EMPIRICAL STUDIES

doi: 10.1111/j.1471-6712.2008.00632.x

Implementation of a nutritional programme in elderly people

admitted to resident homes
Kerstin Wikby RN, PhD1,2, Anna-Christina Ek RN, PhD (Professor)1 and Lennart Christensson RN, PhD2
1

Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, Linkoping, Sweden and 2Division of Nursing
Science, University College of Health Sciences, Jonkoping University, Jonkoping, Sweden

Scand J Caring Sci; 2009; 23; 421430

Implementation of a nutritional programme in elderly
people admitted to resident homes
Aim: The aim was to test the hypothesis that education
provided to staff regarding nutritional needs and individualizing nutritional care will improve the nutritional status
and functional capacity of elderly people newly admitted
to resident homes.
Design: Pre- and posttest, quasi experimental.
Setting: Resident homes.
Subjects: Sixty-two residents (20 men, 42 women) in the
experimental group and 53 (14 men, 39 women) in the
control group were consecutively included. Mean age was
85 years.
Methods: On admission and after 4 months, nutritional
status was assessed using a combination of anthropometry
(weight index, arm muscle circumference and triceps
skinfold thickness) and biochemical measurements (serum
albumin and transthyretin). Functional capacity and

Introduction
Protein energy malnutrition (PEM) is a frequent and
serious problem in elderly people (1), and has been found
to be present in one-third of elderly people receiving
community service and care (24). It is a problem for the
individual, the family, the community and the healthcare
system (5). PEM in elderly people is a multidimensional
concept, involving medical, psychological and social factors
(1, 6). It is common in connection with chronic disease (7)
and affects quality of life, morbidity and mortality (8). In
many countries around the world the population is ageing
(9) and, as a result, elderly people with PEM will represent
an increasing group in the future (5).

Correspondence to:
Kerstin Wikby, Division of Nursing Science, University College of
Health Sciences, Box 1026, SE-551 11 Jonkoping, Sweden.
E-mail: kerstin.wikby@hhj.hj.se

overall cognitive function were also assessed. In the

experimental unit, the staff received education about
nutritional needs and individualized nutritional care.
Results: After 4 months the number of residents assessed as
protein energy malnourished decreased from 20 to seven
in the experimental (p = 0.004), and from 17 to 10 in the
control group (p = 0.1). In the experimental group, motor
activity (p = 0.006) and cognitive function (p = 0.02) increased. In the control group, motor activity decreased
(p = 0.02).
Conclusions: The results indicate that the intervention had
effects, as the number of protein energy malnourished
residents decreased in the experimental group and motor
activity and cognitive function improved. No such
improvements were seen in the control group.
Keywords: education, nutritional intervention, individualized care, elderly people, resident homes.
Submitted 22 January 2007, Accepted 29 April 2008

To determine how to improve nutritional status in

elderly people at nutritional risk, studies have often been
designed to investigate the effect of oral supplements to
regular meals as standard care plans (10, 11). The results of
two Cochrane reviews of 49 (10) and 55 trials (11),
respectively, whereby oral supplementation was given
showed a small but consistent weight gain in elderly people. In a majority of the trials, a reduced mortality rate was
also observed in the supplemented groups (10, 11). However, the result was not unambiguous as 10 trials reported
gastrointestinal disturbance with oral supplements (11)
and there was no evidence of improvement in functional
benefit in the supplemented groups (10). These reviews
point out that the results of standard actions on nutritional
problems in elderly people are unclear (10, 11).
As eating is complex and not only a biological phenomenon striving to satisfy hunger, and as energy
expenditure differs with age, gender, disease, body weight
and extent of physical activity (1), an individualized programme may be a more effective approach. Besides
ensuring bodily needs, eating also has a psychological,

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K. Wikby et al.

social and religious meaning (1, 12). According to the

National Board of Health and Welfare in Sweden, an
individual care plan based on individuals desires, needs
and resources is a goal in nursing action (13). To provide
individual nutritional care, caregivers must have considerable knowledge and skill not only in nutritional matters
but also in the social, psychological and spiritual dimensions of eating (12).
During a period of 3 months, ordinary food based on
individual nutritional requirements, resources and desires,
was given to 11 residents assessed as PEM in a study with a
single-case design. After the 3-month period the residents
nutritional status and functional capacity had improved
significantly, showing that individualized nutritional care
had positive effects on residents assessed as being PEM
(14).
The aim of this study was to test the hypothesis that staff
education regarding nutritional needs and individualizing
nutritional care will improve nutritional status and functional capacity in elderly people newly admitted to resident
homes, as measured by anthropometric and biochemical
measures.

