Malnutrition in Elderly Staying in Nursing Homes

Full text

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
46
ORIGINAL
ARTICLE
Emine Ozer Kucuk1
Sevgisun Kapucu2
1 Ankara Numune Hospital,
Health Technology Assessment
Unit, Ankara, Turkey
2 Hacettepe University Faculty
of Nursing, Department Of
Medical Nursing, Ankara,
Turkey
Corresponding Address:
Sevgisun Kapucu,
Hacettepe University Faculty of
Nursing, Sıhhiye, 06100, Ankara
Tel: +90 312 3051880/124
E-mail: sevgisun@hacettepe.edu.tr
Geliş Tarihi: 02.06.2017
Kabul Tarihi: 22.08.2016
DOI: 10.18521/ktd.318404
Konuralp Tıp Dergisi
e-ISSN1309–3878
konuralptipdergi@duzce.edu.tr
konuralpgeneltip@gmail.com
www.konuralptipdergi.duzce.edu.tr
Malnutrition in Elderly Staying in Nursing Homes
ABSTRACT
Aim: The aim of this study was to assess the prevalence of malnutrition of
elderly people in living either public or private nursing home.
Methods: The sample of this descriptive study was 308 elderly, who were living
in public and private homes for the elderly in Ankara. Data were collected by
using an interview form, the Mini-Nutritional Assessment (MNA), the
Standardized Mini-Mental Test (SMMT), and the Barthel index.
Result: 28.6% of the elderly staying in the nursing home suffered from
malnutrition and 44.5% of them were at risk for malnutrition. Furthermore,
27.3% of participants were found to have sensory losses, 53.6% had
gastrointestinal problems, and 40% had deficiencies in their oral and dental
health. Those suffering from gastrointestinal problems have a lower mean
nutritional score (MNA) (p<0.05).
Conclusion: Results of this study demonstrated a higher incidence of
malnutrition among the elderly people receiving care in public or private nursing
homes
Keywords: Elderly, Malnutrition, Nursing Home, Nutrition.
Huzurevinde Kalan Yaşlılarda Malnutrisyon
ÖZET
Amaç: Bu çalışmanın amacı, kamu ya da özel huzurevinde yaşayan yaşlıların
malnutrisyon prevalansını değerlendirmektir.
Yöntem: Tanımlayıcı olarak yapılan çalışmada örneklemi Ankara ilinde bulunan
özel ve devlet huzurevlerinde kalan 308 yaşlı birey oluşturmaktadır. Veriler anket
formu, Mini Nutrisyonel Değerlendirme (MND), Standardize Mini Mental Test
(SMMT) ve Bartel İndeksi (Bİ) kullanılarak toplanmıştır.
Bulgular: Çalışma sonucunda, huzurevlerinde kalan yaşlılarda malnutrisyon
oranı %28.6, malnutrisyon riski oranı ise %44.5 bulundu. Ayrıca yaşlıların
%27.3’ünde duyu kayıpları, %53.6’sında gastrointestinal sorunlar ve %40’ında
ağız ve diş sağlığı sorunları saptanmıştır. Gastrointestinal sorunu olana yaşlıların
beslenme skorları (MNA) düşük çıkmıştır (p<0.05).
Sonuç: Bu çalışmanın sonucunda özel ve devlet huzurevinde kalan yaşlılarda
malnutrisyon oranının oldukça yüksek olduğu saptanmıştır.
Anahtar Kelimeler: Beslenme, Huzur Evi, Malnutrisyon, Yaşlı.

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
47
INTRODUCTION
Malnutrition is more commonly seen among
the elderly (1,2). The prevalence of malnutrition is
considerably higher (25-49%) of elderly people in
the world (1-5). The prevalence of malnutrition risk
was 28-53.6% and malnutrition frequency was 8-
15.9% among elderly people in Turkey (6-11). It is
a problem experienced by all elderly living in their
own house or staying in a care-giving institution
such as a nursing home or hospital that is
significant, common, and often late diagnosed.
