients’ medical records were care of the patients performed all independence during mealtime, used. No direct cognitive assess- measurements in which direct con- and a measurement of mid-arm and ment or diagnostic process was tact with the patients were necessary. calf circumference. The maximum done during the registration. All data were then collected by the score is 30, whereas a score less than Severity of dementia was deter- primary investigator (RM) through a 17 indicate malnutrition, 17 to 23,5 mined using the CDR (20). The series of interviews with the nurses indicate a risk of malnutrition, and a CDR assesses the patients’ memory, who performed the measurements. score from 24 to 30 indicate normal orientation, judgment, social acti- The registration forms, MNA, MUST, nutritional status. MNA also inclu- vity, home and leisure interests, NJ, Clinical Dementia Rating Scale des two questions were the patients and ability to care for oneself. The (CDR), and demographic data were are asked about their own health patients were categorized using the completed during the interviews. status compared to others, and their following scale: 0 = no dementia, self-view of nutritional status (17). 0.5 = uncertain, 1 = mild, 2 = Demographic data Regarding these two questions the moderate, and 3 = severe dementia. The patients’ age, gender, and length nurses, after discussing with other of stay in the institutions, were regis- caregivers, had to answer for those Ethical considerations tered. To avoid direct identification patients unable to speak for them- The project was submitted to the of the patients, their exact age was selves due to lack of language or Norwegian Center for Research not recorded. Age was divided in severe dementia. Data (NSD). Informed consent was eight categories: less than 65 years, MUST is a screening tool prima- not required as mapping of nutritio- 65-70 years, 71-75 years, 76-80 rily developed to identify malnutri- nal status is included in the routine years, 81-85 years, 86-90 years, tion in acute settings, and to help care in Norwegian nursing homes. 91-95 years, and more than 95 years. draw up an action plan for persons All data was registered anonymo- who are undernourished (18). The usly as required by the NSD. Health Screening of Nutritional screening follows three steps where personnel working in the nursing Status patients' BMI, weight loss over the facilities carried out all anthropo- To evaluate the nutritional status of last three to six months, and possi- metric measurements. Exact age, the participants comprehensively, ble acute illness is registered. Each name, and date of birth were not three nutritional screening forms item is given a score of 0 to 2, and given. The researcher did not have were utilized: MNA, MUST, and the risk of malnutrition is given access to patients’ records nor have

16 Malnutrition among patients in nursing homes

Table 1. Description of the participants, n=97.

Age in years n (%)

< 65 2 (2.1)

65-70 0 (0.0)

71-75 8 (8.2)

76-80 9 (9.3)

81-85 19 (19.6)

86-90 31 (32.0)

90-95 22 (22.7)

>95, 6 (6.2)

Female, Number of months in institution, mean (SD)* 77 (79.4) 26.0 (20.2)

Body Mass Index (kg/m2)

<20 21 (21.6)

20-24.9 29 (29.9)

25-29.9 31 (32.0)

≥30 16 (16.5) Dementia Diagnosis

Alzheimer’s Disease 18 (18.6)

Vascular dementia 5 (5.2)

Lewy Body dementia 1 (1.0)

Mixed Type dementia 4 (4.1)

Other Types of dementia 1 (1.0)

Dementia, no subtype 45 (46.4)

No dementia diagnosis 23 (23.7) Dementia Severity Using CDR

No dementia 14 (14.4)

Mild Dementia 20 (20.6)

Moderate Dementia 32 (33.0)

Severe Dementia 31 (32.0)

*Number of months are given as mean (SD) SD=standard deviation CDR=Clinical Dementia Rating Scale

direct contact with the patients NY: IBM Corp. MNA, MUST, and NJ classify during data entry. Descriptive analyses of the parti- the patients into three risk cate- cipants were done initially. By visual gories that we labelled low risk Statistical Analysis inspection of a histogram and a nor- (MNA= normal, NJ= good, MUST= All statistical analysis was perfor- mal Q-Q plot, all continuous data low risk), medium risk (MNA= at med using IBM SPSS Statistics for were normally distributed and the- risk, NJ= risk, MUST= medium Windows, Version 24.0. Armonk, refore presented as mean ± SD. risk), and high risk (MNA= mal-

17 Malnutrition among patients in nursing homes

Table 2: Classification of nutritional status using MNA, MUST, and NJ. Values refer to number of participants.