Material and methods

Design
The study had a pre- and posttest, quasi experimental
design. A total of eight resident homes were involved in
the study, three constituting the experimental unit and
five the control unit. The participants were admitted to
available vacant accommodation places in the resident
homes. Consequently, it was not possible to implement a
blinded randomized trial because of assignment based on
supply and demand. The newly admitted residents were
consecutively included in the study from October 2000
until April 2002. Each resident participated in the study for
a 4-month period and the intervention constituted education and instructions regarding an individualized nutritional programme.

Sample
Eight resident homes, in a municipality in the south of
Sweden were involved in the study. The resident homes
were geographically separated from one another. The
experimental unit included 135 accommodation places
divided into three resident homes, called A, B and C.
Resident homes A, B and C contained 36, 49 and 50
accommodation places respectively. In the control unit 142
accommodation places were divided into five resident
homes, called DG, with 36, 18, 36, 36 and 16 accommodation places respectively. The number of staff in the
experimental unit constituted 71 nurse aids (NAs) and in
the control unit 102 NAs. Approximately half of the NAs

had 2 years of upper secondary school education in a

nursing care programme, and in the remaining NAs
nursing care education varied from a number of days to
half a year. In each resident home an NA was given the
task of acting as dietary ombudsman (NAO). The NAOs
received continuous education in nutritional issues, half of
a day four times per year.
The burden of work was judged to be equal, as the staff
in resident home A were also responsible for the palliative
care units, and the staff at resident homes DG were also
responsible for units not involved in this study, such as day
care units, and group areas for demented residents. The
experimental and the control units were similar regarding
workload, type of nursing care, nursing competence and
number of staff. Two Registered Nurses (RNs) were employed at resident home A, and one at each of the
remaining homes BG. All the RNs were women, all had
worked 10 years or more as RNs at resident homes, and
their ages ranged from 32 to 63 years.
During the study period, 134 residents, 65 years or
older, entered any of the resident homes involved. Of these
residents, six did not wish to participate and one died
unexpectedly before the examination was performed.
Sixty-eight residents entered the experimental units and
59 the control units. Exclusion criteria were terminal stage,
malignant disease and kidney and liver disease. Two residents, one in each group, dropped out during the study
period because of newly diagnosed malignant diseases.
From the time of admission to 4 months later, five residents in each group died. Sixty-two residents (20 men, 42
women) in the experimental group and 53 (14 men, 39
women) in the control group completed the study.

Intervention
The intervention in the experimental units was introduced
in four steps. In the first step, all staff received information
about the study and the nutritional programme. Every staff
member received the book Food and dietary management
in elderly people problems and opportunities in Swedish
(15).
In the second step, all RNs (n = 4) and NAs (n = 3),
received information about managing a study circle. They
were also taught how to identify individual needs and
underlying causes of nutritional problems. The RNs were
trained in assessing nutritional status using the Mini
Nutritional Assessment (MNA), a tool developed especially
for identifying elderly people at risk for malnutrition and
in need of nutritional attention (16, 17).
The MNA involves anthropometric assessment (weight,
height, and arm and calf circumferences), general assessment (six questions related to lifestyle, medication and
mobility), dietary assessment (eight questions related to
number of meals, food and fluid intake, and autonomy of
feeding), and self-assessments (self-perception of health