Elderly face a higher risk of malnutrition because of
physical and physiological changes associated with
aging (12,13). The most fundamental cause of
malnutrition is insufficient nutrient consumption.
The second is the increase in the need for nutrients
due to fever, infection, or catabolic disorders.
Common physiological problems that affect the
nutritional status of elderly are sensory loss, poor
mouth and dental health, decreased appetite,
chewing problems and dependency on help for
eating. Among the psychological factors leading to
malnutrition are depression, dementia, alcoholism,
and loss of beloved individuals. Theliterature
showed that the social factors are poverty, living
alone, social isolation, lack of social support, lack
of ethnic food supply for those who live in care-
giving institutions, inability to buy or prepare
foods, and inability to feed oneself (14-16).
Malnutrition has negative effects on many
functions of the body. These include
cardiovascular, renal, respiratory, gastrointestinal,
immunity-related, and mental effects. Because of
all these effects, untreated malnutrition leads to a
higher rate of morbidity and mortality among the
elderly (17,18). Determining malnutrition and
malnutrition risk at early stages enables taking
precautions and initiating appropriate nutritional
support on time. By this way the rate of
complications of malnutrition can be reduced. And
nurses play the role of health care professional in
evaluating the nutritional status of elderly staying in
a nursing home. In this study, we evaluated
nutritional status for malnutrition of elderly staying
in either public or private nursing home.
MATERIAL AND METHODS
Setting and sample: This is a descriptive
study that aims to examine the risk factors
associated with nutrition and malnutrition among
the elderly individuals staying in nursing homes.
The population of this research was 1554 elderly
individuals and above staying in a public elderly
care institution or a private nursing home, and the
sample consisted of 308 individuals who are living
seven nursing home (accepting research) from the
population. Using stratified random sampling, 56%
of the sample (173 individuals) was selected from
public care-giving institutions, while 44% (135
individuals) were selected from private nursing
homes.
The exclusion criteria were: 1- staying
temporarily or living in the institution for <3
months, 2- receiving supplements or tube feeding 3-
being in a terminal condition of health, 4- not
accepting to take part in this survey.
Instruments: The nutritional status of
participants was assessed using the “Mini
Nutritional Assessment” test (MNA), their cognitive
status was assessed using the “Standardized Mini-
Mental State Test” (SMMT), and “Mini-Mental
State Test for the Uneducated” (SMMT-E), and
their functional health status was assessed using the
“Modified Barthel Index”.
The MNA full form test consists of 18 items
structured in 4 parts: anthropometric assessment
(weight loss, body mass index, mid-arm
circumference and calf circumference), global
assessment (mobility, prescription drugs,
independent life, psychological stress or acute
disease, pressure sores or skin ulcers and
neuropsychological problems), dietary assessment
(full meals eaten daily, food intake decline, fluid
consumption, protein intake, fruit and vegetable
intake and mode of feeding) and self-assessment
(self-view of nutritional status and self-view of
health status) (19).
SMMT, Molloy and Standish (1997) created
a standardized version of the Mini-Mental State
Examination (MMSE) developed by Folstein et al.
(1975) (20,21). The test is commonly used
especially to assess the cognitive status of elderly
individuals. The reliability and validity test of the
Turkish version of the scale was conducted by
Gungen et al. (2002) (22).
The Modified Barthel Index developed by
Mahoney and Barthel (1965) helps evaluate the
dependency status of individuals on help for taking
care of themselves (23). The validity and reliability
test of the Turkish version of the scale was
performed by Yavuzer at al. (2000) (24). This
instrument aims to evaluate the capacity of
individuals to perform the activities of daily living
(such as eating, going to the restroom, taking a
bath, dressing up, getting around indoors, and
getting around outdoors) without any help from
others.
Data collection procedure: The “Interview
Form” which consisted of questions addressing
descriptive characteristics and medical,
socioeconomic, and psychological status of
participants were filled in by examining the patient
files in these institutions as well as through face-to-
face interviews conducted with the participants.
