Nutrition and Medication Management in Home-dwelling Older Adults. Study II: Malnutrition in Older Adults: An Intervention Based on Medication Review and Individual Nutritional Plan
Phase: NA
Conditions: Malnutrition, Polypharmacy, Aged
Sponsor: University of Oslo

Faculty of Medicine                            
University of Oslo 
 
 
 
Institute of Health and Society 
Postal addr.: PO Box 1130 Blindern, 0318 
Oslo 
Visiting addr.: Frederik Holsts hus, 
Kirkeveien 166 (Ullevål sykehus), 0407 Oslo 
Phone: (+47) 22 85 05 50 
Telefax: (+47) 22 85 05 90 
postmottak@medisin.uio.no 
www.med.uio.no/helsam 
Org. no.: 971 035 854 
 
 
 
 
 
 
Nutrition and Medication 
management in home-
dwelling older adults 
 
 Associations between nutritional status and drug therapy 
 Individual tailored nutritional plan and medication 
review, an intervention in the malnourished or those at 
risk 
    
                                                             Protocol, 17.12 2019, Mari Fiske, MD, PhD(c) 
      Clinical Trial unique protocol ID 2017/12883-2 
                        
 
 
 

 
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Nutrition and Medication management in home-dwelling 
older adults 
ABSTRACT 
Malnutrition is common in older adults. The etiology is complex and include unintended 
medication effects. An increasing number elderly with impaired health live in their own homes, 
supported by home nursing service and follow-ups from a General Practitioner (GP). Good 
nutritional status and proper drug treatment can help the older adults to live longer in their own 
homes, maintaining independence and dignity and reducing the need for space in nursing homes. 
The purpose of this study is to investigate the prevalence of malnutrition in older adults (≥70 years), 
who receives home nursing service in two municipalities, and to explore possible associations 
between their nutritional status and ongoing drug treatment. Further we will recruit those who are 
malnourished or at nutritional risk to participate in an interventional follow-up study.  
 The project consists of two sub-studies: 
  I.  
Mapping the nutritional status and medication use of older adults in two 
municipalities. A cross-sectional study. 
 
               II.  
In older adults, who are malnourished or at nutritional risk, investigate the effect of a 
composite intervention with an individual nutrition plan and medication review. A 
pragmatic clinical controlled study. 
 
In order to reach the goal that older adults attain best possible health and quality of life, and allow 
them to live as long as possible in their own homes, prevention and treatment of malnutrition and to 
the degree possible optimal medication treatment is paramount. The study is expected to provide 
knowledge about (a) associations between nutritional status and medication treatment, and (b) effect 
of a composite intervention consisting of individually tailored nutrition plan to improvement of 

 
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their nutritional status and a systematic medication review, specifically evaluating medication with 
gastro-intestinal / nutritional influence. The intervention study involves multidisciplinary 
collaboration in primary health care and user participation. 
INTRODUCTION 
Malnutrition is common in older adults. The etiology is complex and include unintended 
medication effects (1). An increasing number of elderly with impaired health, remain in their own 
homes depending on home nursing service and follow-up from their GP (2, 3). 
Malnutrition is defined as a situation where the lack of energy, protein and/or other nutrients causes 
measurable, adverse effects on body composition and functions. The result is weight loss, muscle 
loss and occasionally altered organ functions (1). Reported incidences of malnutrition in the elderly 
varies depending on the methods used and the thresholds set for the diagnosis (1). The incidence of 
malnutrition among home-dwelling older adults ≥ 65 years is around 5 % (4, 5). Among community 
living persons, who are both old and with impaired health, studies show that around one in ten are 
malnourished (1), while a further 35 % are at risk of developing malnutrition (6, 7). MNA, Mini 
Nutritional Assessment, is one of the most widely used, validated nutritional assessment tools for 
screening in the elderly over 65 years. The short version of MNA, Mini Nutritional Assessment 
short form, MNA-SF (8, 9), is recommended as a screening tool for home-dwelling older adults 
(10). 
Reduced food intake is the main reason for malnutrition, and may be due to decreased appetite, 
discomfort or nausea, chewing and/or swallowing problems, disability, cognitive impairment or 
emotional (e.g. depression) and social conditions (e.g. loneliness). Decreased sense of smell and 
taste, as well as reduced salivary secretion also plays a major role (11). In addition, for certain 
diseases, or after injuries or surgeries, the body has increased energy requirements (1). Limited 
knowledge, interest or attention by health professionals about nutrition and risk of malnutrition, is a 
major reason for the condition being undiagnosed and treatment interventions starts too late (12, 
13). Malnutrition reduces both physical and mental function, increases the risk of complications of 
illness, delays recovery, reduces quality of life, and is associated with increased mortality (1). 