MNA MUST Nutritional Tools Nutritional Status Good At risk Good At risk

Good 28 42 N/A N/A MUST At risk 3 24 N/A N/A

Good 26 37 59 4 NJ At risk 5 29 11 23

MNA= Mini Nutritional Assessment MUST= Malnutrition Universal Screening Tool NJ= Nutritional Journal

Agreement between MNA and MUST: Kappa score: 0.20 Agreement between MNA and NJ: Kappa Score: 0.22 Agreement between MUST and NJ: Kappa Score: 0.64 nourished, NJ= severe malnutri- dences for people with dementia, Nutritional status using the tion, MUST= high risk). and 41 patients were living in ordi- MNA, the MUST, and the Nutritional status was then reor- nary nursing homes. 14 patients Nutritional Journal ganized into two categories to con- were excluded. Accordingly, the The mean (standard deviation) form with earlier studies comparing total number of included patients BMI-score in our patients was 24.6 screening tools (21, 22): good nutri- was 97, which was 83% of the ini- (4.7). Grouped BMI-scores are pre- tional status (MNA= normal , Nutri- tially selected participants. sented in Table 1. tional Journal= good, MUST= low Among the 97 included pati- Online supplemental figure 1 risk), and at risk for undernutrition ents, 79 were female and 20 were illustrates the nutritional status of (MNA= malnourished and at risk, male. The length of stay in insti- patients with obesity. All 16 pati- Nutritional Journal= risk and severe tution ranged from three to 74 ents with obesity had low nutritio- malnutrition, MUST= medium risk months. The mean (SD) number of nal risk using NJ. Using the MUST, and high risk). The two categories months in institution was 26 (20). 15 were at low risk, while one pati- were used when calculating the A further description of included ent was at medium nutritional risk. variation in nutritional status related patients is given in Table 1. Using the MNA, five patients were to severity of dementia, as well as 74 of the 97 patients had a for- at low risk, 10 at medium risk, and presenting the agreement between mal diagnosis of dementia, and the one patient was classified with high the tools. subtype of dementia was diagnosed nutritional risk. Kappa statistics (23) was used in 29 of these patients. Among Online supplemental figure 1 to calculate the pairwise agreement those with known dementia sub- also illustrates the different results between the screening tools. type, 18 had Alzheimer’s dementia, MNA, MUST, and NJ yielded To explore the association bet- five had vascular dementia, one using three categories. The per- ween severity of dementia and had Lewy body dementia, four had centage of patients in high risk nutritional status, the Mantel-Ha- mixed dementia, and one patient varied from 11.3% using the enszel test was used to calculate had other type of dementia. The MUST, 13.4% using the MNA, to linear-by-linear association. number of patients registered with 15.5% using NJ. Medium nutritio- no dementia diagnosis based on nal risk varied from 17.5% using Results medical record was 23. Using CDR the MUST, 19.6% using the NJ, to Selection and Description however, 14 patients were registe- 54.6% using the MNA. Low risk of participants red to have no dementia. Accor- varied from 32.0% using the The patient flow is presented in ding to CDR, 20 of the patients had MNA, 64.9% using the NJ, to Figure 1. Among the 114 patients mild dementia, 32 had moderate 72.2% using the MUST. The available for inclusion, 73 patients dementia, and 31 patients suffered results of nutritional assessments were residents of communal resi- from severe dementia. when reorganized into two cate-

18 Malnutrition among patients in nursing homes

Table 3. Patients’ nutritional status related to severity of dementia using Clinical Dementia Rating Scale (CDR) and use of nutritional screening tools. Values refer to number of participants unless otherwise noted.

Moderate Severe No dementia Mild dementia p-value dementia dementia

NJ

Risk of undernutrition 4 6 10 14

Good nutritional status 10 14 22 17

Mantel-Haenszel-test 0.223

MNA

Risk of undernutrition 2 11 23 30

Good nutritional status 12 9 9 1

Mantel-Haenszel-test 0.001

MUST

Risk of undernutrition 3 5 8 11

Good nutritional status 11 15 24 20

Mantel-Haenszel-test 0.303

MNA= Mini Nutritional Assessment MUST= Malnutrition Universal Screening Tool NJ= Nutritional Journal