Under nutrition was defined as a body mass index
<18.5. Anthropometric parameters (arm
circumference, waist circumference and triceps

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
48
skinfold thickness) were measured, and information
was gathered on nutritional habits.
Anthropometric measurements: The
researcher performed all anthropometric
measurements and interviews necessary for the
assessment of nutritional status after take course
related to anthropometric measurements. Weight
was recorded to the nearest kilograms (kg). Height
in meters (m) was estimated from the demi-span
(distance from the tip of middle finger to midline of
the sternum) of all residents 20.
Ethical consideration: Official permission
was obtained from care-giving institutions prior to
the study. The researchers also obtained the
approval of the Hacettepe University Ethics
Committee (Issue: 886 Decree No: LUT 09/1-30).
An oral consent was obtained from participants
after informing them about the research.
Statistical analysis: The data collected from
participants were statistically analyzed using SPSS
15 software package (Statistical Package for Social
Sciences). Descriptive analyses were presented
using means and standart deviations. The
relationship between the nutritional status of elderly
individuals and independent variables were
analyzed using the t-test, chi-square, regression
analysis, and correlation test. P values <0,05 value
were accepted statistically significant in tests used.
RESULTS
According to result, malnutrition risk was
determined in 44.5% and malnutrition was
determined in 28.57% of the participants according
to MNA assessment (Figure 1). It was found that
58% were female; the mean±SD age of the
participants was 78.70±7.87 years (Table 1).
Female participants were found to have a lower
mean MNA score than males. A negative
relationship with a strength of 24.2% was found
between MNA scores and age, that is, MNA scores
went down as age increased.
It was found that 53% of participants had a
GIS-related problem (n=165.The most commonly
seen problems were loss of appetite (51.5%),
constipation (43.4%), dyspepsia (31.5%), and
difficulty chewing (28.4%). Those who were
suffering from loss of appetite, dysphagia,
vomiting, and difficulty chewing had a lower mean
nutritional score than those who did not suffer from
these gastrointestinal problems (p<0.05) (Table 2).
It was found that 40% of elderly individuals
staying in nursing homes had a mouth health-
related problem. Those who had a mouth health-
related problem had a lower mean nutritional score
than those who did not (p<0.05) (Table 2). Those
who lacked teeth (70,8%), had dentures or denture-
related problems(31,4%) and those who suffered
from dry mouth (34,9%) had a lower mean
nutritional score than those who did not have these
problems (p<0.05) (Table 2).
Figure 1. The nutritional status of the participants.
According to Barthel index, 25.3% of
participants were fully independent, while 22,7%
were moderately dependent, 21,7% were severe
dependent and 19.4% were completely dependent
(Table 2). Those who were independent in their
activities of daily living had a higher mean MNA
score than those who were dependent. The scores
received from the MNA test and the Barthel Index
was found to be positively correlated with strength
of 53.3%. It was also found that the nutritional
scores increased as the level of independence in
daily activities increased. 53.5% of participants did
not have a cognitive impairment, while 17,2% had
mild cognitive impairment, and 13.3% had a severe
cognitive impairment. The difference between the
mean MNA scores according to the cognitive health
status of participants were found to be statistically
significant (p<0.05) (table 2). Those whose
cognitive status was normal according to their
Standardized Mini-Mental Test score had a higher
mean MNA score than those who had cognitive
inefficiency. A positive correlation with a strength
of 51.7% was identified between cognitive health
status and MNA score. One's MNA score increased
as their cognitive health status got better (Table 2).
Variables affecting nutritional status (socio-
demographic characteristics, and variables
concerning medical, socio-economic, and
psychological status) were added to a multiple
regression model (Table 3). The total effect of
these independent variables on nutritional status as
the dependent variable (MNA score) was
investigated. Using the Stepwise Regression
Technique, the variables that were not significant
were gradually eliminated in order to find the ones
that were statistically significant. According to the
results of this regression analysis, the following
independent variables were found to have an effect
on MNA scores: use of medication, the presence of
GIS-related problems, dysphagia, reluctance about
joining in social activities, cognitive inefficiency,
dependency in the activities of daily living, and
lack of interest in food.

