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Introduction

Older people are particularly prone to poor nutritional statusdue to age-related physiological changes, social circumstances,a high prevalence of chronic diseases, poly-pharmacy, andreduced physical activity (1). Factors contributing tomalnutrition may be depression, reduced cognitive function,physical dependency, and problems with chewing andswallowing (2, 3). Malnutrition is more difficult to treat inolder compared to younger people since the former are morefrequently affected by loss of appetite and may have a reducedability to absorb nutrients (4).

Malnutrition is a common and serious problem among olderhospitalized adults. Poor nutritional status increases the risk ofbeing admitted to hospital (5) and prolongs the stay (6). Poornutrition is very common in older people admitted with a hipfracture (7). Further, malnutrition increases the risk ofcontracting infectious diseases such as urinary tract infections(UTI) and pneumonia when older people are admitted to thehospital (8-10).

Malnutrition is also common among older people inresidential care facilities (6). In Sweden, 21 to 71% of olderpeople living in various types of residential care facilities wereclassified as malnourished according to the Mini NutritionalAssessment (MNA) (11). Despite its high prevalence, less is

known about factors associated with malnutrition in residentialcare facilities compared to hospital settings. One study innursing homes revealed that low MNA scores were associatedwith female gender, a longer stay in the nursing home, impairedfunctioning, dementia, swallowing difficulties, constipation andeating less than half of the offered portion (12). Another studyamong older people living in service flats revealed that lowercognitive function, poor general well-being and low activitiesof daily living (ADL) were more prevalent among participantswith malnutrition, but there is no further evaluation of theseassociations (13). However, neither of these two studiesinvestigated whether there is an association between poornutritional status and infectious disease. Thus, more knowledgeis needed about factors associated with poor nutritional status inolder people living in residential care facilities.

The aim of the present study was to investigate whether poornutritional status is associated with medical conditions, druguse, or physical and cognitive impairments in older peopledependent in ADL and living in residential care facilities.

Methods

Settings and ethicsThe study was conducted at nine residential care facilities in

Umeå in northern Sweden. All facilities comprised private flats

POOR NUTRITIONAL STATUS IS ASSOCIATED WITH URINARY TRACTINFECTION AMONG OLDER PEOPLE LIVING IN RESIDENTIAL CARE

FACILITIES

M. CARLSSON1, L. HAGLIN2, E. ROSENDAHL1,3, Y. GUSTAFSON1

1. Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden; 2. Department of Public Health and Clinical Medicine, FamilyMedicine, Umeå University, Umeå, Sweden; 3. Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden. Corresponding Author: Maine

Carlsson, Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, SE-901 87 Umeå, Sweden. Phone: +46 907858769, Fax +46 90130 623, E-mail: [email protected]

Abstract: Aim: To investigate factors associated with poor nutritional status in older people living in residentialcare facilities. Methods: 188 residents (136 women, 52 men) with physical and cognitive impairmentsparticipated. Mean age was 84.7 y (range 65−100). The Mini Nutritional Assessment (MNA), Barthel ADLIndex, Mini Mental State Examination (MMSE), and Geriatric Depression Scale were used to evaluate nutritionalstatus, activities of daily living, cognitive status and depressive symptoms. Medical conditions, clinicalcharacteristics and prescribed drugs were recorded. Univariate and multivariate regressions were used toinvestigate associations with MNA scores. Results: The mean MNA score was 20.5 ± 3.7 (range 5.5−27) and themedian was 21 (interquartile range (IQR) 18.8−23.0). Fifteen per cent of participants were classified asmalnourished and 66% at risk of malnutrition. Lower MNA scores were independently associated with urinarytract infection (UTI) during the preceding year (ß = − 0.21, P = 0.006), lower MMSE scores (ß = 0.16, P =0.030), and dependent in feeding (ß = − 0.14, P = 0.040). Conclusion: The majority of participants were at risk ofor suffering from malnutrition. Urinary tract infection during the preceding year was independently associatedwith poor nutritional status. Dependence in feeding was also associated with poor nutritional status as were lowMMSE scores for women. Prospective observations and randomized controlled trials are necessary to gain anunderstanding of a causal association between malnutrition and UTI.

Key words: Malnutrition, Mini Nutritional Assessment, residential care facilities, urinary tract infection,cognitive impairment, old people.