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Implementation of nutritional programme in elderly people

and nutrition). The tool distinguishes between elderly
people with malnutrition, at risk for malnutrition, and
those who are well nourished (16, 17). The RNs were also
trained in calculating energy requirement, based on estimated metabolic rate, using the equation given by the
Nordic Nutrition Recommendation (18).
In the third step, nutritional problems were discussed.
This was organized in study circles involving RNs, NAOs
and NAs, with the RN and the NAO as leaders. Eight to 10
NAs were included in each circle. On five afternoons for
3 months, each study circle met at the same time as the
ordinary workplace meetings. Each study circle was guided
by a study guide, prepared by the third author (LCh). The
guide focused on issues concerning nutritional problems in
elderly people, with the aim of stimulating the NA to
scrutinize how he/she could improve daily nutritional
arrangements. The NAs were taught to use a dietary plan,
previously developed and used by Christensson et al. (14),
and how to document in a food record. To make it possible
to give the residents service at appropriate level, meals
were described in domestic terms, e.g. a small or normal
slice of bread, a small- or medium-sized potato, a decilitre
of soup or peas. The meals in the dietary plan covered
every meal every day during a 10-week period, and were
presented at three base levels: 5500, 7200 and 9000 kJ
(1 kcal = 4.186 kJ). A simplified food record based on the
dietary plan was used to evaluate the residents daily intakes. No upper limit for energy intake was set. The dietary
plan was intended to be used for residents with nutritional
problems, and their energy intake was recorded. When the
residents did not reach their calculated daily energy intake
requirement, supplements such as sandwiches, soups,
snacks and/or enriched drinks were to be added. The food
was prepared by kitchen staff with a cooks education
varying from 1 to 3 years of upper secondary school.
In the fourth step, the RNs were told to assess nutritional
status in newly admitted residents using the MNA. In those
identified as malnourished or at risk for malnutrition, the
RNs were told to predict the energy requirement, examine
the causes of the nutritional problems, and design a
nutritional programme. The NAs were told to serve the
food according to the dietary plan, implement individualized nutritional care, and register food intake.
During a 4-month study period, the RNs in the experimental and control units were told to document actions
regarding eating and events interrupting eating in all
residents, which also included consultations with, e.g.
physician, occupational therapist and dietician. For this
purpose, a form specially developed for this study was
used. In the control unit, the staff received no education
and no changes were made in the residents food or the
arrangement of their meals.
A questionnaire was used to examine how time consuming the use of the dietary plan and the food record was.
All the NAs in the experimental and control units were

423

asked to fill in the questionnaire before the intervention

was implemented and 1 year later. The staffs were instructed to estimate the time they needed to portion out
one resident breakfast, lunch and dinner. On the second
occasion the staff at the experimental unit were asked to
estimate the time they needed when they used the dietary
plan and the food record.

Instruments
In all newly admitted residents, in the experimental as well
as in the control group, the pretest was carried out during
the first 2 weeks after admission, and the posttest after
4 months. The tests included objective nutritional assessment, functional capacity and overall cognitive function.
The objective nutritional assessment was also performed
2 months after admission. The anthropometric and biochemical measures were carried out by one person (the
first author). Prescription medications were classified
according to the Anatomical Therapeutical Chemical
Classification (ATC) system (19), and medical diseases
according to the International Classification of Diseases
(20).
Objective nutritional assessment was conducted by
measuring height, body weight, mid-arm circumference
(MAC), triceps skinfold thickness (TSF), arm muscle circumference (AMC), serum albumin and transthyretin, to
assess residents as having PEM or non-PEM (Table 1).
Height was measured with the resident in a supine position
on a flat bed. It was measured to the nearest centimetre,
using a measuring instrument with a fixed foot plate and
an adjustable head plate.
Each residents weight was measured to the nearest
0.1 kg using a mechanical balance chair. The weight was
adjusted using a list of estimated weight for every article of
clothing. The mechanical balance chair was checked for

Table 1 Criteria used to determine protein energy malnutrition

Anthropometry
WI
TSF
AMC
79 years
>79 years
Biochemical measures
Albumin
Transthyretin

Men

Women

<80%
6 mm

<80%
12 mm

23 cm
21 cm

19 cm
18 cm

<36 g/L
<0.23 g/L

<36 g/L
<0.23 g/L

A resident was defined as having protein energy malnutrition if two or

more of the nutritional variables were subnormal, including at least one
anthropometric and one biochemical measurement.
WI, weight index; TSF, triceps skinfold thickness; AMC, arm muscle
circumference.