 
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Patients who also suffer from malnutrition are like to stay in hospital up to three times longer than a 
patient with normal nutritional status (14). 
Nutritional therapy is defined as an intervention to alleviate nutrition to meet/satisfy patients' needs 
for carbohydrates, fats, proteins, vitamins, minerals and trace elements (15). Nutritional treatment 
for home- dwelling older adults can lead to weight gain, improved functional levels, reduced 
incidence of falls, and is also likely to have beneficial effects on the immune system (1) as well as 
hand grip strength (16). In sum, increased focus on prevention and treatment of malnutrition will 
not only have a positive effect on older adults wellbeing and quality of life, but can also bring about 
significant improvements in resource utilization and savings in health care (17, 18, 19). 
In recent years, malnutrition in older adults has received increasingly more attention.  In Norway, 
"National Guidelines for the Prevention and Treatment of Malnutrition" (10), was published already 
in 2009, and follow bye "The Diet Manual, a guide in nutrition work in the health and care sector" 
in 2012 (20). Prevention of malnutrition is an area of focus in the patient safety program (21), and 
systematic assessment and follow-up of nutrition for patients is established as a national quality 
indicator for municipal health and care services (22). In 2018 The Norwegian Ministry of Health 
and Care Services came with a quality reform for older persons, “A full life- all your life” (23). 
Food and meals is one of the targets. It is also of value to note that The United Nations have 
proclaimed the decade of Action on Nutrition (2016-2025) (24) 
Modern pharmacological treatment helps many older adults, despite illness and/or loss of function, 
to live active lives and preserve quality of life despite their health problems. Nevertheless, there are 
many challenges associated with medication treatment. Increasingly, attention is drawn to 
unintended side effects, questions are raised about negative health effects as a result of medication 
use and treatment. Normal aging processes alter both the pharmacokinetics and pharmacodynamics 
of drugs, and these changes are often exacerbated by disease (25). A number of frequently used 
drugs can cause side effects that cause or contribute to malnutrition. Mouth dryness due to less 
salvia production and constipation are common among the elderly, and problems increase or are 
often caused by unintended medication effects, e.g. if agents comes with anticholinergic effects. 

 
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Likewise, gastrointestinal ailments such as nausea and discomfort are common medication side 
effects that can easily result in loss of appetite, anorexia and subsequently weight loss, e.g., use of 
cholinesterase inhibitors, SSRIs, bisphosphonate or metformin (26). Side effects of medication are 
often overlooked in the elderly, either because the symptom is perceived as an expression of normal 
aging or as part of symptoms that follows the known disease or as part of the prescribed medication 
regime. 
Older adults are treated with increasingly sophisticated medication regimes, seen as increasing 
numbers of medication (27, 28). Polypharmacy denotes the use of many drugs in the same person, 
however, there is no clear consensus on the definition. Polypharmacy is commonly defined as daily 
use of five or more drugs, while the use of more than 9-10 drugs daily is often regarded as 
pronounced polypharmacy (28). A Norwegian study, reported in 2011 showed that 57% of the 
elderly (≥ 65 years) were prescribed more than five different drugs, while 21% received more than 
ten different drugs (29) Compared to other European countries, Norway has a relatively low 
prevalence of polypharmacy (30). 
Polypharmacy often involves the use of medications that can be unnecessary or even 
contraindicated for the patient (31, 32). To guide and alleviate such challenges, the Norwegian 
General Practice criteria (NORGEP criteria) (33), and the Norwegian General Practice Nursing 
Home ( NORGEP-NH) criteria (34) is developed as a set of explicit criteria for identifying 
pharmacologically potentially inappropriate prescriptions in general practice for patients over 70 
years of age. In this study we choose NORGEP-NH criteria since it is the most updated one, and we 
consider many of the participants are similar to patients living in nursing homes.   
 
A study based on 2008 data from the Norwegian Prescription Register revealed that 1/3 of home-
dwelling older adults, 70 years or older, were prescribed at least one medicine that, based on the 
NORGEP criteria, could be considered as potentially inappropriate and thus potentially harmful. Of 
these, one in five received ≥ 10 drugs (31). Misuse and side effects of drugs can be serious and 
ultimately contribute to, or cause death (35, 36). As part of efforts to reduce inappropriate drug 