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The Journal of Nutrition, Health & Aging©Volume 17, Number 2, 2013

Received September 19, 2011Accepted for publication March 8, 2012

18 CARLSSON/p/C_04 LORD_c 05/03/14 09:48 Page186

with access to common dining rooms, alarms, nursing, andpersonal care. Four facilities also comprised special units forpersons with dementia. The participants, or their relatives whenappropriate because of cognitive impairment, gave informedconsent to participate. The study was approved by the EthicsCommittee of the Medical Faculty of Umeå University (§391/01).

Study design and participantsThis study was part of the Frail Older People—Activity and

Nutrition Study in Umeå (the FOPANU Study) (14). In thepresent cross-sectional study, we investigated baselinenutritional status and associated factors. The FOPANU Studyinclusion criteria were: aged 65 years or older; dependent onassistance from one person in one or more personal activities ofdaily living (ADLs) according to the Katz ADL Index (15);being able to stand up from a chair with an armrest with helpfrom no more than one person; having a score of ten or more onthe Mini−Mental State Examination (MMSE) (16); andphysician approval. All residents at the nine facilities (n = 487)were screened for eligibility and 191 persons were included.Assessment of nutritional status using the MNA was notcompleted for three of the participants and thus 188 participantsare included in the present study (Figure 1). The age range forthis study population is 65 to 100 years and women comprised72% of the sample.

The participant’s registered nurse assigned to the facilityrecorded medical diagnoses, clinical characteristics, andprescribed drugs. A diagnosis of urinary tract infection (UTI)was made, if the participant had a documented symptomaticUTI with either short or long term on-going treatment withantibiotics. The UTI diagnosis was supported by previouslaboratory tests or bacterial cultures. All medical records andmedication records from hospitals, general practitioners, andthe residential care facility were examined to assess for anyUTI during the preceding year. Dependence in ADLs wasmeasured using the Barthel ADL Index (0−20 points) where 20points indicate total independence in personal ADLs (17, 18).Dependence in feeding was assessed using the Barthel ADLindex and results were dichotomized as dependent or partlydependent (needs help cutting, spreading butter, etc) versusindependent. Cognitive function was assessed using the MMSE(0−30 points) (16), where a score of 18-23 indicates mildcognitive impairment and ≤17 indicates severe cognitiveimpairment (19). The Geriatric Depression Scale (GDS−15)was used to screen for depressive symptoms (20), where scoresof 5−9 might indicate mild depression and 10−15 moderate tosevere depression. A specialist in geriatric medicine examinedthe documentation of previous and current diseases,information about prescribed drugs, and all assessments toestablish diagnoses according to the same criteria for allparticipants. Dementia and depression were diagnosedaccording to the Diagnostic and Statistical Manual of MentalDisorders criteria (DSM−IV criteria) (21).

Nutritional assessmentParticipant nutritional status was assessed using the MNA,

which is a reliable and validated screening tool developed todetermine malnutrition and the risk of malnutrition in olderpeople in residential care facilities (22). Classification ofnutritional status is derived from the 18 MNA questions on a30−point scale: < 17, malnourished; 17−23.5, at risk ofmalnutrition; and ≥ 24, well−nourished (22-24). Anexperienced dietician in cooperation with the staff wasresponsible for all assessments using the MNA questionnaire.

Anthropometric measurementsParticipants were weighed to the nearest 0.5 kg, wearing

light indoor clothing, without shoes, while sitting on acalibrated chair scale. Participant heights was measured in asupine position to the nearest 0.5 cm. Body mass index (BMIkg/m2) was calculated. Arm and calf circumferences weremeasured using a tape measure. Body mass index and arm andcalf circumferences are included in the MNA instrument.

Statistical analysisData were analysed using the Statistical Package for the

Social Sciences (SPSS) statistical software (Version 18.0 forWindows SPSS Inc, Chicago, IL). Student’s t−test was used toanalyse continuous variables when comparing thecharacteristics of women and men participants. The chi-squaretest was used for dichotomous variables. A P−value of < 0.05was regarded as statistically significant.

Univariate linear regressions were used to investigateassociations between the dependent variable of MNA (0−30)and independent variables. A multiple linear regression analysisincluding age, sex, and variables related to lower MNA scores(P ≤ 0.15) in the univariate analyses was used. The independentvariables were age, sex, constipation, pneumonia, UTI duringthe preceding year, dependent in feeding, use of diuretics,MMSE score, GDS score, and number of prescribed drugs. Thefollowing were excluded from the multiple linear regressions:indwelling urinary catheter (IUC) since all participants with anIUC also had an on-going UTI; an on-going UTI because it wasincluded in the variable UTI in the preceding year; treatmentwith laxatives since this is highly correlated with constipation (r> 0.7 in the bivariate correlations analysis); the Barthel totalscore since dependence in feeding is included; and depressionsince the GDS score measuring current symptoms is included.Additional interaction analyses were conducted between sexand all independent variables in the multivariate linearregression. Univariate comparisons were made for variablesthat were significant in the interaction analysis.