Mantel-Haenszel test was used to calculate linear-by-linear association, to explore the association between severity of dementia and nutritional status

gories: at risk for undernutrition Nutritional status related valence of undernutrition varies gre- and good nutritional status, are to severity of dementia atly according to screening tools presented in Figure 2. The preva- The relationship between nutritio- used and the way the outcome is lence of at risk for undernutrition nal status using NJ, MUST and presented. When presenting the was then 68%, 28%, and 35% MNA, and severity of dementia result of the nutritional screenings using MNA, MUST, and NJ respe- using the CDR is illustrated in using three categories, the MNA ctively. Good nutritional status Figure 3 (available online). The classified 54.6% of the patients in was found in 32%, 72%, and 65% number of patients in each group medium nutritional risk, compared of the patients using MNA, MUST, in Figure 3 is given in Table 3. to 17.5% and 19.6% for MUST and and NJ respectively. Using the Mantel-Haenszel test, NJ respectively. Although the result there was a positive correlation bet- varied minimally at high risk, which 3.3. Agreement in diagno- ween the severity of dementia and was 13.4%, 11.3% and 15.5% using sing malnutrition between the risk for undernutrition using MNA, MUST and NJ respectively, MNA, MUST, and NJ MNA (p<0.001). This was not obser- the outcome changed drastically The agreement between the three ved for severity of dementia and risk when the results were organized screening tools is illustrated in of undernutrition was not found into two categories to conform with Table 2. MNA and MUST yielded a using MUST (p= 0.303), nor NJ (p= earlier studies (21). With two cate- Kappa score of 0.20. Between MNA 0.223). gories, the prevalence of risk for and NJ, the Kappa score was 0.22, undernutrition was 68%, 29%, and while the Kappa score between Discussions 35% using MNA, MUST and NJ MUST and NJ was 0.64. Our study of 97 patients living in respectively. Velasco and colleagues nursing facilities shows that the pre- (21), presented their results using

19 Malnutrition among patients in nursing homes

two categories, and got the same tion. MUST and NJ showed best pitals and private homes (27) . It is result as our study: the MNA pre- agreement, while MNA had slight also validated for older persons in sents a much higher prevalence of agreement with the other tools. long-term care (28). Likewise, undernutrition than the MUST. We Likewise, obese patients were MNA is used as a gold standard found that it was the patients in placed in different categories depen- along with SGA when comparing medium risk for undernutrition ding on the tool used. That patients other nutritional screening tools for who mainly accounted for the diffe- are classified differently depending validity and accuracy (24) . MUST rence between the screening tools. on which instrument used is not sur- is also a well validated tool (29, 30) Moreover, some recent local studies prising as the majority of the tools’ and has been used in several using either MNA or MUST (14-16) questions are not identical. Also, in comparative studies; although it found comparable prevalence as our shared questions, different cut-offs was not specifically validated for study using three categories, and are applied. BMI for instance is older persons in long term insti- when transforming their results into common for the three instruments, tutions. Among the three screening two categories, MNA would present but each uses different BMI cut-offs tools used in our study, MUST has a higher prevalence of risk of as an indicator of undernutrition. the lowest BMI cut-off with a BMI of undernutrition than MUST. Several studies have been con- 20 or higher considered as normal. The agreement between the ducted to compare the validity and As a BMI above 23.0 is recommen- tools calculated using Kappa-statis- reliability of the different nutritio- ded for older people (31) due to tics, revealed that the different tools nal screening tools (21, 24, 25). reduced mortality, the use of MUST did not necessarily identify the MNA is the most well validated may lead to underdiagnosis, unless same patients at risk of undernutri- tool for older persons (26) in hos- the BMI cut-off is adjusted.

Figure 2: The patients’ nutritional status using MNA (Mini Nutritional Assessment), MUST (Malnutrition Universal Screening Tool), and NJ (Nutritional Journal), categorized into two nutritional status. N=97. The values reflect prevalence of risk for malnutrition, and good nutritional status. 80% 72% 70% 68% 65%

