Supporting the self-management of hypertension: Patients' experiences of using a mobile phone-based system.

Globally, hypertension is poorly controlled and its treatment consists mainly of preventive behavior, adherence to treatment and risk-factor management. The aim of this study was to explore patients' experiences of an interactive mobile phone-based system designed to support the self-management of hypertension. Forty-nine patients were interviewed about their experiences of using the self-management system for 8 weeks regarding: (i) daily answers on self-report questions concerning lifestyle, well-being, symptoms, medication intake and side effects; (ii) results of home blood-pressure measurements; (iii) reminders and motivational messages; and (iv) access to a web-based platform for visualization of the self-reports. The audio-recorded interviews were analyzed using qualitative thematic analysis. The patients considered the self-management system relevant for the follow-up of hypertension and found it easy to use, but some provided insight into issues for improvement. They felt that using the system offered benefits, for example, increasing their participation during follow-up consultations; they further perceived that it helped them gain understanding of the interplay between blood pressure and daily life, which resulted in increased motivation to follow treatment. Increased awareness of the importance of adhering to prescribed treatment may be a way to minimize the cardiovascular risks of hypertension.

Nutritional status and associated factors on geriatric admission.

INTRODUCTION: The proportion of elderly patients who are undernourished is high and undernutrition has serious health implications. No consensus exists regarding nutritional screening measurements suitable for elderly patients. There is a need to identify risk factors for undernutrition in elderly patients to enable prevention and treatment. AIM: To identify clinically identifiable risk factors for undernutrition in geriatric patients on admission. METHODS: Newly admitted patients (n=196, mean age 83.7 years) were examined for nutritional risk factors by the nursing staff. Analyses of variance and multiple regression analyses were used to identify risk factors for undernutrition. RESULTS: Undernutrition was present in 41% of the patients using a Body Mass Index cut-off < 22 (kg/m2) as definition of undernutrition. Poor appetite, oral cavity problems, constipation and nausea or vomiting were frequent problems; the patients also used a high number of medical preparations, including preparations that induced nausea. No help with cooking before admission, poor appetite, oral cavity problems and high age were all significantly associated with undernutrition. CONCLUSION: To improve nursing care and to prevent undernutrition, it is recommended to routinely examine the patient's mouth and teeth on admission and to assess patients not only for their physical condition (appetite, oral health and nutritional status), but also for their living conditions e.g. help with cooking.

Distress and coping in cancer patients: feasibility of the Icelandic version of BSI 18 and the WOC-CA questionnaires.

The aim of this study was to test the feasibility of two instruments within an Icelandic context, the Brief Symptom Inventory 18 (BSI 18) and the Ways of Coping Inventory--Cancer Version (WOC-CA) with specific focus on gender and type of treatment and coping techniques among cancer patients during time of treatment. The sample consisted of 40 cancer patients in three oncology outpatient clinics in Iceland, 53% were women and 47% men. The majority of the participants belonged to the age group 51-70. Cronbach alpha, means, confidence intervals and standard deviations were used for analysis as well as Mann-Whitney U-test for testing differences between genders in relation to psychological distress and coping. Anxiety was the factor causing the greatest distress, mainly reported by patients receiving chemotherapy. More women experienced depression than men, women (18.4%), men (8.3%). Distancing was the most frequently reported coping strategy, and men seemed to focus on the positive side more often than women did (P < 0.01). Although the results should be approached with caution, as the sample size was small, they do provide support for the strength of the measurements. Also the findings indicate that gender differences should be taken into account.

Patients' experiences of living with peripheral arterial disease awaiting intervention: a qualitative study.

The aim of this study was to investigate patients' experiences of living with peripheral arterial disease (PAD) and the influence on activities of daily living. Twenty-four patients with various degrees of PAD were interviewed. The transcribed texts were analysed using manifest and latent content analysis. Living with PAD meant carrying a hard-to-bear physical, social and emotional burden, and struggling for relief. The experience of burden was interpreted in the following themes representing consequences and strategies for gaining control in daily life: (I) "being limited by the burden" (II) "striving to relieve the burden" (III) "accepting and adapting to the feeling of burden". The use of different coping strategies was crucial to achieve some relief. Pain and sleep disturbance emerged as a major feature of living with PAD, and by combining both analgesics and non-pharmacological methods some pain relief was received. To provide optimal alleviation of pain for these patients, education about pain and pain management is of great importance followed by regular evaluations of the pain and pain management. Furthermore, the study underlines the importance of preventing the progression of the vascular disease and from the individual power and knowledge support and preserve as independent life as possible.