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
49
Table 1. Socio-demographic characteristics of individuals according to groups (n=308).
Future of Personal
Malnutrition
(n=83)
Risk of Malnutrition
(n=137)
Normal
(n=88)
p
Age (n=308)
80.7 + 8,2
78.8 + 7,3
76.4 + 7,5
0.001
Gender
Female (n=179, 58%)
59 (33,0%)
86 (48,0%)
34 (19,0%)
0.002
Male (n=129, 42%)
29 (22,5 %)
51 (39,5%)
49 (38,0%)
Education
status
Illiterate (n=86, 28%)
22 (25,6%)
38 (44,2%)
26 (30,2%)
0.497
Literate (n= 38, 12%)
9 (23,7%)
15 (39,5%)
14 (36,8%)
Elementary school (n=90, 29%)
30 (33,3%)
36 (40,0%)
24 (26,7%)
Junior high school (n=23, 8%)
5 (21,7%)
13 (56,5%)
5 (21,7%)
High school (n=40, 13%)
13 (32,5%)
21 (52,5%)
6 (15,0%)
University (n=31, 10%)
9 (29,0%)
14 (45,2%)
8 (25,8%)
Civil status
Single (n=72, 23%)
19 (26,4%)
34 (47,2%
19 (26,4%)
0.063
Married (n=45, 15%)
9 (20,0%)
19 (42,2%)
17 (37,8%)
Widow (n=191, 62%)
60 (31,4%)
84 (44,0%)
47 (24,6%)
The
frequency of
contact with
relatives
Frequent (n=136, 44%)
36 (26,5%)
59 (43,4%)
41 (30,1%)
0.608
Rare (n=73, 24%)
17 (23,3%)
35 (47,9%)
21 (28,8%)
Never (n=53, 17%)
19 (35,8%)
25 (47,2%)
9 (17,0%)
No relatives (n=46, 15%)
16 (34,8%)
18 (39,1%)
12 (26,1%)
Table 2. Medical conditions of individuals according to groups (n=308).
Features
Malnutrition
(n=83)
(mean + SD)
Risk of
malnutrition
(n=137)
(mean + SD)
Normal
(n=88)
(mean + SD)
p
MMSE scores (0-30) (cognitive impairment)
0-9 (Severe) [(n:41/13,3%), (14,7±4,6) ]
10-19 (Moderate) [(n:49/15,9%), (17,3±4,2)]
20-23 (Mild) [(n:53/17,2%), (19,7±4,6)]
24-30 (No) [(n:165/53,5%), (22,0±4,4) ]
15,8+ 9,1
22,1+ 7,3
26,5+ 4,1
0.000
Barthel index scores
0-20 (Complete dependent) [(n:60/19,4%), (15,3±5,7) ]
21-61 (Severe dependent ) [(n:67/21,7%), (18,4±4,2) ]
62-90 (Moderate dependent) (n:71/22,7%), (21,5±3,59 ]
91-99 (Mild dependent) [(n:32/10,3%), (22,0±3,9) ]
100 (Normal) [(n:78/25,3%), (22,3±4,6) ]
37,8+ 37,2
69,5+ 30,4
85,5+ 25,1
0.000
Regular taking drugs (n= 269)
4,1+ 2,3
4,0+ 2,6
3.1 + 2,8
0.026
Acute
Disease
Present (n=35, 11%)
16 (45,7%)
11 (31,4%)
8 (22,9%)
0.055
Absent (n=273, 89%)
72 (26,4%)
126 (46,2%)
75 (27,5%)
Chronic
Disease
Present (n=272, 88%)
81 (29,8%)
122 (44,9%)
69 (25,4%)
0.070
Absent (n=36, 12%)
7 (19,4%)
15 (41,7%)
14 (38,9%)
Sensory
loss
Present (n=84, 27%)
31 (36,9%)
27 (32,1%)
26 (31,0%)
0.001
Digestive
problems
Appetite (51,5%)
Constipation (43,4%)
Dyspepsia (31,5%)
Difficulty chewing
(28,4%)
Present
(n=165, 53%)
58 (35,2%)
68 (41,2%)
39 (23,6%)
0.001
Absent
(n=143, 46%)
30 (21,0%)
69 (48,3%)
44 (30,8%)
Oral
health of
problem
Lacked teeth (70,8%)
Dentures problem
(31,4%)
Dry mouth (34,9%)
Mucositis (13,1%)
Present
(n=124, 40%)
66 (32,0%)
90 (43,7%)
50 (24,3%)
0.032
Absent
(n=84, 60%)
22 (21,6%)
47 (46,1%)
33 (32,4%)

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
50
Table 3. The results of multiple regression analysis of the MNA score of risk factors on the effect nutritional
status.