60%

50% At risk Good 40% 35% 32% 30% 28%

20%

10%

0% MNAMUSTNJ

20 Malnutrition among patients in nursing homes

NJ is a locally developed tool, Strengths and limitations Conclusion which is widely utilized in many of the study The prevalence of malnutrition Norwegian municipalities. However, Strengths of our study is that the among patients living in nursing it is to our knowledge not validated same interviewer conducted all the facilities vary depending on the (13) , and has not been included in interviews with care-personnel. Only nutritional screening tools applied comparative studies before. care-personnel with good knowledge and how the result is presented. In their guideline for prevention of the included patients’ health were The risk of undernutrition among and treatment of malnutrition, the interviewed. Moreover, except from patients with dementia increases Norwegian Directorate of Health the NJ, only validated instruments with the severity of dementia, does not comment on validation of measuring both degree of dementia regardless of screening tool, howe- the tools it recommends, nor reve- and nutritional status were used. ver, the intensity was most appa- als that the different tools may pro- Some limitations must also be rent with MNA. Obesity is also duce quite different outcomes. addressed. Old height measurements found among older patients in the Various municipalities choose dif- were used if difficult to measure institutions, but they are classified ferent tools due to lack of a gold accurate height. In addition, some of into different nutritional status standard. When different nursing the patients with dementia were una- depending on the screening tool facilities in one municipality use ble to give self-report of own health- used. different tools, their statistic will and nutritional status. Another not be comparable. Furthermore, limitation is the lack of direct assess- ACKNOWLEDGEMENT: since the use of different tools ment of cognitive function, and that Special thanks to the staff of could lead to different diagnosis, the severity of dementia was based the following for their partici- some patients might not get the on CDR alone. The sample size is pation during the data colle- right treatment nor covered their also small, and a larger study may ction: The communal nutritional needs, which can have yield more exact data. residences for people with major consequences for the pati- The aim of our study was not to dementia in Sandefjord ent`s health. reveal what tool is most suitable for (Nygårdsvollen, Ranvikskogen A recent study concluded that older patients in nursing facilities, & Bøkeveien); Mosserødhjem- met, Post 1, 2 & 3; Tjølling the degree of malnutrition is cor- nor to discuss the validation or Nursing Home, Huseby Ward related with the severity of demen- sensitivity issues among the scree- & Kaupang Ward. tia irrespective of the type of ning tools. However, these impor- dementia (8). This means that as tant issues need further research. FUNDING dementia progresses, the risk for No funding was received for undernutrition increases. Our Implications for Practice the implementaton of the pro- study has a similar result, but the When assessing the nutritional sta- ject. This project is a part of a degree of correlation depends on tus of older patients in nursing faci- master thesis as a completion nutritional screening tool used. lities, it is important to be aware that of the program Master in With the use of NJ and MUST, the different instruments may yield dif- Geriatric Health Care. The risk for undernutrition increases ferent results. The same patients’ project was implemented in at a gradually low pace from no nutritional status may therefore cooperation with the Univer- dementia to severe dementia. change if using different screening sity of South-Eastern Norway, With the use of MNA though, the tools. municipality of Sandefjord rate increases at a regular high Close monitoring of the nutritio- and municipality of Larvik. pace from no dementia to severe nal status of patients with dementia CONFLICT OF INTEREST dementia. Presence of dementia is is especially important, as dementia one of the components in MNA, poses risks to patients` nutritional None. which may contribute to its asso- health. Healthcare professionals ciation with severity of dementia. should also be aware that as demen- Whether this may lead to an over tia progresses, nutritional problems diagnosis of nutritional risk in may also increase. Individual nutri- patients with dementia is not tional care plan and management is known. therefore vital for these patients.