The meaning of having to live with cancer in old age.

Little is known about how older people with cancer experience their life situation. To increase the understanding of how illness is experienced in older people with cancer, the aim of this study was to investigate the meaning of living with cancer in old age. The hermeneutic phenomenological method as described by van Manen and referred to as 'phenomenology of praxis' was used. Ten persons (seven women and three men) aged 75 and over, who had a diagnosis of cancer and who had just completed cancer treatment, were interviewed in their own homes. The analysis revealed a life world affected to varying degrees by the cancer disease. The lived experiences across the interviews were revealed in four overarching essential themes: transition into a more or less disintegrated existence, sudden awareness of the finiteness of life, redefinition of one's role in life for good and for bad, meeting disease and illness. To provide individual support and appropriate care to older people with cancer it is important for health care professionals to identify and take care of disabilities and to support the reorientation in the disintegrated life situation. It is also important to have preparedness to meet the old person's thoughts about death. Thus, it is important to encourage the old person to describe her/his illness experience to increase understanding about what is meaningful for her/him.

Quality of life of elderly persons with newly diagnosed cancer.

The aim was to investigate quality of life (QoL) in elderly persons newly diagnosed with cancer (65+ years) in relation to age, contact with the health-care system, ability to perform activities of daily living (ADL), hope, social network and support, and to identify which factors were associated with low QoL. The sample consisted of 101 patients (75 women and 26 men) newly diagnosed with cancer. EORTC QLQ-C30, Nowotny's Hope Scale, Katz ADL and the Interview Schedule for Social Interaction (ISSI) were used. The analysis was carried out in four age groups and revealed no significant differences in QoL. Compared with the other age groups, those of a high age (80+ years) more often lived alone, used more home-help service and had a smaller social network. Factors associated with low QoL were 'no other incomes than retirement pension', 'low level of hope' and 'lung cancer'. In addition, 'being told that the cancer disease has not come to an end', 'needing more help in activities of daily living', 'getting help from grown-up children' and 'needing help with PADL' were associated with low QoL. Those at risk of inferior QoL, that is, having poor economy, low level of hope and lung cancer need special attendance and specific interventions to improve QoL.

Quality of life in older people with cancer -- a gender perspective.

The aim of this study was to investigate quality of life (QoL) and its association with sense of coherence (SOC), complaints, comorbidity, social resources, perceived economic situation and receiving help for daily living, investigating differences between women and men aged 75 and above with cancer and comparing women and men aged 75 and above without cancer. A further aim was to identify which of these factors were associated with low QoL in older people with cancer. The sample consisted of women (n = 74) and men (n = 76) with the inclusion criteria aged 75 and above and a cancer disease, and a matched comparison group of women (n = 64) and men (n = 74) without cancer. EORTC QLQ C-30, SF-12 and SOC-13 were used. Women with cancer were more vulnerable than their male counterparts in QoL, SOC, perceived economic situation and social resources. Factors associated with low QoL in older people with cancer were receiving help for daily living, comorbidity, degree of complaints and pain. From a caring perspective the findings suggest a focus on symptoms and treatment, to acquire an understanding of how a cancer disease, comorbidity and various complaints affect QoL and independence in older women and men and to intervene accordingly. It also suggests that socio-economic and social problems and needs influence their treatment and care and therefore should be in focus.

Health-related quality of life after osteoporotic fractures.