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424

K. Wikby et al.

accuracy twice during the study period using a standard

weight. Weight index (WI) in per cent was calculated from
actual weight divided by the reference weight and multiplied by 100. The reference weight for women was calculated to be 0.65 height (cm) ) 40.4 (kg), and for men
0.80 height (cm) ) 62.0 (kg) (21, 22). The correlation
coefficient between WI and body mass index (BMI) [body
weight (kg) divided by squared height (m2)] was 0.99,
according to Pearsons correlation analysis. A WI of 80%
was equivalent to a BMI of approximately 20.0. TSF was
measured in mm using a Harpender skinfold calliper at the
midpoint of the upper arm between the processes of
acromion and olecranon and MAC to the nearest 0.1 cm
with a measuring tape (23). The mean of three measurements was used and the nondominant arm was measured,
unless the arm was paralysed or otherwise injured (2, 23,
24). AMC in centimetre was calculated as AMC
(cm) = MAC (cm) ) 0.1 [p TSF (mm)]. Serum albumin
and transthyretin were measured, as serum albumin
reflects protein intake over weeks (25) while transthyretin
reflects it over days because of its shorter biological half-life
(20 days compared with 2 days) (26). Local reference
values of serum albumin and transthyretin were used.
A resident was considered as having PEM if two or more
of the nutritional variables were subnormal, including at
least one anthropometric and one biochemical measurement (2, 23, 24). C-reactive protein (CRP) was measured
to give information about ongoing infection or inflammation that might increase the possibility of incorrectly classifying a non-PEM resident as PEM (25, 26).
Activity Index (AI) was used to assess functional
capacity. It was developed to evaluate functional capacity
and consists of 16 variables, divided into three parts:
mental capacity, motor activity and activity of daily living
(ADL) function. Part one, mental capacity, includes four
items and comprises degree of consciousness, orientation,
communication and psychological activity (432 points).
The second part is motor activity, which includes six items
and comprises motor activity in left and right arm and leg
(624 points). Part three, ADL functions, includes six items
comprising ambulation, personal hygiene, dressing, feeding, and functional bladder and bowel (636 points). The
total activity score ranges from 16 (reflecting poor functional capacity) to 92 (reflecting good functional capacity)
(27).This tool has been validated in Sweden by Hamrin
and Lindmark (28) and in the USA by Chong (29), and has
been found to be useful in other patient groups as well
(14). The AI was used in this study because of its ability to
reflect variations in the outcome variable functional
capacity.
To screen for overall cognitive function in the residents,
the Mini-Mental State Examination (MMSE) (30) was
used, as it is a widely used tool both internationally (31,
32) and nationally (33). It is a brief 11-item assessment
tool developed by Folstein et al. (30), and attempts to

quantify the individuals capabilities in orientation, registration, attention and calculation, recall, and language.
The maximal and best score is 30 points. In the original
paper (30), 20 points or less was the cutoff score for cognitive impairment. Crum et al. (34) have thereafter recommended different cut off scores, since cognitive ability
varies in the population by age and educational level.
Different cutoff scores have also been used for classifying
individuals as either cognitively intact, moderately impaired or demented (35). In this study, a score of 20 points
or less was considered as representing cognitive impairment (30). Seven residents were not tested according to
MMSE, because of aphasia in six residents and unwillingness to participate in one.
Data such as medical diagnosis, prescription medications, actions regarding eating and events interrupting
eating were obtained from the residents and their records.
If necessary, a proxy and the staff who knew the residents
well answered the questions.

Statistics
Results are given as frequencies, percentages, medians and
quartile deviations, and as arithmetic mean and standard
deviation when applicable. Differences between subgroups
were determined using the t-test, MannWhitney U-test
and chi-square test. Paired t-test, ANOVA for repeated
measures and Wilcoxons-signed rank test were used to
analyse differences within groups. When determining
means between subgroups for repeated measures, MANOVA
was employed. The McNemar test was used to test differences in residents assessed as PEM and non-PEM at baseline and after 4 months. Differences were considered
significant at a p-value below 0.05. The statistical program
SPSS version 13.0 (Chicago, IL, USA) was used.