The risk factors
B
Std. Error
t
p
%95 CI
Status of Drug Use
1.948
0.619
3.147
=0.002
0,73 - 3,16
Problems of digestive
1.390
0.433
3.213
=0.001
0,54 - 2,24
Difficulty in Swallowing
2.684
0.752
3.568
<0.000
1,21 - 4,16
Participation in Social Activities
-0.553
0.267
-2.074
=0.039
-1,08 - -0,03
Reduction of the interest to food
3.901
0.579
6.732
<0.000
2,77 - 5,04
The score of MNA
0.179
0.029
6.101
<0.000
0,12 - 0,24
The score of Barthel Index
0.036
0.007
5.328
<0.000
0,02 - 0,05
R²=0.545; F=51.250
<0.05
DISCUSSION
In Turkey, some studies have been
performed in these settings: It was found the
malnutrition risk and malnutrition incidence to be
31-71% and 8-15.9% respectively (6-11). In our
study, according to the MNA scores received on the
Mini Nutritional Assessment test, participants had a
malnutrition risk of 44,48% and a malnutrition
incidence of 28.6. We think that early diagnosis of
elderly individuals with malnutrition risk is very
important as it increases the likelihood of a timely
intervention and helps prevent possible future
complications.
Various studies on elderly individuals living
in nursing homes or in the society identify gender
as a dependent risk factor for malnutrition (7,26). In
harmony with these previous studies, our study
identified being female as a risk factor for
malnutrition.
Gastrointestinal problems can be seen
among elderly just like any other age group, and
they bear special importance because of their
relationship with nutrition. Our study found that
participants who had a gastrointestinal problem had
a lower mean MNA score than those who did not
have one. Participants who suffered from a
gastrointestinal problem such as loss of appetite,
dysphagia, vomiting, and difficulty chewing had a
lower mean nutritional score than those who did
not. Many studies indicate a strong relationship
between mouth health and malnutrition (27,28).
Participants who had a mouth health problem
associated with lack of teeth, dry mouth, or
dentures had a lower mean nutrition score than
those who did not.
Other Factors Affecting Nutritional
Status; Dependency in ADLs and Cognitive
Health Status: Many studies indicate a strong
relationship between dependency in the activities of
daily life and mean MNA scores (10,12,26-29). Our
study suggested that participants who were
dependent in the activities of daily living according
to their Barthel Index score had a lower mean MNA
score than those who were independent. Nutrition
score also goes down as a dependency in the
activities of daily living goes up. Our study
suggested that participants who had a normal
cognitive status according to the Standardized
Mini-Mental Test had a higher mean MNA score
than those who had a cognitive problem. MNA
score goes up as cognitive health status increases.
Studies focusing on the relationship between
cognitive status and nutritional status show that the
individuals suffering from cognitive problems bear
a greater malnutrition risk than individuals who do
not have any cognitive problems (16,29).