OBJECTIVE: To estimate the impact of osteoporosis fractures on health-related quality of life (HRQOL) in postmenopausal women. METHODS: To compare the impact on HRQOL of different osteoporotic fractures, 600 consecutive women 55-75 years old with a new fracture (inclusion fracture) were invited by mail. After exclusions by preset criteria (high-energy fractures, ongoing osteoporosis treatment, or unwillingness to participate), 303 women were included, 171 (56%) of whom had a forearm, 37 (12%) proximal humerus, 40 (13%) hip, and 55 (18%) vertebral fracture, respectively, and all were investigated and treated according to the current local consensus program for osteoporosis. In addition, HRQOL was evaluated by the SF-36 questionnaire and compared with local, age-matched reference material. Examinations were performed 82 days (median) after the fracture and 2 years later. RESULTS: HRQOL was significantly reduced at baseline regarding all SF-36 domains after vertebral fractures and most after hip fractures, but only regarding some domains after forearm and humerus fracture. After 2 years, improvements had occurred after all types of fractures, and after forearm or humerus fracture, HRQOL was completely normalized in all domains. However, 2 years after hip fracture, HRQOL was still below normal regarding physical function, role-physical and social function, while after vertebral fracture, scores were still significantly lower for all domains, physical as well as mental. Patients with one or more previous fractures before the inclusion fracture had lower HRQOL at baseline and after 2 years, compared with those with no previous fracture. Patients with osteoporosis (T-score <-2.5 in hip or spine) had lower HRQOL than those with normal BMD. CONCLUSION: Vertebral and hip fractures have a considerably greater and more prolonged impact on HRQOL than forearm and humerus fractures. The number of fractures was inversely correlated to HRQOL. These differences should be taken into account when making priorities in health care programs.

Oral health problems in elderly rehabilitation patients.

A combination of poor oral hygiene and dry mouth may be hazardous to the oral health status. However, systematic assessments in order to detect oral health problems are seldom performed in the nursing care of the elderly. The aims of this study were to investigate the occurrence of oral health problems measured using the Revised Oral Assessment Guide (ROAG) and to analyse associations between oral health problems and age, gender, living conditions, cohabitation, reason for admission, number of drugs, and functional and nutritional status. One registered nurse performed oral health assessments using ROAG in 161 newly admitted elderly patients in rehabilitation care. Oral health problems were found in 71% of the patients. Thirty per cent of these patients had between four and eight problems. Low saliva flow and problems related to lips were the most frequent oral health problems. Problems in oral health status were significantly associated with presence of respiratory diseases (problems with gums, lips, alterations on the tongue and mucous membranes), living in special accommodation (low saliva flow, problems with teeth/dentures and alterations on the tongue), being undernourished (alterations on the tongue and low saliva flow) and being a woman (low saliva flow). The highest Odds ratio (OR) was found in problems with gums in relation with prevalence of respiratory diseases (OR 8.9; confidence interval (CI) 2.8-27.8; P < 0.0005). This study indicates the importance of standardised oral health assessments in order to detect oral health problems which can otherwise be hidden when the patients are admitted to the hospital ward.

Nottingham Health Profile and Short-Form 36 Health Survey questionnaires in patients with chronic lower limb ischemia: before and after revascularization.

OBJECTIVE: The purpose of this study was to compare the usefulness of the Nottingham Health Profile (NHP) and the Short-Form 36 Health Survey (SF-36) as general outcome measures after vascular intervention for lower limb ischemia with respect to patients' quality of life, on the basis of validity, reliability, and responsiveness analyses. PATIENTS AD METHODS: Eighty patients, 40 with claudication and 40 with critical ischemia, were assessed before and one month after revascularization by using comparable domains of the NHP and the SF-36 questionnaires. RESULTS: The SF-36 scores were less skewed and were distributed more homogeneously than the NHP scores. Discriminate validity results showed that NHP was better than SF-36 in discriminating among levels of ischemia with respect to pain and physical mobility. For both questionnaires, the reliability standards were satisfactory in most respects. The NHP was more responsive than the SF-36 in detecting within-patient changes. All of the NHP domains not zero at baseline were improved significantly one month after hemodynamically successful revascularization for patients with claudication, whereas patients with critical ischemia showed significant abatement of pain and improvements in physical mobility and social isolation. The SF-36 scores indicated a significant decrease in bodily pain and improvements in physical functioning and vitality for patients with claudication, and decrease in bodily pain and improvement in physical functioning for patients with critical ischemia. CONCLUSIONS: The findings indicated that both NHP and SF-36 were reliable. The SF-36 scores were less skewed than the NHP scores, whereas NHP discriminated better among levels of ischemia and was more responsive in detecting quality-of-life changes over time than SF-36 in these particular patients.

Eating difficulties in relation to gender, length of stay, and discharge to institutional care, among patients in stroke rehabilitation.

