Ett angeläget och aktuellt problem inom äldrevården är att många äldre riskerar att bli undernärda. Med stigande ålder riskerar människan att drabbas av förluster av olika slag, som gör henne mer sårbar. En del av deras problem består av minskad aptit, otillräckligt näringsintag och som i förlängningen kan resultera i undernäring. Undernäring försämrar ytterligare den åldrande människans liv genom sänkt livskvalitet, försämrad fysisk och mental förmåga, samt ökad risk att dö i förtid.
Det övergripande syftet med studierna var att studera om en intervention, baserad på utbildning av personal och införandet av ett individuellt anpassat nutritionsprogram, kunde förbättra nyinflyttade vårdtagares näringstillstånd och minska risken för utveckling av undernäring. Vidare var syftet att studera effekterna av förändringar i den kommunala äldreomsorgen över en fyraårsperiod, att utföra diagnostiska test och inter-bedömarreliabilitet av Mini Nutritional Assessment (MNA) och att identifiera och beskriva faktorer av betydelse för vårdtagarnas aptit.
Vid inflyttningen och efter en fyra månaders interventionsperiod, blev vårdtagarnas näringstillstånd (protein- energi malnutrition, PEM) bedömt med hjälp av kroppsmått och serumproteiner. Vid båda tillfällena bedömdes också fysisk förmåga med Aktivitetsidex (psykiskt status, motorik och ADL) och kognitiv förmåga med Mini Mental Test. För att identifiera vårdtagare i behov av individuellt anpassade nutritionsåtgärder använde tränade sjuksköterskor MNA och beslutade om behov av åtgärder eller inte. Vid inflyttningen samlades information in om vårdtagarnas sjukdomar och mediciner. Totalt 127 vårdtagare inkluderades konsekutivt till åtta äldreboenden i en kommun i södra Sverige. Tre av äldreboendena utgjorde experimentenhet (n = 68) och fem kontrollenhet (n = 59). Femton vårdtagare intervjuades med en kvalitativ metod om vad som påverkar deras aptit.
Resultatet visar att vid inflyttningen bedömdes 32 % av vårdtagarna som undernärda, vilket var jämförbart med resultatet i en studie genomförd fyra år tidigare. En högre andel av vårdtagarna i den nuvarande studien hade allvarliga sjukdomar och nedsatt psykiskt status, vilket indikerar att inflyttningskriterierna har förändrats under de fyra år som har förflutit mellan studierna.
Vid jämförelser mellan experiment- och kontrollgruppen fanns inga statistiskt signifikanta skillnader beträffande kroppsmått eller serumproteiner. Däremot fanns statistiskt signifikanta skillnader inom grupperna, där antalet vårdtagare bedömda som PEM minskade i experimentgruppen och deras motoriska förmåga och psykiska status förbättrades. I kontrollgruppen försämrades vårdtagarnas motoriska förmåga. Detta tyder på att trots brist på skillnader mellan experiment- och kontrollgrupp så hade interventionen förbättrat näringstillståndet, motorisk förmågan och psykiskts status hos vårdtagarna i experimentgruppen. En orsak till att det inte fanns skillnader mellan experiment och kontrollgrupp kan vara att sjuksköterskorna inte bedömde alla vårdtagare på experimentenheten och därmed missade vårdtagare som behövde individuella åtgärder.
Diagnostisk sensitivitet var 73 % hos MNA gentemot PEM, och 89 % hos kortversionen av MNA (MNA-SF) gentemot totala MNA, vilket visar på en relativt hög diagnostisk sensitivitet i båda fallen. Inter-bedömarreliabiliteten mellan samtidiga MNA bedömningar utförda av sjuksköterskor och forskare visade en moderat överensstämmelse på 62 % (kappa 0.41).
I intervjustudien framkom att viljan att äta är vad som påverkar vårdtagarnas aptit. Viljan att äta inrymmer interna faktorer, som sinnesstämning och personliga värden, och yttre faktorer, som nyttigheter, mat, ätmiljö och måltidsgemenskap. När omvårdnadshandlingar planeras och genomförs bör faktorer som påverkar vårdtagarnas aptit beaktas.
Sammanfattningsvis framkom att det är viktigt att införa och utveckla strategier för att genomföra individuellt anpassad omvårdnad i syfte att förebygga och behandla undernäring hos äldre. Detta är i linje med rekommendationer givna av European Society of Parenteral and Enteral Nutrition (ESPEN) och med Socialstyrelsens allmänna råd om omvårdnad inom hälso- och sjukvården (SOSFS 193:17).
ACKNOWLEDGEMENTS
I would like to express my deep gratitude to everyone who has any part in the work of this thesis. I am especially grateful to:
All residents, their relatives and staff members, who participated in this study and without whom this work would not been accomplished.
Anna-Christina Ek, Professor, my main supervisor, for excellent scientific guidance, constructive criticism and for continuous encouragement and for accepted me as a doctoral student.
Lennart Christensson, PhD, my co-supervisor, for guiding me into the world of research within nutrition, for constructive criticism, and for inspiring me becoming a researcher.
Astrid Fägerskiöld, PhD, my co-author in study IV, for stimulating discussions and for guiding me into the world of qualitative research.
All doctoral student, colleges and friends at the Department of Medicine and Care, the Division of Nursing Science, Faculty of Health Sciences, Linköping University for your support, helpful criticism during seminars, stimulating discussions and friendship during this period.
Susan Barclay Öhman, Urban Morén, thanks for your excellent revision on the English language.
Eva Borg and Erika Lindén, former and current secretaries at the Department of Medicine and Care, the Division of Nursing Science, Faculty of Health Sciences for all practical help and support.
All colleagues and friends at the Highland Hospital, Eksjö, thank you for your support and friendship.
The colleagues and friends at the University College of Health Sciences, Jönköping, thank you for given me support and encouragement during my doctoral studies.
The staff at the library at the University College of Health Sciences, Jönköping, thanks for valuable assistance of references.
The studies were supported by grants from Vårdalstiftelsen no. 98/359, 03/042, the Faculty of Health and Sciences, Linköping University, Linköping, Sweden, and Signe Thorfinn´s foundation.
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