Ethical considerations
The newly admitted residents, or their next of kin, received
oral and written information explaining the aims of the
study, what participation would mean, and that they could
withdraw their participation whenever they wanted without giving any explanation. They gave their informed
consent to participate, and during the study great attention
was paid to their autonomy and privacy by respecting their
wishes and minimizing alteration of their life situation as
much as possible. Residents with cognitive dysfunctions
were included in the study as it would have been unethical
to discriminate against them by excluding them, and because these elderly people represent a major part of newly
admitted residents. Approval was received from the management of the municipality, and the study was seen as part
of the internal improvement work. The study was approved
by the Research Ethics Committee, Faculty of Health Sciences, Linkoping University (Registration no. 00-243).

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Implementation of nutritional programme in elderly people

Results
Basal characteristics
The mean age in the experimental and control groups was
85.5 6.1 and 85.2 6.5 respectively. In both the
experimental and control groups, the median number of
prescribed medications was five (47). According to the
ATC, in total 82% of the residents were on medication
affecting the nervous system, 65% were on medication
affecting the heart and circulatory system, 65% the blood
and blood-producing organs, and 39% the digestive
organs and metabolism. No significant differences were
seen between the two groups regarding prescribed medications. The number of residents diagnosed as having
dementia disease, cerebrovascular disease or symptomatic
heart failure was one in three for each diagnosis. Some
residents had more than one disease. Other diagnoses
seen among the residents were diabetes mellitus (16%)
and ischaemic heart disease (13%). No significant differences in disease distribution were seen between the residents in the two groups.

The nutritional programme

In the experimental unit, the RNs carried out the MNA in
42 residents of 62. Of these 42 residents, the RNs assessed
24 as well nourished, 10 as at risk for malnutrition and
eight as malnourished. In 17 residents assessed as at risk for
malnutrition or malnourished, energy requirement was
predicted and registration of food intake was carried out
using the dietary plan. In one resident, energy requirement was not predicted and no registration of food intake
was carried out. Reasons for the RNs not carrying out the
MNA in 20 residents were forgetfulness and absence because of illness.
Food registration was carried out for a median of
111 days (98113) in the residents. Reasons for missed
data were incomplete registration by the staff and lost food
records, as well as the residents being elsewhere on some
occasions, such as visiting relatives. In 13 residents, energy
intake reached 90% or more of the calculated requirement. In two residents, energy intake reached 88% of
requirement, and in another two residents 83% and 71%
respectively. Within the group of 17 at-risk or malnourished residents, mean body weight (kg) on admission, after
2 months, and after 4 months, was 55.5 9.0, 56.6 9.5
and 57.8 8.8 (ns) respectively.
The RNs in the experimental unit documented actions
regarding eating and events interrupting eating in 50 residents. The documentation involved strictly nursing and
medical actions in 14 and eight residents, respectively, and
a mix in 28 residents. Nursing care involved actions such as
eating in peace and quiet and in smaller groups, and with
people the residents liked; following habits at mealtimes;

425

supporting physical activity to stimulate appetite; serving

food the residents wanted; adjusting the consistency of the
food as well as the aids and techniques used to facilitate
eating.
In the control unit, the RNs had documented actions
regarding eating and events interrupting eating in 29 residents. The documentation involved a mix of medical and
nursing actions in eight residents, and was delimited to just
medical actions in 21 residents. Nursing care involved actions such as adjustments of the consistency of the food as
well as the aids and techniques used to facilitate eating. In
both the experimental and the control units, documented
medical actions involved activities such as contacting the
residents general practitioners to discuss and treat diseases
and unpleasant symptoms such as pain and nausea.
Before the intervention, the NAs in the experimental
and control units estimated that they needed in average
3.0 and 2.9 minutes, respectively, to prepare and serve
breakfast to each resident (ns). The corresponding figures
at lunch and dinner were 3.6 and 3.7 (ns), and 3.2 and 3.1
(ns) respectively. After 1 year, the RNs in the experimental
and control units estimated the need of time for preparing
and serving breakfast, lunch and dinner, to 3.6 and
2.9 minutes (p < 0.05), 4.4 and 3.4 minutes (p < 0.05),
and 4.2 and 2.9 minutes (p < 0.01) respectively. Preparing
and serving food according to the dietary plan and using
the food record increased the time consumption from 9.8
to 12.2 minutes per resident and day in the experimental
group.