 
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treatment and reduce the risk of adverse drug effects, systematic drug reviews are recommended 
(37). 
Polypharmacy is associated with poor nutritional status (38). Malnutrition can relate to unintended 
or adverse drug effects, and is likely to apply primarily to older adults with multiple concurrent 
diseases and with a comprehensive medication regime. A number of diseases also increase the risk 
of malnutrition, hence, conclusive evidence about direct or indirect importance of medication 
treatment to nutritional status can be difficult. However, a Finnish study of home-dwelling older 
adults, where they adjusted for comorbidity, report that use of more than 9-10 medicines correlated 
significantly to reduced nutritional status, whereas in those using 6-9 medications the same 
correlation could not be demonstrated (38).  
The relationship between nutritional status, risk or manifest malnutrition, and medication use is not 
sufficiently explored. To our knowledge, few have previously investigated possible associations 
between nutritional status and medication use, and in particular possible relationships between 
inappropriate and potentially harmful medication treatment and nutritional status. Therefor we sat 
out to examine effects of a composite intervention combining an individualized nutrition plan 
(nutritional therapy) and measures taken as a result of a critically medication review in people who 
are malnourished or at nutritional risk. 
To contribute to more knowledge in this field, we have defined the following three objectives for 
the project "Nutrition and Medication management": 
For adults (> 70 years) we will: 
1. Screen the patients' nutritional status 
2. Describe the patients' medication use, incidence of inappropriate drug treatment and use of 
medicines, potentially leading to loss of appetite, nausea and dry mouth and investigate 
possible associations between nutritional status and drug treatment. 
3. Investigate the impact of a composite intervention with individual nutrition plan and critical 
medication review on elderly people who are malnourished or at nutritional risk. 

 
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"Nutrition and Medication management" is designed as a PhD-project, where these three objectives 
will be the topic of a scientific article each. 
 
METHODS AND MATERIALS  
Subject and setting 
The subjects that will be recruited as participants are older adults (≥ 70 years), receiving home care 
nursing services. They will be recruited from two municipalities in Buskerud County, Norway; 
Øvre Eiker (ØE) and Nedre Eiker (NE). The municipalities are comparable according to population 
composition and services for community living older persons with impaired health and function. ØE 
has approximately 18.500 inhabitants, and NE approximately 24.500 (39).  Ø.E has 25 nursing 
home places in short-time wards and approximately 280 users of home care nursing services. NE 
has approximately 32 nursing home beds in a short time ward, and 390 receivers of home nursing 
services. The participants will be recruited by the home nursing services or by a nurse at a short-
time ward in the nursing home. 
Methods 
The project consist of two sub-studies, addressing the objectives, is described separately: 
Study I 
Nutritional status and medication treatment in home-dwelling older adults 
Design 
Cross-sectional study 
Subject and settings 
Older adults (70 +) receiving regular health care from the home nursing service.  
 
 

 
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Inclusion criteria 
Exclusion criteria  
 
Age 70 + 
 
Receiving home nursing service 
at least  every second week  
 
Medication administrated by 
home nursing service. 
 Informed consent by patient or 
next of kin in case of slightly 
reduced capacity to consent 
• Patient or next of kin refrain from participation 
or do not wish to participate  
 
Measurements 
 MNA-SF: Food intake, weight loss, mobility, psychological stress, neuropsychological 
problems, height and weight according to data collection scheme.  
 Medication in use: A photo of the medicine prescription card will be taken. 
Outcomes 
 Nutritional status, assessed by Mini Nutritional Assessment Short Form (MNA-SF) 
 Potential Inappropriate medication, assessed by use of the Norwegian General Practice 
Nursing home (NORGEP-NH) criteria 
 Medication with high probably to interact with nutrition; causing nausea, poor appetite or 
dry mouth will be recorded. 
 
 
 

 
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Study II: 
Malnutrition in Older Adults. An intervention based on medication review and 
individual nutritional plan. 
Design 
Pragmatically controlled clinical study.  
Subject and settings 
Older adults (70 +)  receiving regular health care from the home nursing service and classified as  
malnourished or at risk of malnutrition, according to MNA-SF.  
Inclusion criteria 
Exclusion criteria 
 Age 70 years or more 
 Receiving home nursing 
service at least each second 
week or more often  
 Medication administrated by 
home nursing service. 
 MNA-SF 0-11 
 Informed consent by patient or 
next of kin 
 Life expectance less than 6 months 
 Serious cognitive impairment or other 
difficulties for cooperation. 
 In need of enteral-/parenteral nutrition 
 Not able to stand up for weight measure 
 The home nursing service are not responsible 
for medication administration /delivery 
 Patient or next of kind do not want to 
participate  
 
To pragmatically control for spill over between intervention and control group, participants 
allocated to the intervention group, will be recruited from one municipality (Øvre Eiker) and the 
control group will be participant from the neighbor municipality (Nedre Eiker). We deem 
geographic diversion as practical and feasible given available resources, as it could be difficult to 
manage and avoid spill-over between the two groups of participants, if we make both intervention 
and control in the same municipality, and especially in the same home nursing district.  Based on 