21 Malnutrition among patients in nursing homes

11. Nazarko L. Maintaining good nutrition 20. C. P. Hughes, Berg L, L.Danziger W, et in people with dementia. Nursing and al. A new clinical scale for the staging of Residential Care. 2013;15(9):590-5. dementia (abstract). British journal of 12. Guttormsen AB, Hensrud A, Irtun Ø, et psychiatry 1982;140(6):566-72. References al. Nasjonale faglige retningslinjer for 21. Velasco C, Garcia E, Rodriguez V, et al. forebygging og behandling av Comparison of four nutritional 1. Katsilambros N, Dimosthenopoulos C, underernæring (National professional screening tools to detect nutritional risk Kontogianni M, et al. Clinical Nutrition guidelines for prevention and treatment in hospitalized patients: a multicentre in Practice. United Kingdom: Blackwell of malnutrition ). Oslo:Helsedirektor- study. European journal of clinical Publishing Ltd; 2010. atet;2013. nutrition. 2011;65(2):269-74. 2. Cederholm T, Barazzoni R, Austin P, et 13. Gjerlaug AK, Harviken G, Uppsata S, et 22. Gerasimidis K, Drongitis P, Murray L, et al. ESPEN Guidelines on Definitions and al. Verktøy ved screening av risiko for al. A local nutritional screening tool Terminology of Clinical Nutrition2016. underernæring hos eldre (Tools for compared to malnutrition universal 3. St-Onge M-P, Gallagher D. Body screening the risk of malnutrition in the screening tool. European journal of composition changes with aging: The elderly). Sykepleien Forskning.2016 clinical nutrition. 2007;61(7):916-21. cause or the result of alterations in 11(2)(148-156) 23. Viera AJ, Garrett JM. Understanding metabolic rate and macronutrient 14. Eide HD, Aukner C, Iversen PO. Interobserver Agreement: The Kappa oxidation? Nutrition 2010;26(2):152-5. Nutritional status and duration of Statistic. Family Medicine. 4. Sortland K. Eldre og Ernæring (Older overnight fast among elderly residents 2005;37(5):360-3 people and nutrition). In: Bondevik M, in municipal nursing homes in Oslo. 24. Young AM, Kidston S, Banks MD, et al. Nygaard HA, editors. Tverrrfaglig VÅRD I NORDEN 2012;32:20–4. Malnutrition screening tools: Geriatri (Interdisciplinary geriatrics). 15. Hagen K. Uten mat og drikke… Comparison against two validated 3rd edition ed. Bergen: Bokforlaget; Ernæring Kroken sykehjem 2011 nutrition assessment methods in older 2012. p. 157- 81. (Without food and drink ...Nutrition medical inpatients. Nutri- 5. Mathus-Vliegen EM. Obesity and the Kroken Nursing Home 2011). tion.29(1):101-6. elderly. Journal of clinical gastroenterol- Utviklingssenter for sykehjem i Troms; 25. Neelemaat F, Meijers J, Kruizenga H, et ogy. 2012;46(7):533-44. 2012. al. Comparison of five malnutrition 6. Pivi GAK, Bertolucci PHF, Schultz RR. 16. Aukner C, Eide HD, Iversen PO. screening tools in one hospital inpatient Nutrition in Severe Dementia. Current Nutritional status among older sample. Journal of Clinical Nursing. Gerontology and Geriatrics Research. residents with dementia in open versus 2011;20(15-16):2144-52. 2012;2012:983056 special care units in municipal nursing 26. MNA- Mini NUtritional Status: Nestle 7. Kai K, Hashimoto M, Amano K, et al. homes: an observational study. BMC Nutrition Institution; 2004 [Available Relationship between eating distur- geriatrics. 2013;13:26. from: http://www.mna-elderly.com/ bance and dementia severity in patients 17. Veiledning for utfylling av skjema for validity_in_screening_tools.html. with Alzheimer’s disease. PLoS ONE. ernæringsvurdering: Mini Nutritional 27. Vellas B, Guigoz Y, Garry PJ, et al. The 2015;10(8) Assessment (A guide to completing the Mini Nutritional Assessment (MNA) 8. Camina Martin MA, Barrera Ortega S, Mini Nutritional Assessment MNA) and its use in grading the nutritional Dominguez Rodriguez L, et al. [Internet]. Nestlé Group. Available state of elderly patients. Nutrition. [Presence of malnutrition and risk of from: http://www.mna-elderly.com/ 1999;15(2):116-22. malnutrition in institutionalized elderly forms/mna_guide_norwegian.pdf. 28. Christensson L, Unosson M, Ek AC. with dementia according to the type 18. Elia M, Baxter J, Carole Glencorse, Jack- Evaluation of nutritional assessment and deterioration stage]. Nutricion son A, et al. “MUST” Brosjyren techniques in elderly people newly hospitalaria. 2012;27(2):434-40. (“Malnutrition Universal Screening admitted to municipal care. European 9. Bednarska-Makaruk M, Graban A, Tool”). The British Association for journal of clinical nutrition. Wiśniewska A, et al. Association of Parenteral and Enteral Nutrition. 2003. 2002;56(9):810-8. adiponectin, leptin and resistin with 19. Aagaard H, Roel S. Utvikling av 29. Skipper A, Ferguson M, Thompson K, inflammatory markers and obesity in ernæringsjournal: beskrivelse av et al. Nutrition Screening Tools. Journal dementia. Biogerontology. 2017;18 (4): ernæringsjournalen og dens praktiske of Parenteral and Enteral Nutrition. 561-580 gjennomføring foretatt av sykepleiestu- 2011;36(3):292-8. 10. Strand BH, Tambs K, Engedal K, et al. denter (Development of Nutritional 30. Validated Malnutrition Screening and [How many have dementia in Norway?]. Journal: Description of nutritional Assessment Tools: Comparison Guide Tidsskrift for den Norske laegeforening. journal and its practical implementa- In: (NEMO) NEMO, editor.: the State of 2014;134(3):276-7 tion). Halden: Høgskolen i Østfold; Queensland (Queensland Health); 2014. 2004. 31. Mowe M. [Treatment of malnutrition in elderly patients]. Journal of the Norwegian Medical Association (Tidsskr Nor Laegeforeng). 2002;122(8):815-8.

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