Experimental vs. control groups

According to at least one anthropometric and one biochemical subnormal value 20 residents in the experimental group and 17 in the control group were assessed as PEM
on admission (p = 0.98). Four months later, this number
had decreased to seven in the experimental group
(p = 0.004) and 10 in the control group (p = 0.14). When
the two groups were compared, no significant differences
were seen in anthropometric and biochemical values on
admission, after 2 months or after 4 months (Table 2).
According to repeated measures by MANOVA, no statistically
significant differences were seen during the study period
between the two groups, in any anthropometric or biochemical measurements.
Within-group analysis showed significant improvements
regarding WI and TSF in the experimental group, and in
WI and AMC in the control group (Table 2). Within the
experimental group, mean body weight (kg) on admission,
after 2 and after 4 months was 61.4 10.3, 62.1 10.2
and 62.8 9.7 (p < 0.001) respectively. The corresponding
figures in the control group were 59.5 11.4, 60.0 11.5
and 60.7 11.7 (p < 0.001) respectively. In PEM residents, CRP median value was 0.0 (0.016.5), and 0.0 (0.0
19.2) in non-PEM residents (p = 0.8).

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426

K. Wikby et al.

Group

Subset

Time

Experimental
(n = 62)

Control
(n = 53)

Betweena
p-value

Weight index (%)

0
2
4
Withinb
0
2
4
Withinb
0
2
4
Withinb
0
2
4
Withinb
0
2
4
Withinb

94.8 (15.5)
96.1 (15.4)
97.2 (15.2)
p-value 0.002
12.4 (5.0)
13.0 (5.4)
13.1 (5.3)
p-value 0.005
23.2 (2.9)
23.3 (2.6)
23.6 (2.8)
p-value 0.198
37.1 (5.0)c
37.6 (3.9)c
38.1 (3.9)c
p-value 0.081
0.22 (0.068)c
0.23 (0.069)c
0.23 (0.062)c
p-value 0.214

92.0 (14.8)
93.0 (14.6)
93.9 (14.7)
p-value 0.011
11.2 (5.4)
11.9 (5.3)
12.1 (5.6)
p-value 0.158
22.6 (2.5)
22.7 (2.4)
22.9 (2.3)
p-value 0.047
37.2 (4.0)d
37.3 (3.9)d
37.4 (3.8)d
p-value 0.826
0.23 (0.052)d
0.23 (0.043)d
0.24 (0.056)d
p-value 0.704

0.331
0.278
0.241

Triceps skinfold thickness (mm)

Arm muscle circumference (cm)

Albumin/s (g/L)

Transthyretin/s (g/L)

Table 2 Anthropometric and biochemical

data, on admission and after 2 and 4 months,
in residents newly admitted to community
resident homes, in an experimental and a
control group

0.247
0.250
0.311
0.202
0.178
0.156
0.953
0.481
0.512
0.377
0.823
0.319

Each value is given as the mean (SD).

Time: 0 = admission; 2 = after 2 months; 4 = after 4 months.
a
t-test.
b
ANOVA for repeated measures.
c
Two missing values.
d
Six missing values.

Upon admission, residents in the experimental group

had better mental capacity and ADL function and total
activity score according to AI, when compared with the
control group. After 4 months, residents in the experimental group improved regarding motor activity and
overall cognitive function according to MMSE, when
compared with the residents in the control group.
According to within-test analysis, motor activity and
MMSE function increased in residents in the experimental
group. During the same period, motor activity decreased in
the control group (Table 3).