PURPOSE: To describe and compare eating difficulties from admission to discharge, with regard to length of stay (LOS) and discharge to institutional care, as well as in relation to gender. METHOD: Patients, aged 65 or above, admitted for stroke rehabilitation, having at least one eating difficulty were observed (n =108) as regards to eating on admission and at discharge. Analysis followed earlier findings in which eating difficulties had been found to have three components, i.e. ingestion, deglutition and energy. RESULTS: Of the components, ingestion difficulties were the most common, followed by low energy. The most common single difficulties were low food consumption, difficulties in manipulating food on the plate and transporting it to the mouth. Ingestion difficulties especially decreased during the rehabilitation period. Women were older and ate less on admission and at discharge than men, improved less than men, and also a higher proportion had a low food intake at the time of discharge if having longer LOS and/or being discharged to institutional care. Patients with longer LOS and those discharged to institutional care had more eating difficulties on admission and were more dependent in activities of daily living (ADL) than those with shorter LOS and those who returned home. LOS was mainly explained by ingestion difficulties on admission and low age. Discharge to institutional care was explained by living alone before admission, ingestion difficulties at discharge, male gender and high age. CONCLUSIONS: Ingestion difficulties on admission indicate a longer in-hospital stay and decrease to a greater extent than other types of eating difficulties. If these difficulties persist at the time of discharge the patients are more likely to need institutional care. It is important to assess and take systematic measures for each of the three variants of eating difficulties, i.e. ingestion, deglutition, and energy, to improve eating abilities. Women in particular need attention with regard to low food intake.

Perspectives of elderly people receiving home help on health, care and quality of life.

From a nursing perspective it is important to have information about the type of care needed, the reasons care is needed and quality of life among the most elderly people living in their own homes, in order to support their independence and maximise their quality of life. Thus a study was performed to investigate people aged 75 years and older dependent on care from professionals and/or a next of kin, their functional health, diseases, and complaints in relation to quality of life as perceived by themselves. The sample (n = 448) comprised those who, in an age-stratified randomised sample of adults living in their own homes, responded that they were dependent on help from others. The questionnaire covered sex, age, living conditions, civil status and number of children and cohabitation, respondents' health, diseases, quality of life, help from another person, and the type and amount of help received. The number of elderly persons dependent on help ranged from 18.5 to 79.1% in the different age groups. The help came mainly from informal carers (84.1%), and, in 53.1% of cases, from the home help service and home nursing care. Help from formal caregivers was given in combination with that from a next of kin in 38.8% of the cases. More next of kin than formal carers helped in all Instrumental Activities of Daily Living (IADL) and Personal Activities of Daily Living (PADL) tasks, with the exception of cleaning the house and providing a bath/shower. Although the respondents received help themselves, they also helped another person in 6.5% of cases. The elderly reported a median of three diseases and ten different complaints of which pain and impaired mobility were the most frequent. Between 20 and 40% of the respondents in the different age groups reported restricted ability to be alone and one third of them reported low or very low quality of life. Multiple linear regression analysis showed the number of complaints, restricted ability to be alone, living alone and age to have a significant relationship on low quality of life.

Eating difficulties, complications and nursing interventions during a period of three months after a stroke.

AIM: The aim of this study was to describe eating difficulties and especially swallowing in patients with dysphagia, types of nursing intervention, and the development of complications over 3 months. The aim was also to explore common characteristics of eating difficulties that influenced the ability to finish meals. METHODS: Twenty-four consecutive patients admitted because of stroke and dysphagia were included. Nursing interventions, based on assessments, were individually designed. RESULTS: Three subgroups could be identified: those (n=9) who were unable to complete a meal, despite assisted feeding, because of reduced alertness/energy and impaired swallowing function; those (n=5) who could complete a meal, despite suffering from reduced alertness/energy; and those (n=10) who could complete meals with minor difficulties. Patients in the first two groups developed complications such as respiratory infections and/or malnutrition. There was a tendency towards that complications in the third group were less frequent and the hospital stay was significantly shorter than in the other groups. CONCLUSION: The level of alertness/energy in patients with dysphagia after stroke was important for the ability to eat and swallow and the development of complications over time, and thus of great importance for the interventions applied.

Actions seen as demanding in patients with severe dementia during one year of intervention. Comparison with controls.