 
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the principles of complex interventions (40) we will make a consecutive evaluation of the 
interventions and if necessary allow for adjustments. 
The composite intervention consists has two components (A and B): 
Component A: Clinical assessment and critical medication review 
Drawing on information from the medical history, clinical finding according to examination made 
by the principal investigator (trained physician), information from the GP and the findings from 
blood tests, we will make a systematic and critical medication review. This systematic review has 
the following considerations: 
 Are drug-drug unintended interactions likely to occur? Interaction analysis supported by  
https:// www.interaksjoner.no  
 Are there use of potentially inappropriate medication? Assessed based on the Norwegian 
General Practice Nursing - Home criteria ( NORGEP NH-criteria)  
 Could nutritional related problems like loss of appetite, dry mouth, nausea, or 
constipation be attribute to adverse drug effects? Assessed by the list we made of drugs 
who often contributes to these side effects according to The Norwegian Pharmaceutical 
Product Compendium (Felleskatalogen AS) (41). 
Component B: Nutritional intervention- individual nutrition plan                                                       
Drawing on the principles for good nutritional practice, and the national guidelines, this component 
include the following considerations: 
 Nutritional status by use of MNA-SF, and further in- depth nutrition assessment if MNA-SF 
in range 0-11. 
 Assessment of the nutritional needs. 
 Assess food and drink intake with a 3- day dietary record to the estimated nutritional needs. 
 In collaboration with the home nurse, the participant and if possible/ necessary a next to kin, 
focusing on individual problems and develop an individual nutritional plan.  

 
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The project is about a controlled implementation of measures recommended in current national 
guidelines. We will follow a principle known as the “Nutritional Stairs”, and choose interventions 
in the nutritional plan as close to “normal” food as possible. This means that the individual 
nutritional plan takes into account: 
 Physical and mental disorders are diagnosed and optimal treated. (Oral health care included) 
 Intervention to optimize the meal environment and meal itself, e.g., enough light in the 
room, specific tools to make eating possible if necessary, company 
  The frequency of meals, length of night fasting, special diets as energy- and nutrient dens 
diets, consistency customized diet (liquid or solid food) 
 Enriched food and in between meals/snacks  
 Nutritional supplements  
Tabell 1.  An overview of the data collection in the intervention (I) and Control group (C).  
 
Baseline  
4.week 
  
 
12.wee
k 
24.wee
k 
Medical histories 
 
 
 
 
Medical historie  
I 
 
 
I 
Clinical examination and blood tests. 
I 
 
 
 
Admission to hospital and nursing home 
during the last six months  
I/C 
 
 
I/C 
Function 
 
 
 
 
             Heath related quality of life 
I/C 
 
 
I/C 
             Barthel`s ADL-index 
I /C 
 
 
I/C 
Nutrition 
 
 
 
  
BMI (kg/ m2)) 
I /C 
 
I 
I/C 

 
12 
 
 
Baseline  
4.week 
  
 
12.wee
k 
24.wee
k 
Nutritional status (MNA-SF)  
I /C 
 
I 
I/C 
Nutritional assessment  /nutritional related 
problems/ nutritional adjustment according 
to the nutritional plan 
I                  I        
I 
 
  
 
 
 
 
Medication     
 
 
 
 
Numbers of drugs in use 
I/C 
 
I 
I/C 
Drugs in use with high risk for adverse 
effect as  reduced appetite, dry mouth, 
nausea  
I 
 
I 
I/C 
Potentially inappropriate medication 
according to NORGEP-NH-criteria 
I/C 
 
I 
I/C 
 
 
 
 
 
 
The intervention last six months, and participants in the intervention group will receive four visits at 
home; baseline and after 4, 12 and 24 weeks. At baseline and at week 24, the principal investigator 
(trained physician) and the nurse will visit the participants. At week 4 and 12, only the nurse will 
visit them. The control group, are visited by a nurse twice: at baseline and after 24 weeks, and are 
follow-up by the home nurse service and their GP "as usual".  
Drop- out during the study period and reasons for “loss to follow-up (LTFU)” will be registered; 
e.g., moved from the municipality, acute illness that make further participation difficult, admission 
to long time ward in nursing home, or any other reason to withdraw participation. In the 
intervention group, we will on behalf of and subject to the participant’s consent, make an 

 
13 
 
appointment for consultation by the GP, if the clinical assessment suggests undetected diseases or 
diseases not optimal treated. If oral health problems are encountered, we will recommend a 
consultation by a dentist. 
Measurements 
 Mini nutritional assessment short form (MNA-SF) (8). Maximal points is 14.  0 -7 points 
indicates malnutrition. 8-11 points indicate risk for malnutrition. 12-14 points indicates well 
nourished.  
 Barthel`s ADL-index focus on primary activities of daily living, and consist of ten basic, 
everyday activities: eating, bath/ shower, personal hygiene items, to get dresses, control of 
gut and bladder, visit a toilet, move from bed to chair, mobility and to walk up a flight of 
stairs. 
 Health related quality of life, assessed by one simple question “Consider your health, would 
you say it is: excellent- very good- good- pretty good- bad.   
  The Norwegian General Practice Nursing Home (NORGEP-NH) Criteria (34) for 
assessing potentially inappropriate medication in use. NORGEP-NH, is developed for use in 
nursing homes consisting of A: criteria based on single drugs and B) combination criteria 
and C) a list of prescriptions recommended to be considered for discontinuation (Attachment 
1) 
 Use of medicines who we considered to cause nausea, loss of appetite or dry mouth will be 
listed. (Attachment 2) We use The Norwegian Pharmaceutical Product Compendium 
registry of drugs, (Felleskatalogen AS) (41) and clinical experience.  
 