Discussion
In this study, we tested the hypothesis that staff education
regarding nutritional needs and individualizing nutritional
care would improve nutritional status and functional
capacity of elderly people newly admitted to community
care. No statistically significant differences according to
anthropometric and biochemical measures were seen between the experimental and control groups. However,
within-group analysis showed that the number of residents
assessed as PEM in the experimental group had decreased
significantly during the study period but this was not the
case in the control group.

After 4 months, motor activity and overall cognitive

function was significantly better in the experimental
group, when compared with the control group. Improved
nutritional status and functional capacity because of individualized nutritional care, based on ordinary food, has
been described previously (14). However, as other studies
including elderly people in nursing homes (3638) and
hospital settings (10, 11) have shown positive nutritional
effects using oral supplements, a similar improvement to
that in this study may have been reached.
In this study, the residents mean age was very high.
Several diseases, as well as quite a number of prescribed
medications, were commonly present, and one-third was
assessed as PEM. This is in line with earlier studies in
which malnutrition has been seen in connection with a
variety of chronic diseases and prescription medications
(7). During the study period, within-group analysis
showed that mean body weight increased in both the
experimental (1.4 kg) and control (1.2 kg) groups. Elderly
people newly admitted to resident homes are often in poor
condition, arriving from nonfunctioning living conditions
(2, 24). Consequently, it might be expected that they improve during their first period at the resident home.
On admission, the residents in the experimental group
had better mental and ADL function, and higher total

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Implementation of nutritional programme in elderly people

Table 3 Total activity score (AI) and overall
cognitive function (MMSE), on admission and
after 4 months, in residents newly admitted to
community resident homes, in an experimental
and a control group

427

Group

Subset
Functional capacity (AI)
Mental capacity (432)

Motor activity (624)

Activity of daily

Total activity score (1692)

Overall cognitive function

MMSE (030)

Time

Experimental
(n = 62)

Control
(n = 53)

Betweena
p-value

0
4
Withinb
0
4
Withinb
0
4
Withinb
0
4
Withinb

28 (2430)
28 (2530)
p-value 0.219
23 (1824)
24 (1924)
p-value 0.006
27 (2234)
29 (2236)
p-value 0.583
79 (6886)
79 (6988)
p-value 0.052

27 (1828)
27 (1830)
p-value 0.113
22 (1924)
20 (1724)
p-value 0.025
23 (16-28)
24 (1632)
p-value 0.264
72 (5579)
70 (5383)
p-value 0.607

0.018
0.014

0
4
Withinb

17 (622)c
19 (624)c
p-value 0.021

12 (021)d
11 (021)d
p-value 0.990

0.863
0.016
0.007
0.035
0.014
0.011

0.090
0.029

Each value is given as the median (inter-quartile range). A higher score indicates a higher activity
capacity.
Time: 0 = admission; 4 = after 4 months.
AI, Activity Index; MMSE, Mini-Mental State Examination.
a
MannWhitney U-test.
b
Wilcoxon-signed rank test.
c
Four missing values.
d
Two missing values.

activity score, when compared with the control group,

which remained after 4 months. No statistically significant
differences were seen between the experimental and the
control groups on admission in motor activity and overall
cognitive function. During the intervention period, the
experimental group improved statistically significantly in
motor activity and overall cognitive function, but in the
control group motor activity deteriorated statistically significantly and the MMSE median score decreased from 12
to 11. As a result of these, the differences between the
experimental and the control group became statically significant regarding motor activity and over all cognitive
function. The fact that the experimental group scored
higher in some variables already on admission might have
influenced the posttest result. Nevertheless, the differences
were pronounced, which may be due to the intervention
(Table 3).
The food record was not used as an exact measurement
of energy intake, but rather as a helpful tool for the staff.
Most of the 17 residents in the experimental group, in
which energy requirement was predicted and registration
of food intake was carried out, met 90% or more of the
calculated energy requirement. This was confirmed during
the study period, as these residents mean body weight
increased 2.3 kg, when compared with 1.2 kg in the con-