Univariate comparisons, using Chi-square test or one−wayanalysis of variance with post hoc testing, were made for theMNA score, (divided into three groups of < 17, 17−23.5, ≥ 24)and conditions that were significant in the multivariate analysis(UTI preceding year, dependent in feeding, and MMSE).

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Results

Nutritional status, medical conditions, physical andcognitive impairments

Characteristics of the 188 participants (136 women, 52 men)are presented for in Table 1. The mean MNA score was 20.5 ±3.7 (range 5.5−27) and the median was 21 (interquartile range(IQR) 18.8−23.0). Fifteen per cent of the participants wereclassified as malnourished and more than half (66%) were atrisk of malnutrition, with no gender differences. The mostprevalent medical conditions were depression, constipation,dementia, and UTI during the preceding year. There was nodifference in prevalence of UTIs between women and men(48% vs. 37%, P = 0.37). Women had significantly lowerMMSE scores, and men had higher prevalence's of malignancyand IUC (Table 1).

Associations and interactionsTable 2 shows age, sex, assessments, types and number of

drugs, and medical conditions among the participants and theassociations of these factors with baseline MNA scores. Theunivariate linear regressions revealed significant associationsbetween lower MNA scores and dependence in feeding, UTI inthe preceding year, lower Barthel scores, pneumonia,constipation, higher GDS scores, current UTI, and lowerMMSE scores. The multiple linear regression analysis revealedthat a lower MNA score was independently associated withUTI in the preceding year (ß = − 0.21, P = 0.006), lowerMMSE scores (ß = 0.16, P = 0.030), and dependent in feeding(ß = − 0.14, P = 0.040). Other related factors lost theirsignificance in the multivariate model (Table 2).

In the multivariate interaction analysis between sex and theother independent variables, significant interactions were foundfor UTI in the preceding year (P = 0.011) and MMSE (P =0.023). Additional univariate linear regression analyses showed

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Table 1Participant characteristicsa

All Women Men P−value(188) (136) (52)

Age (years) 84.7 ± 6.5 84.9 ± 6.6 84.0 ± 6.2 0.374BMI (kg/m2) 24.8 ± 4.5 25.0 ± 4.6 24.3 ± 4.4 0.387AssessmentsMini Mental State Examination (0−30) 17.7 ± 5.1 17.1 ± 4.7 19.2 ± 5.9 0.013Geriatric Depression Scale (0−15) 4.4 ± 3.2 4.4 ± 3.1 4.3 ± 3.3 0.819Barthel ADL score (0−20) 13.1 ± 4.1 12.9 ± 4.3 13.5 ± 3.9 0.352Barthel score

Dependent in feedingb 46 (24) 36 (26) 10 (19) 0.304MNA score (0−30) 20.5 ± 3.7 20.3 ± 3.7 21.1 ± 3.8 0.172MNA (score)

5.5−16.5 28 (15) 22 (16) 6 (12) 0.58017−23.5 124 (66) 91 (67) 33 (64) 0.32024−27.5 36 (19) 23 (17) 13 (25) 0.906

Drugsc

Laxatives 100 (53) 77 (57) 23 (44) 0.129Antidepressants 93 (50) 67 (49) 26 (50) 0.929Diuretics 93 (49) 69 (51) 24 (46) 0.577Analgesics (ASA) 82 (44) 59 (43) 23 (44) 0.940Benzodiazepines 64 (34) 47 (35) 17 (33) 0.810Oestrogensd 55 (29) 40 (29) 15 (29) 0.940Neuroleptics 42 (22) 33 (24) 9 (17) 0.308Proton pumps inhibitors 40 (21) 33 (24) 7 (14) 0.107Number of drugs 9.1 ± 4.5 9.4 ±4.7 8.4 ± 3.5 0.145Medical conditionsc