Outcome 
The outcome/effect measures will be analyzed for all included patients, and separately for the 
groups with malnutrition and nutritional risk. 

 
14 
 
• 
Primary outcome measure: relative and absolute weight change in the individual 
participant. 
• 
Secondary outcome measure: Changes in MNA-SF,BMI, p- ADL, health-related quality of 
life, number of drugs in use, number of drugs considered inappropriate, number of drugs 
with high risk causing loss of appetite, nausea and dry mouth. In addition, the number of 
admissions / bed days in hospitals / nursing homes during the project period. 
PROCESSING OF DATA  
We have created an online solution for collection of these sensitive data, including photos of the 
medication prescription card. The data will automatically be stored in a secure database at the 
University of Oslo (TSD). We create a link key to link the personal identified information to the de- 
identified data. The key linking the participant to the collected research data is stored separately. 
Further analyses will be performed in the secure database. 
STATISTICAL ISSUES - analyses  
Primary outcome in study II, changes in body weight, is used to calculate the necessary sample 
sizes. A mean difference of 5 % is considered to be a clinically relevant difference between the 
intervention group and the control group. Based on significance level of 0, 05 and power at 80 %, 
and a SD for intervention/control = 2, 3 / 3, 0, the number of participants is calculated to 40, 20 in 
the intervention group and 20 in the control group. Five individuals will be added in each group in 
case of drop-out / LTFU.   
Descriptive statistic as frequencies and standard deviations will be used to understand the baseline 
characteristics of the participants. To understand changes in weight by time, we will use the 
multiple linear regression model. Estimate of inter-cluster correlation coefficient (ICC) will support 
considerations of level of variability who characterized the difference between the participations. 
MNA-SF as score ranged from 0-14, will be categorized in three ordinal categories; 0-7 
(malnourish), 8-11 (nutritional risk) and 11-14 (well nourish). To explore factors associated with 
risk for MNA-SF score, ordinal logistic regression model will be used.  

 
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ETHICAL CONSIDERATIONS AND DATA PRIVACY  
Participants will provide written, informed consent prior to inclusion in the study. Among the 
elderly who receive home care nursing, there is high likelihood of varying degrees of cognitive 
decline/dementia, and reduced consent capacity. At the same time, these individuals belong to a 
group with particular risk of malnutrition. In the case of inclusion of participants with reduced 
consent capacity, consent from the next of kin will be obtained. If the patient's cognitive decline is 
so pronounced that it complicates participation in the project, the person is not included in this 
study. The control group will receive the follow-up/treatment for patients with nutritional and 
medication related challenges in the relevant municipality.  
The project is about a controlled implementation of measures recommended in current national 
guidelines. The individualized nutrition plan is knowledge-based, and the measures will not involve 
any dangers or discomfort to the participants. The critical medication review aims to reduce the risk 
of drug-related unintended consequences or adverse effects, and is expected to benefit the 
participants in the intervention group. The GP will be informed about the study before the start and 
will be informed when their patients are included. 
The project is approved by The Norwegian National Committees for Research Ethics, Region 
South-East B. Approval Number: 2018/1045B. Privacy as well as proper storage and processing of 
collected data is taken care of through data storage in the TSD.  
 
PROJECT ORGANIZATION / ASSOCIATION 
Mari Fiske is a specialist in general medicine, physical medicine and rehabilitation. She is a nursing 
home physician in a 50 % position in Øvre Eiker municipality. She was appointed as a fellow in 50 
% position at the Department of Health and Society, University of Oslo (UiO), 1.2. 2018. Mari 
Fiske is responsible for conducting the study. She attends the National Research School in General 
Medicine (NAFALM). Applicant was admitted to the PhD program at the University of Oslo, 
27.8.2018. The supervisors are Professor Jørund Strand (general medicine) and Professor Anne 
Moen (nursing science), both at the Institute for Health and Society, UiO. 
 

 
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FUNDING AND TIME SCUDULE  
Until November 2019: Under the guidance of Straand and Moen, Mari Fiske has completed work 
on the study protocol, prepared a web form and collected data from the ØE  and NE to study I. 
Planned assignments in 2018 and 2019 has been postponed due to prolonged absence in connection 
with serious illness in the immediate family. As of November, 2019, 313 are included in Study I. A 
start of Study II is scheduled for January 2020. A PhD project with a timeframe of 4 years is 
planned. The project is financed by the Norwegian Research Fund for General Practice. The aim is 
to promote a new application to the Research Found annually. 
• 2020: MF works in 50% position with project. 
• 2021 and 2022: MF works 100% on the project.  
 