trol group. Increased body weight has been seen as a positive outcome in different studies (10, 11, 14). From this
point of view, the extra work caused by using the dietary
plan must be seen as time well spent in relation to the
benefit. Arguments such as lack of time may be seen as
invalid as regards withholding individualized nutritional
care from elderly people in resident homes.
Different circumstances may have affected the outcome
of the intervention. First, PEM in elderly people is a multidimensional concept involving medical, psychological
and social factors, which in different ways may have
interacted with the intervention. Second, increased
mobility in the residents in the experimental group may
explain why increased energy intake had a moderate effect
on the residents weight gain, which has also been seen in
a study by Elmstahl et al. (39). Third, the intervention
period lasted for a period of four months in each resident,
which might be seen as a rather short time to affect
nutritional status and functional capacity in elderly people,
which Kayser-Jones (40) has also found. Fourth, one-third
of the residents in the experimental group were not assessed with the MNA, despite the RNs having been trained
in its use. Consequently, no energy requirement was
predicted and no registration of food was carried out using
the dietary plan in these residents. It has been seen that

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428

K. Wikby et al.

nutrition does not have high priority among nurses and

physicians (41) and that malnutrition in elderly people is a
neglected problem (42). Christensson et al. (43) have
shown in the same groups of staff that despite implementation of the educational programme it is difficult to
influence staff attitudes towards nutritional nursing care.
To overcome the problem of the RNs not carrying out
nutritional assessments in all residents, more resources are
perhaps needed. Suggested supports are providing the RNs
with more education about nutritional issues and the twostep MNA procedure, but also giving them continuous
supervision to motivate and support them in including all
residents in need of nutritional attention. Directions
within the organization of elderly care may also be needed,
with instructions to the RNs to priorities nutritional
assessments and issues.
Theoretically, a randomized and blinded clinical trial
would have been the ideal study design (44), but obvious
practical and ethical reasons made this impossible. The
assignment of available places was a result of the vacant
place situation, which made a blinded, randomized trial
impossible. Residents were at first hand admitted to resident
homes in the neighbourhood, to minimize the alteration of
their life situation as much as possible and so as not to expose them to unnecessary stress. At second hand, the residents were admitted to vacant places. It would have been
unethical to randomize the residents to either the experimental or control unit without respect to their wishes (45).
To have as equivalent study groups as possible, the
experimental and control groups were in the same
municipality. This might have affected the results in the
control group, as it was not possible to keep them totally
isolated from each other. Thus, the control group may
have assimilated information concerning the intervention.
Also, the staffs knowledge of being involved in a study
might have affected their behaviour, and different nursing
care in the various resident homes could exert an important influence on the homogeneity of the result (45).
C-reactive protein values had slightly increased in a few
individuals, in both residents assessed as PEM and those
assessed as non-PEM. It is known that an ongoing infection or inflammation may affect serum protein levels (25,
26). However, this does not seem to have affected the PEM
or non-PEM classification in this study.
Individualized actions directed toward PEM residents are
in line with the recommendation of the European Society
of Parenteral and Enteral Nutrition (46), and with the
Swedish goal of nursing action (13). Nursing action
regarding nutritional problems should not only be to offer a
standard care plan, such as giving oral supplementation to a
group of patients or residents, it demands a deeper analysis
of the underlying causes (40). Nutritional supplements
should be considered only if it is not possible to meet the
individuals nutritional requirements with food, or if
additional food has been ineffective in treating PEM (47).

Conclusions
No statistically significant differences according to
anthropometric and biochemical measures were seen
between the experimental and control groups. However,
within-group analysis show a reduced number of malnourished residents after the nursing staff had received
nutritional education. These findings indicate a possible
effect by the intervention, but to confirm this hypothesis
a more stringently performed intervention study is
needed, or at least adherence among the nurses to
comply.

Acknowledgements
We would like to thank all residents and staff who participated in the study. We would also like to thank the
organization in the municipality that granted permission to
carry out the study.

Author contributions
Kerstin Wikby collected and analysed the data and drafted
the manuscript. Anna-Christina Ek and Lennart Christensson were responsible for the study planning and design, and provided critical revisions and supervision at all
stages of the study.

Funding
The study has been funded by grants from the Vardal
Foundation (nos 98/359 and 03/042) and the Faculty of
Health and Sciences, Linkoping University, Linkoping,
Sweden.

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