Depression 114 (61) 86 (63) 28 (54) 0.241Constipation 102 (54) 78 (54) 24 (46) 0.170Dementia 97 (52) 70 (52) 28 (54) 0.772UTI in the preceding year 84 (45) 65 (48) 19 (37) 0.167Previous stroke 53 (28) 39 (29) 14 (27) 0.812Heart failure 52 (28) 35 (26) 17 (33) 0.343Diabetes 36 (19) 23 (17) 13 (25) 0.209Gastric ulcer 36 (19) 29 (21) 7 (14) 0.223UTI, currente 33 (18) 22 (17) 11 (21) 0.425Hip fracture (last 5 y) 30 (16) 19 (14) 11 (21) 0.231Malignancy (last 5 y) 24 (13) 12 (9) 12 (23) 0.009Pneumonia 13 (7) 11 (8) 2 (4) 0.308Indwelling urinary catheter 11 (6) 4 (3) 7 (14) 0.006

Abbreviations: ASA = acetylsalicylic acid, BMI = body mass index, MNA = Mini Nutritional Assessment. UTI = urinary tract infection. a. Values are given as mean ± SD or as n (%), b.Dependent or partly dependent (needs help cutting, spreading butter, etc.) versus independent. c. Descending order. d. Only systemic oestrogens, e. on-going UTI with or without on-going treatment.


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that UTI in the preceding year was significantly associated withlower MNA scores for men (ß = − 0.51, P < 0.001) and women(ß = − 0.18, P = 0.038). The analyses also showed that lowerMMSE score was associated with lower MNA scores forwomen (ß = − 0.006, P < 0.001) but not for men (ß = 0.32, P =0.969).

Table 3 shows conditions that were independently associatedwith lower MNA scores in the multivariate analysis (UTI in thepreceding year, dependent in feeding, and MMSE score) inrelation to nutritional status. Malnourished participants (MNA≤ 17) had a higher prevalence of UTI during the preceding year,were more dependent in feeding, and had lower MMSE scoresthan those who were well nourished (MNA ≥ 24). Participantswho were at risk (MNA 17-23.5) did not differ significantly

Table 2Age, sex, assessments, type and number of drugs, and medical conditions in older people living in residential care facilities and

their associations with MNA scores at baseline

MNA Ba 95% CI for B βb P valuec P valued

mean ± SD

Age — — −0.1 −0.2 — 0.0 −0.1 0.055 0.116Women (y/n) 20.3 ± 3.7 21.1 ± 3.8 −0.8 −2.0 — 0.4 −0.1 0.172 0.829MMSE — — 0.2 0.1 — 0.3 0.2 0.002 0.030GDS — — −0.2 −0.4 — 0.0 −0.2 0.019 0.173Barthel — — 0.3 0.2 — 0.5 0.4 <0.001Dependent in feedinge (y/n) 18.7 ± 3.7 21.0 ± 3.5 −2.3 −3.5 — −1.1 −0.3 <0.001 0.049Laxatives (y/n) 20.0 ± 3.6 21.0 ± 3.7 −1.0 −2.1 — 0.0 −0.1 0.057Antidepressants (y/n) 20.2 ± 4.0 20.7 ± 3.4 −0.5 −1.6 — 0.6 −0.1 0.346Diuretics (y/n) 20.0 ± 3.7 21.0 ± 3.7 −1.0 −2.0 — 0.1 −0.1 0.077 0.116Analgesics (ASA) (y/n) 20.8 ± 3.6 20.2 ± 3.8 0.5 −0.5 — 1.6 0.0 0.328Benzodiazepines (y/n) 20.4 ± 3.9 20.5 ± 3.4 0.1 −1.0 — 1.2 0.01 0.857Oestrogensf(y/n) 19.4 ± 4.2 20.9 ± 3.4 −1.4 −2.6 — −0.2 −0.2 0.239Neuroleptics (y/n) 20.2 ± 4.3 20.5 ± 3.5 −0.3 −1.6 — 1.0 −0.0 0.618Pruton pumps inhibitors (y/n) 19.7 ± 2.6 20.7 ± 3.9 −0.9 −2.2 — 0.4 −0.1 0.155Number of drugs (y/n) — — −0.1 −0.2 — 0.0 −0.1 0.054 0.842Depression (y/n) 20.1 ± 3.5 21.0 ± 4.0 −0.9 −1.9 — 0.2 −0.1 0.126Constipation (y/n) 19.9 ± 3.7 21.2 ± 3.6 −1.4 −2.4 — −0.3 −0.2 0.013 0.653Dementia (y/n) 20.1 ± 4.0 20.9 ± 4.4 −0.7 −1.8 — 0.4 −0.1 0.189UTI preceding year (y/n) 19.3 ± 4.0 21.4 ± 3.2 −2.0 −3.1 — −1.0 −0.3 <0.001 0.006Previous stroke (y/n) 19.9 ± 3.6 20.7 ± 3.7 −0.8 −2.0 — 0.4 −0.1 0.185Heart failure (y/n) 20.1 ± 3.6 20.6 ± 3.8 −0.6 −1.8 — 0.6 −0.1 0.349Diabetes (y/n) 21.5 ± 3.3 20.2 ± 3.8 1.3 −0.1 — 2.6 0.1 0.066Gastric ulcer (y/n) 19.6 ± 2.7 20.7 ± 3.9 −1.0 −2.3 — 0.3 -0.1 0.131UTI current (y/n) 19.2 ± 4.0 20.8 ± 3.6 −1.6 −3.0 — −0.2 −0.2 0.025Hip fracture (y/n) 20.7 ± 3.1 20.4 ± 3.8 0.3 −1.2 — 1.8 0.0 0.683Malignancy (y/n) 20.4 ± 4.0 20.5 ± 3.7 −0.1 −1.7 — 1.5 −0.0 0.930Pneumonia (y/n) 17.9 ± 4.7 20.7 ± 3.6 −2.7 −4.8 — −0.7 −0.2 0.010 0.659Indwelling urinary catheter (y/n) 18.5 ± 3.9 20.6 ± 3.7 −2.1 −4.3 — 0.2 −0.1 0.075