In conclusion, according to our study,
among elderly individuals, those who were female,
those who had an acute and chronic illness, those
who were on medication, those who were suffering
from sensory loss, those who had gastrointestinal
problems, and those who had a mouth health issue
had a higher incidence of malnutrition. Being
dependent in the activities of daily living and
having a cognitive problem were found to be a risk
factor for malnutrition. It is necessary that the
elderly individuals be scanned for their nutritional
status and associated risk factors when they are first
admitted to care-giving institutions. Individuals
suffering from a nutritional problem should be
given proper dietary support.
Acknowledgements: This study was
conducted as a Thesis funded by Hacettepe
University of Scientific Research Projects
Coordination Unit (Project no: 2009-4892).
Declaration of interest: The authors declare
that there is no conflict of interest.
REFERENCES
1. Bolmsjo BB, Jakobsson U, Mo lstad S, Ostgren CJ, Midlöv P. The nutritional situation in Swedish nursing
homes – A longitudinal study. Arch Gerontol Geriat. 2015; 60(1):128–33. doi:
10.1016/j.archger.2014.10.021. Epub 2014 Nov 6.
2. De Rouvray CL, Jésus P, Guerchet M, et al. The nutritional status of older people with and without dementia
living in an urban setting in Central Africa: the EDAC study. J Nutr Health Aging. 2014;18(10):868-75, doi:
10.1007/s12603-014-0483-7.
3. Isaia G, Mondino S, Germinara C, et al. Malnutrition in an elderly demented population living at home.
Arch Gerontol Geriat. 2011;53(3):249-51. doi: 10.1016/j.archger.2010.12.015. Epub 2011 Jan 13.

Kucuk EO et al.
Konuralp Tıp Dergisi 2017;9(3):46-51
51
4. Lelovics Z, Bozo RK, Lampek K, Figler M. Results of nutritional screening in institutionalized elderly in
Hungary. Arch Gerontol Geriat. 2009;49(1):190-6. doi: 10.1016/j.archger.2008.07.009. Epub 2008 Sep 10.
5. Serrano-Urrea R, Garcia-Meseguer MJ. Malnutrition in an Elderly Population without Cognitive
Impairment Living in Nursing Homes in Spain: Study of Prevalence Using the Mini Nutritional Assessment
Test. Gerontology. 2013;59(6):490-8. doi: 10.1159/000351763. Epub 2013 Aug 14.
6. Ulger Z, Halil M, Kalan I, et al. Comprehensive assessment of malnutrition risk and related factors in a large
group of community-dwelling older adults. Clin Nutr. 2010;29(4):507-11. doi: 10.1016/j.clnu.2010.01.006.
Epub 2010 Feb 1.
7. Ulger Z, Halil M, Cankurtaran M, et al. Malnutrition in Turkish Nursing Homes: A Correlate of Short Term
Mortality, J Nutr Health Aging. 2013;17(4):305-9. doi: 10.1007/s12603-013-0016-9.
8. Kucukerdonmez O, Koksal E, Rakicioglu N, Pekcan G. Assessment and evaluation of the nutritional status
of the elderly using 2 different instruments. Saudi Med J. 2005; 26(10):1611-6.
9. Saka B, Kaya O, Ozturk GB, et al. Malnutrition in the elderly and its relationship with other geriatric
syndromes. Clin Nutr. 2010; 29(6):745-8. doi: 10.1016/j.clnu.2010.04.006. Epub 2010 Jun 2.
10. Sanlier N, Yabanci N. Mini nutritional assessment in elderly: living alone, with their family and nursing
home in Turkey. J Nutr Food Sci. 2006; 36(1): 50-8.
11. Cankurtaran M, Saka B, Sahin S, et al. Turkish nursing homes and care homes nutritional status assessment
project (THN-malnutrition). Eur Geriatric Med. 2013;4(5):329–334. DOI: 10.1016/j.eurger.2013.02.003.