The project (by Øvre Eiker municipality) has been granted innovation funds from the County 
Governor of Buskerud (NOK 350,000). We therefore have the opportunity to "free" personnel from 
the home care nursing service for work related to the study, as well as hire a nutritionist, etc. 
 
PUBLISHING 
The findings from the studies are planned to be published in the form of three articles in 
international scientific journals (working titles): 
 
 Nutritional status of older adults with home nursing services. A cross-sectional study in two 
Norwegian municipalities (Study I) 
 Associations between drug treatment and nutritional status in older adults with home nursing 
services. A cross sectional study (Study I). 
 Does an intervention composite of Individual Nutrition Plan and critical Medication Review 
improve nutritional status, functional ability and quality of life, and does the intervention 
reduce hospital- and nursing- home admissions?  A pragmatically controlled clinical study 
(Study II). 

 
17 
 
Current authorship rules are followed. In addition to scientific publishing, results and experiences 
from the project will be communicated to the health and care services in the two municipalities 
concerned and otherwise in various professional forums and in the media. 
 
STATUS for project work (10.9.2019) 
Of 234 included participants from ØE to study I, 9% (21 participants) were malnourished, assessed 
by MNA-SF. 53.4%, (125 participants) are at nutritional risk. This therefore suggests that it will be 
possible to include a sufficient number of participants to the intervention group in study II. As of 
November 2019, 75 participants from Nedre Eiker are included in study I. New users of home 
services in Øvre Eiker (with start-up services after July 17) will also be included in Study I in fall 
2019 and 2020. Scheduled start-up for Study II in January/February 2020. 
 
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30. Fialová, D, Topinková E, Gambassi et al. Potentially Inappropriate Medication Use Among Elderly Home Care Patient in Europe, JAMA, 
Mach 16, 2005-Vol293, No. 11 
31. Nyborg G, Straand J, Brekke M. Inappropriate prescribing for elderly- a modern epidemic? Eur J Clin Pharmacol (2012) 68: 1085-1094          
32. Viktil KK, Blix HS, Moger TA, Reikvam A (2007) Polypharmacy as commonly defined is an indicator of related problems. Br J Clin 
Pharmacol 63(2):187-195limited value in the 
33. Rognstad S, Straand J, Spigset O, Wyller TB, Brekke M, Fetveit A. Defining explicit criteria for assessing                                              
inappropriate prescriptions to elderly patients in general practice. The Norwegian General Practice (NorGeP) criteria Scan J Prim Health 
Care. 2009; 27:153-9 
34. Nyborg G, Straand J, Kloving A, Brekke M: The Norwegian General Practice-Nursing home criteria (NORGEP-NH) for potential 
inappropriate medication use: a web-based Delphi study. Scan J of Primary care medicine 2015; 33:134-14. 
35. Ebbesen J, Buajordet I, Erikssen J, Brors O, Hilbetrg T, Svaar H, Sandvik L (2001)Drug -related deaths in a department of internal 
medicine. Arch Intern med 161(19); 2317-2323 
36. Wester K, Jonsson AK, Spigset O, Druid H, Hagg S (2008) Incidence of fatal adverse drug reactions; a population based study. Br J Clin 
Phamacol 65(4): 573-579 
37. The Norwegian Directorate of Health, IS-1998, Guide to medication review  
38. Jyrkkä J, Enlund H. Association of polypharmacy with nutritional status, functional ability and cognitive capacity  over a three-year period 
in and elderly population, Pharmacoepidemiology and drug safety 2011; 20: 514-522  
39. Norway Statistic, 3rd quarter 2016 
40. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. (2008). Developing and evaluating complex interventions: the new 
Medical Research Council guidance. BMJ, 337(sep29 1), a1655–a1655  
41. The Norwegian Pharmaceutical Product Compendium (Felleskatalogen AS) 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 

 
19 
 
 
Attachment 1: 
The Norwegian General Practice Nursing Home (NORGEP-NH) criteria for potentially inappropriate 
medication use in elderly (>70 years) 
A: Singel substance criteria 
Regular use should be avoided 
Comments, adverse effects 
1.Combination analgesic codeine/paracetamol 
Poor long-term effects. Constipation, 
sedation, falls 
2.Tricyclic antidepressants (TCAs)1 
Anticholinergic effects, cardiotoxicity 
3.NSAIDs 
High risk of side effects and 
interactions 
4. First generation antihistamines2 
Anticholinergic effects, prolonged 
sedation 
5. Diazepam 
Over-sedation, falls, fractures 
6. Oxazepam: Dosage >30 mg/day 
Over-sedation, falls, fractures 
7. Zopiclone: Dosage >5 mg/day 
Over-sedation 
8. Nitrazepam 
Over-sedation, falls, fractures 
9. Flunitrazepam 
Over-sedation, falls, fractures, 
addiction 
10. Chlometiazole 
Poor safety record. Risk of 
cardiopulmonary death 
11. Regular use of hypnotics 
Over-sedation, falls, fracture 
B: Combination criteria 
    Combinations to avoid 
 