y/n = yes vs no for each variable concerning MNA scores, MNA = Mini Nutritional Assessment, CI = Confidence Interval, ASA = Acetylsalicylic Acid, MMSE = Mini Mental StateExamination, GDS = Geriatric Depression Scale. a. B= Unstandardized coefficients, b. β = Standardized coefficients Beta, c. Univariate linear regression, d. Multiple linear regression, e. The multivariate regression model explained 20% of the variance of MNA scores, i.e. Only systemic treatment oestrogens, f. Dependent or partly dependent (needs help cutting,spreading butter etc) versus independent.

Table 3Conditions independently associated with lower MNA scores in the multivariate analysis

in older people living in residential care facilities, classified as malnourished, at risk of malnutrition,or well-nourisheda

MNAMalnourished Risk of malnutrition Well−nourished

Factors, (yes vs. no) <17 (n = 28) 17−23.5 (n = 124) > 24 (n = 36) P−value

UTI in preceding year 19 (68)* 54 (44) 11 (31)* 0.040b

Dependent in feedingc 12 (43)* 30 (24) 4 (11)* 0.014b

MMSE 15.6 ± 4.5* 17.7 ± 5.1 19.2 ± 5.3* 0.024d

Abbreviations. MNA = Mini Nutritional Assessment. UTI = urinary tract infection. MMSE = Mini Mental State Examination. *Groups that are significantly different from one another atthe P < 0.05 level. a. Values are given as mean ± SD or as n (%). b. Comparison between participants in the three MNA categories, chi-square test. c. Dependent or partly dependent (needshelp cutting, spreading butter, etc.) versus independent. d. Comparison between participants in the three MNA categories (ANOVA) and post hoc test.


from either participants with malnutrition or those who werewell nourished (Table 3).

Figure 1Overview of the inclusion and exclusion of participants

MMSE = Mini-Mental State Examination; MNA = Mini Nutritional Assessment

Discussion

This study confirms that poor nutritional status is common inolder people dependent in ADLs and living in residential carefacilities. Poor nutritional status was significantly associatedwith having a UTI in the preceding year and with beingdependent in feeding among both women and men, and withcognitive impairment in women.

The major finding of the present study is that poornutritional status was independently associated with UTI inolder people dependent in ADLs and living in residential carefacilities, even after controlling for contributing factors. To ourknowledge, no previous studies have shown this associationamong older people living in residential care facilities.However, a small pilot study found that UTI is common amongolder people with poor nutritional intake, and subsequentweight loss, and living in special units for older people withdementia (25). The association between UTI and poornutritional status is also found among older people with recentadmissions to various hospital settings, who suffer loss ofappetite, chewing problems, and have poor nutritional intakeand poor nutritional status (3, 8). The association between poornutritional status and UTI may be explained by the fact thatpoor nutrition results in an impaired immune system, whichincreases the risk of infections (26). UTI is associated with poorappetite, weight loss, fever, physical malaise (27), lethargy anda change in mental state due to circulation of cytokines in thebody (28). Nutritional demands may increase due toinflammation and increased production of white and red bloodcells, as well as loss of white and red blood cells and protein in

the urine when suffering from repeated and chronic UTI. Inaddition, UTI is often recurrent and sometimes chronic (29).Older people who suffer from recurrent UTIs may have agreater risk of entering into a vicious circle where loss of activecell mass and severe malnutrition is followed by further risk ofinfection and a higher degree of morbidity and mortality. Inaddition, the reduced cell mass can result in lower energyneeds, resulting in a lower nutritional intake that may furtherimpair nutritional status.