12. Stanga Z. Basics in clinical nutrition: Nutrition in the elderly. E-SPEN, the European e-Journal of Clinical
Nutrition and Metabolism. 2009; 4(6). DOI: 10.1016/j.eclnm.2009.06.019.
13. Ferry M, Gilbert T, Guerin O, et al. Frailty and nutrition: Searching for evidence. J Nutr Health Aging.
2015;19(3):250-7.
14. Holmes S. The effects of undernutrition in hospitalized patients. Nurs Stand. 2007; 22(12):35-8.
15. Lee LC, Tsai AC, Wang JY. Need-based nutritional intervention is effective in improving handgrip strength
and Barthel Index scores of older people living in a nursing home: A randomized controlled trial. Intl J Nurs
Stud. 2015;52:904–12.
16. Muurinen S, Soini H, Suominen M, Pitkala K. Nutritional status and psychological well-being. e-SPEN, the
European e-Journal of Clinical Nutrition and Metabolism. 20010; 5(1):26–9.
17. Lilamand M, Kelaiditi E, Demougeot L, et al. The Mini Nutritional Assessment-Short Form and mortality in
nursing home residents-Results from the INCUR study. J Nutr Health Aging. 2015; 19(4): 383-8.
18. Peng LN, M.-H. Lin MH, Liu LK, et al. Nutritional status plays the mediating role of the functional status
and comorbidity among older patients admitted to the Geriatric Evaluation and Management Unit: A Tobit
model application. Eur Geriatric Med. 2014;5: 87–91.
19. Sarikaya D, Halil M, Kuyumcu ME, et al. Mini nutritional assessment test long and short form are valid
screening tools in Turkish older adults, Arch Gerontol Geriat. 2015; 61(1):56-60. doi:
10.1016/j.archger.2015.04.006. Epub 2015 Apr 22.
20. Folstein MF, Folstein SE, McHugh PR. Mini mental state” a practical method for grading the cognitive state
of patients for the clinician. Journal Psychiatric Research. 1975;12:189-98.
21. Molloy DW, Standish TIM. A guide to the standardized mini mental state examination. International
Psychogeriatry. 1997;9 (suppl 1):87-94.
22. Güngen C, Ertan T, Eker E, Yasar R, Engin F. Standardize mini mental testin Türk toplumunda hafif
demans tanısında geçerlik ve güvenilirligi. Türk Psikiyatri Dergisi. 2002;13(4):273-281.
23. Mahoney FI, Barthel W. Functional evaluation: the Barthel index. Maryland State Medical Journal.
1965;14:61-5.
24. Yavuzer G, Süldür N, Küçükdeveci A, Elhan A. Türkiye’de nörorehabilitasyon hastalarının
değerlendirilmesinde Fonksiyonel Bağımsızlık Ölçeği ve Modifiye Barthel indeksi’nin yeri. Romatoloji ve
Tıbbi Rehabilitasyon Dergisi. 2000;11(1):26-31.
25. Bassey EJ. Demi-span as a measure of skeletal size. Ann Hum Biol. 1986; 13(5):499-502.
26. Nazemi L, Skoog I, Karlsson I, et al. Malnutrition, Prevalence and Relation to Some Risk Factors among
Elderly Residents of Nursing Homes in Tehran, Iran. Iran J Public Health. 2015; 44(2): 218-27.
27. Van Lancker A, Verhaeghe S, Hecke AV, et al. The association between malnutrition and oral health status
in elderly in long-term care facilities: A systematic review. Intl J Nurs Stud. 2012; 49(12):1568-81. doi:
10.1016/j.ijnurstu.2012.04.001. Epub 2012 Apr 27.
28. Marchi RJ, Hugo F, Hilgert J, Padilha D. Association between oral health status and nutritional status in
South Brazilian independent-living older people. Nutrition. 2008; 2(4):546–53.
29. Stange I, Poeschl K, Stehle P, et al. Screening for malnutrition in nursing home residents: comparison of
different risk markers and their association to functional impairment. J Nutr Health Aging. 2013;17(4):357-
63.