12. Warfarin + NSAIDs 
Increased risk of bleeding 
13. Warfarin + SSRI/SNRI3 
Increased risk of bleeding 
14. Warfarin + ciprofloxacin/ofloxacin/ erythromycin/ 
clarithromycin 
Increased risk of bleeding 
15. NSAIDs/coxibs4 + ACE-inhibitors5/AT2-antagonists6 
Increased risk of kidney failure 
16. NSAIDs/coxibs + diuretics 
Reduced effect of diuretics, risk of 
heart and kidney failure 
17. NSAIDs/coxibs + glucocorticoids 
Increased risk of bleeding, fluid 
retention 
18. NSAIDs/coxibs + SSRI/SNRIs 
Increased risk of bleeding 
19. ACE-inhibitors/AT2-antagonists + potassium or potassium- sparing diuretics 
potassium-sparing diuretics 
Increased risk of hyperkalaemia 
20. Beta blocking agents + cardioselective calcium antagonists Increased risk of atrioventricular block, 
myocardial depression, hypotension, 
orthostatism 
21. Erythromycin/clarithromycin + statins 
Increased risk of adverse effects of 
statins 

 
20 
 
22. Bisphosphonate + proton pump inhibitors 
Increased risk of fractures 
23. Concomitant use of three or more psychotropic drugs7 
Increased risk of falls, impaired 
memory 
24. Tramadol + SSRIs 
Risk of serotonin syndrome 
25. Metoprolol + paroxetine/fluoxetine/bupropion 
Hypotension, orthostatism 
26. Metformin + ACE-inhibitors/AT2-antagonists + diuretics 
Risk of impaired renal function and 
metformin-induced lactacidosis, 
especially in dehydration 
C:  Deprescribing criteria. Need for continued use should be reassessed 8: 
27. Anti-psycotics (incl. “atypical” substances9) 
Frequent, serious side effects. avoid 
long-term use for BPSD10 
28. Anti-depressants 
limited effect on depression in 
dementia 
29. Urologic spasmolytics 
limited effect for urinary incontinence 
in old age risk of anticholinergic side 
effects 
30. Anticholinesterase inhibitors 
temporary symptomatic benefits only. 
Frequent side effect 
31. Drugs that lower blood pressure 
hypotension, orthostatism, falls 
32. Bisphosphonates 
assess risk–benefit in relation to life 
expectancy 
33. Statins 
assess risk–benefit in relation to life 
expectancy 
34. General use of preventive medication 
assess risk–benefit in relation to life 
expectancy 
Notes:1.amitriptyline, doxepine, chlomipramine, trimipramine, nortryptiline; 2.dexchlorfeniramine, 
promethazine, hydroxyzine, alimemazine (trimeprazine); 3.selective serotonin reuptake inhibitors/selective 
norepinephrine reuptake inhibitors; 4.cyclooxygenase-2-selective inhibitors; 5.angiotensin-converting 
enzyme inhibitors; 6.angiotensin II receptor antagonists; 7.from the groups centrally acting analgesics, 
antipsychotics, antidepressants, and/or benzodiazepines; 8.this should be undertaken at regular intervals. 
For criteria 27–29, a safe strategy for re-evaluation is first to taper dosage, then stop the drug while 
monitoring clinical condition; 9.risperidone, olanzapine, quetiapine, aripiprazole; 10.behavioural and 
psychological symptoms in dementia. 
Reference: 
Nyborg G, Straand J, Kloving A, Brekke M: The Norwegian General Practice-Nursing home criteria 
 (NORGEP-NH) for potential inappropriate medication use: a web-based Delphi study. Scan. J of Primary care  
 medicine 2015; 33:134-14. 
 