Behaviours, viewed by nurses as demanding, performed by patients with severe dementia were investigated during one year of intervention. Supervised implementation of individually planned care and systematic clinical supervision were implemented on one experimental ward (EW) while another ward (CW) served as control. Each ward had 11 patients. At baseline and after 6 and 12 months of intervention structured interviews with the patients' assigned nurses were conducted based on the Demanding Behaviour Assessment Scale and Multi Dimensional Dementia Assessment Scale. At the EW there was a decreased frequency (p=0.000) and a reduced occurrence of physical behaviours (p=0.008), a decreased frequency (p=0.029) and a reduced occurrence of vocal behaviours (p=0.002). No significant changes were seen at the CW. Bearing the small sample size in mind, the findings indicate that individually planned care and systematic clinical supervision could be a means of reducing the frequency, and/or effect the nurses' attitude and interpretation of the patients' behaviour as demanding. The findings, however, can only be seen as indications for further research, but point to the importance of including effect variables related to patients when intervening in nursing care.

Recognising pain in older adults living in sheltered accommodation: the views of nurses and older adults.

Sixty-six randomly selected older adults and their contact nurses participated in interviews based on standardised assessments of pain and open-ended questions focusing how pain was expressed and recognised. The sample included older adults with normal as well as cognitively impaired function. Seventy-nine percent of older adults with normal cognition were often in pain. Contact nurses assessed pain in 57% of cognitively impaired older adults. The content in the statements showed that pain recognition was a communicative interactive process based on verbal and non-verbal expressions. The process comprised attempts to understand the cause and intention of the expression and to verify the presence of pain. Changes in mood, facial expressions and physiological responses were described less often by older adults than by their nurses. Contact nurses of cognitively impaired older adults judged immobility as the source of pain, that it was possible to see when the person was in pain and that pain was expressed by paralinguistic and body language more often than contact nurses of cognitively healthy older adults. Characteristics of nurses and older adults could facilitate or hinder pain recognition. The findings indicate a need for reflective discussions in the staff group focusing on how to perform systematic assessments of verbal and non-verbal expressions and of hindrances and facilitators for recognising pain in older adults.

The meaning of preceptorship: nurses' lived experience of being a preceptor.

AIM OF THE STUDY: This phenomenological study is aimed at illuminating nurses' lived experience of the process of preceptoring and the meaning of preceptorship in a Swedish context. METHODS: Seventeen nurses from the North of Sweden with varied previous experience of preceptorship volunteered to participate. Their narratives, describing their experience of being a personal preceptor for a student nurse during practical training on a hospital ward in the third year of a 3-year diploma programme within a university college of nursing in Sweden, were transcribed verbatim. A phenomenological-hermeneutic interpretation disclosed the themes 'sheltering the students when learning' and 'facilitating the students' learning', together with eight sub-themes, which created an understanding of the meaning of preceptorship. FINDINGS AND DISCUSSION: The meaning of preceptorship was understood as reducing the risk of the students learning helplessness and empowering the students when learning in practice. The meaning of preceptorship highlighted the need for further preceptor support and development of the role of the preceptor. On the basis of the findings, suggestions were made to increase the preceptors' awareness of values in nursing practice and use of pedagogical strategies in the process of preceptoring. Through such strategies a reciprocal development of the preceptors' and the faculty's knowledge may take place, to the best advantage of the students' learning and the development of the profession.

Acute confusional state in elderly orthopaedic patients: factors of importance for detection in nursing care.

OBJECTIVES: The aims of this study were to identify factors of significance in the development of acute confusional state (ACS) and the differences between patients who developed ACS and those who did not. METHOD AND RESULTS: Assessment, observations and interviews with 505 patients admitted to an orthopaedic clinic revealed that 51 patients developed ACS during their in-hospital stay. Patients admitted for hip fracture had a higher incidence of ACS (20.2%) than patients admitted for elective surgery for coxarthros or gonarthros (3.6%). The highest hazard ratio for ACS was several other physical diseases 15.94 (CI: 4.60-55.31 and p-value <0.00001) and the lowest was age 1.10 (CI: 1.04-1.15 and p-value <0.0002). The ACS lasted from 1 to 9 days, and patients had one (N=42), two (N=8) or three episodes (N=1) of confusion during their stay on the ward. More patients who developed ACS before surgery had two or more confusional episodes and emergency patients developed ACS more rapidly. The ACS lasted longer in patients with a higher score on the OBS scale at admittance and with rapid development of ACS. CONCLUSIONS: Acuteness in the situation seems an important risk indication for ACS in the elderly. Awareness of factors associated with the development of ACS makes it possible to more systematically identify those at risk, for instance by systematic assessment in the first interview with the patient on admission to hospital.

A 1-year follow-up quality of life study after hemodynamically successful or unsuccessful surgical revascularization of lower limb ischemia.