The finding that poor nutritional status was associated withlow MMSE scores, after controlling for other contributingfactors, is in agreement with a previous study showing thatmalnutrition is associated with dementia among older peopleliving in nursing homes (12). Notably, our study reveals thatthe association between poor nutrition and low MMSE scoreswas valid only for women and not for men. This was notinvestigated in the previously mentioned study (12). Oneexplanation for this gender difference may be that men withdementia get better help with nutrition, perhaps because alarger proportion of them have a wife who is still living. Otherfactors such as staff gender or age might also play a role in thecare the men receive (30).

After controlling for contributing factors, being dependent infeeding was associated with poor nutritional status. This agreeswith previous studies in residential care facilities (12, 30).Older people may need nutritional support for many reasons,including complications following stroke, neurologicaldisorders, and dementia. Dietary intake may also be affected ifstaff are unengaged, eating environment is unpleasant ordisturbing, or if they have to eat with unfamiliar people (12,30).

Despite a mean BMI of 24.8 (95% confidence interval24.1–25.5), 81% of the participants were classified asmalnourished or at risk for malnutrition according to MNA.However, BMI can be misleading, especially in women, sincemeasurements of height are included in BMI calculation andthis can be difficult to measure in older people due to kyphosis,and height reduction due to osteoporosis and vertebralcompressions (31).

A methodological strength of this study is that the exclusionand inclusion criteria were well defined and the participantswere well described. This makes it possible to replicate thestudy in other residential care facilities. A limitation is that onlyUTIs, which were diagnosed and documented, were included,and no current urine samples or urine cultures were taken whenthe participants were assessed for the study. In addition, it isuncertain whether the poor nutritional status found amongparticipants in our study was caused mainly by UTI or if theirpoor nutritional status contributed to an increased risk of UTIs.

Conclusion

The high prevalence of poor nutritional status amongparticipants dependent in ADLs and living in residential carefacilities is strongly associated with having had UTI during the

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Excluded (n = 299) Did not meet inclusion criteria (n = 216)- Aged <65 years (n = 19)- Independent in personal ADLs (n = 46)- Not able to stand up from a chair withhelp from one person (n = 69)

- MMSE <10 (n = 68)- Physician did not approve (n = 14)Not present at the facility (n = 9)Declined participation (n = 71)MNA not completed (n = 3)

- Not present at the facility (n = 9)Declined participation (n = 71)Assessment of MNA not completed (n = 3)

Assessed for eligibility (n = 487)

Included in the present study (n = 188)


preceding year and to being dependent in feeding. Poornutritional status is also associated with lower MMSE scores inwomen. Therefore, it is important to detect, prevent and treatmalnutrition in older people in residential care facilities sincethis may reduce the incidence of UTI. More knowledge isneeded about how to help older people with cognitive andfunctional impairments living in residential care facilities, withtheir nutritional intake, in order to prevent development of poornutritional status. Prospective observational and randomizedcontrolled trials among older people living in residential carefacilities are necessary to gain an understanding of any causalassociations between malnutrition and UTI, and to evaluateprevention of UTIs through dietary interventions.

Conflict of interest: The authors declare no conflicts of interest.

Acknowledgments: We would like to thank the residents and staff at the facilities fortheir cooperation and participation. We would also like to thank Elinor Yifter−Lindgren,Lars Nyberg, Håkan Littbrand, Lillemor Lundin−Olsson, and Nina Lindelöf for theircontributions to this study. This trial was registered at Current Controlled Trials.Registration number: ISRCTN31631302.

Funding sources: The study was supported by grants from the County Council ofVästerbotten, Umeå University Foundation for Medical Research, Erik and Anne−MarieDetlof’s Foundation, and the Swedish Research Council, K2005−27VX− 15357−01A andK2009−69P−21298−01−04, the Swedish Dementia Foundation, and the King Gustaf V´sand Queen Victoria´s Foundation of Freemasons.

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