 

 
21 
 
Attachment 2: 
 
 
 
 
 
 
 
 
 
 
 
Drugs who often contributes to side effects as nausea, loss of appetite and dry mouth (NAD) 
 
ATC 
 
 
side effects 
C03DA01 
Spirolakton 
 
Nausea is a prevalent 
side effect 
M01A 
NSAIDs 
 
Risk for gastrointestinal 
ulceration  and nausea 
can be the main 
symptom 
 
Opioides 
 
Central nausea 
stimulating effect 
C01AA05 
Digoxin 
 
Nausa and loss of 
appetite. Especially with 
high serum level 
A06A 
Laxatives 
 
Nausea and 
gastointertinal  
discomfort 
C013CA01 
Diuretics 
 
Nausea and 
gastointertinal  
discomfort 
C08 
Calsium antagonists 
 
Nausea and 
gastointertinal  
discomfort 
C10AA 
Statins 
 
Sometimes nausea is a 
side effect. 
N06A 
Antidepressants; (SSRI) 
Wenlafaxin 
 
Sometimes nausea is a 
side effect. 
Frequent 
gastrointestinal side 
effects 
J01 
Antibiotics 
 
Some antibiotics has a 
nausea-stimulating 
effect (erythromycin) 
A10B A 
Metformin 
 
Loss of appetite 
M05B A 
Bisphosphonates 
 
Erosions in oral cavity 
and esophagus 
B03A 
Iron treatment 
 
Erosions + constipation  
B01AC06 
Acetylsalisylic acid 
 
Gastro4intestinal ulcera 
and erosions 
N06D A 
Anticholinesterase inhibitors 
 
Gastrointestinal 
discomfort 
 
The drugs listed below has anticholinergic side effects: 
Dry mouth, constipation, cognitive impairment 
 
 
 
(ADS) 
 
Antidepressants 
 
 
 
N06AA04 
Anafranil (TCA) 
Klomipramin 
 
3 
N06AA06 
Surmontil (TCA) 
Trimipramin 
 
3 
N06AA09 
Sarotex (TCA) 
Amitryptilin 
 
3 
N06AA10 
Noritren (TCA) 
Nortriptilin 
 
2 

 
22 
 
N06AA11 
Sinequan (TCA) 
Doksepin 
 
3 
N06AB05 
Paroxetin; Seroxat( SSRI) 
Paroxetin 
 
2 
N06AB10 
Esitalopram (Cipralex) Citalopram (Cipramil) 
Citalopram 
 
1 
N06AX11 
Mirtazapin (Remeron) 
Mirtazapin 
 
1 
 
Antipsykotics 
 
 
 
N05AA02 
Nozinan 
Levopromazin 
 
3 
N05AB03 
Trilafon 
Perfenazin 
 
2 
N05AB04 
Stemetil 
Proklorperazin  
1 
N05AH02 
Clozapin, Leponex 
Klozapin 
 
3 
N05AH03 
Olanzapin, ZypAdera, Zyprexa 
Olanzepin 
 
2 
N05AH04 
Quantiapin; Seroquel 
Quetiapin 
 
1 
N05AF03 
Truxal 
Klorprotiksen 
 
3 
 
Antihistamins 
 
 
 
N05BB01 
Atarax 
Hydralyzin 
 
3 
R06AB02 
Phenamin 
Deksklorfenamin 
 
 
3 
R06AD01 
Vallergan 
Alimenazin 
 
3 
R06AD02 
Phenergan 
Prometazin 
 
3 
R06AE05 
Postafen 
Meklozin 
 
3 
R06AX13 
Loratadin, Clarityn 
Loratadin 
 
 
 
Urologic spasmolytics 
 
 
 
G04BD04 
Kentera 
Oxybutinin 
 
2 
G04BD07 
Detrusitol 
Tolterodin 
 
3 
G04BD08 
Vesicare 
Solifenazin 
 
2 
G04BD10 
Emselex 
Darifenazin 
 
1 
G04BD11 
Toviaz 
Fesoterodin 
 
3 
G04CA03 
Sinalfa 
Terazosin 
 
 
N02A 
A/B/E/J/X 
Opiates 
 
 
1 
 
C: Cardiovascular system 
 
 
 
C02 
Antihypertensiva 
 
 
 
C013CA01 
Diuretics ;Furosemid, Diural,Furix,Lasix 
 
 
1 
C01DA8/14 Isosorbid; Imdur,Monoket, 
Sorbangil 
 
 
1 
C01AA05 
Digoxin 
 
 
1 
L01 
L: Antineoplastic drugs: 
Imurel, Sandimun 
 
 
 
1 
R01 
R: Rhinolytica 
 
 
1 
R03A 
R: Antiasthmatics, adrenergic for inhalation 
 
 
1 
N04 B 
Parkinson´s medication: Levodopa 
 
 
1 
J01 
Antibiotics:Amoxicillin, 
ampicillin,gentamycin,klindamycin,piperacillin,vancomycin 
 
 
1 
ATC= The Anatomical Therapeutic Chemical Classification System, ADS= Anticholinergic Drug Scale 

 
23 
 
Ref: Carnahan RM, Lund BC, Perry PJ, Pollock BG, Culp KR. The anticholinergic drug scale as measure of drug- related anticholinergic burden: 
association with serum anticholinergic activity. J Clin Pharmacol 2006; 46: 1481-86 
The Norwegian Pharmaceutical Product Compendium