PURPOSE: The impact of hemodynamically successful or unsuccessful bypass grafting or angioplasty on patients' quality of life was assessed throughout the first year postsurgery. METHODS: A total of 146 patients, 97 patients who underwent successful revascularization and 49 patients who underwent unsuccessful revascularization, were assessed for quality of life with the Nottingham Health Profile. RESULTS: Hemodynamically successful revascularization resulted in an immediate and lasting impact on the patients' quality of life. Despite hemodynamic failure, patients had improvements in pain, emotional reactions, sleep, and family relationships at the 1-year follow-up assessment. A successful revascularization in patients with claudication demonstrated the most marked quality of life benefits, including all health dimensions that were not normal at baseline. Patients with critical ischemia had improved quality of life for pain, sleep, and physical mobility. High ankle pressure, in the claudicant group, and a high sense of coherence were significantly associated with high quality of life. CONCLUSION: The treatment of lower limb ischemia resulted in an immediate and relatively lasting improvement in patients' quality of life. Patients who underwent hemodynamically successful bypass grafting procedures or angioplasty demonstrated higher quality of life benefits than patients who underwent a failed bypass grafting procedure. Quality of life was further determined by means of the patients' sense of coherence.

Acute leukaemia or highly malignant lymphoma patients' quality of life over two years: a pilot study.

The aim of this study was, first, to investigate the quality of life and sense of coherence for acute leukaemia and malignant lymphoma patients at the start of treatment and over 2 years. A second aim was to compare questionnaire responses with patients' statements in open-ended interviews. A consecutive sample of 16 patients responded to the Quality of Life Questionnaire (QLQ-C30), Lund Gerontological Centre questionnaire and the Sense of Coherence Scale at the start of treatment and after 12 and 24 months. The QLQ-C30 questionnaire was administered also after 4, 8, 16 and 20 months. Tape-recorded open-ended interviews were conducted every 4 months before the patients responded to the questionnaires. Quality of life (QoL) and sense of coherence were scored more highly at the beginning of treatment for patients who did not relapse, than for those who relapsed. This difference remained throughout the study period. There was no correspondence in responses between questionnaire and personal interviews, although the results from the interviews, in some aspects, validated the result from the QLQ-C30. Those patients who relapsed may have had different prerequisites or been in a worse position at the onset of the disease and, reasonably, they needed more compensatory nursing care. More knowledge about the correspondence between a person's perceived QoL when discussed in personal interviews compared with responses given in standardised QoL questionnaires is needed before any assumption about clinical relevance can be made.

Eating difficulties, need for assisted eating, nutritional status and pressure ulcers in patients admitted for stroke rehabilitation.

The aim of this study was to describe the types and extent of eating difficulties, the need for assistance when eating, the nutritional status and pressure ulcers in consecutive patients (n = 162) admitted for stroke rehabilitation over a period of 1 year. Structured observations and assessments of eating, nutritional status (subjective global assessment of nutritional status), pressure ulcers and activities in daily living (Katz ADL-index) were performed by a nurse who also trained the staff to perform these assessments. Difficulties in eating were found in 80%, and 52.5% were unable to eat without assistance. Eating difficulties were: 'eats three-quarters or less of served food' (60%), difficulties in 'manipulating food on the plate' (56%), 'transportation of food to the mouth' (46%), 'sitting position' (29%), 'aberrant eating speed' (slow or forced) (26%), 'manipulating food in the mouth' (leakage, hoarding, chewing difficulties) (24%), 'swallowing difficulties' (18%), 'opening and/or closing the mouth' (16%), and 'alertness' (9%). Thirty-two percent were undernourished (49% of patients needing assisted eating and 13% of those not needing assistance, P < 0.0005). Among patients who were dependent in one or more functions according to the Katz ADL-index, 15% had pressure ulcers. The strongest eating variables for predicting nutritional status were 'alertness', 'swallowing difficulties', 'eats three-quarters or less of served food', and 'aberrant eating speed'. Nutritional status could in turn significantly predict pressure ulcers. Eating difficulties among patients with stroke are complex and the patient's situation before stroke adds to this complexity, especially among those dependent on assisted eating. As difficulties occur both among patients needing and not needing assisted eating, all patients with stroke admitted for rehabilitation need to be systematically assessed for eating difficulties and action needs to be taken to facilitate eating, especially as patients with eating difficulties risk becoming undernourished and in turn developing pressure ulcers.