Nutritional Status and Cognitive Function Among Urban And Rural FIlipino Community-dwelling Elderly

NUTRITIONAL STATUS AND COGNITIVE FUNCTION AMONG URBAN

AND RURAL FILIPINO COMMUNITY-DWELLING ELDERLY

A Thesis Presented to the Faculty of the

Institute of Graduate Studies of the

Far Eastern University

Manila

In Partial Fulfillment of the Requirement

For the Degree of

Master of Arts in Nursing

By

Lucky P. Roaquin, RN

March 2013


Institute of Graduate Studies

N. Reyes St., Sampaloc

Manila 1008, Philippines

APPROVAL SHEET

In the fulfillment of the requirements for the degree of MASTER OF ARTS IN NURSING

specialized in MEDICAL-SURGICAL NURSING, this graduate thesis entitled NUTRITIONAL

STATUS AND COGNITIVE FUNCTION AMONG URBAN AND RURAL FILIPINO

COMMUNITY-DWELLING ELDERLY has been prepared and submitted by LUCKY P.

ROAQUIN, RN is hereby recommended for approval.

DR. EUFEMIA OCTAVIANO, RN, MAN

Thesis Adviser

Approved and accepted by the Committee on Oral Examination with as grade of PASSED, on the

12th day of March year of our Lord, 2013.

PANEL OF EXAMINERS

DR. ROSALINDA P. SALUSTIANO, RN, RM, MAN

Chairman

DR. VICTOR T. TABUZO DR. MARILYN COLADILLA Prof. GLORIA YANG

Member Member Member

NUTRITIONAL STATUS AND COGNITIVE FUNCTION AMONG URBAN

AND RURAL FILIPINO COMMUNITY-DWELLING ELDERLY

A Thesis Presented to the Faculty of the

Institute of Graduate Studies of the


Manila

In the Fulfillment of the Requirement

For the Degree of

Master of Arts in Nursing

By


March 2013

ABSTRACT

Aim: The objective of this study was to determine nutritional status of urban and rural Filipino

community dwelling elderly and examine its relationship measures of cognitive function.

Methods: A total of 40 elderly who are living in urban and rural community were selected

through non-probability purposive sampling to participate in this study. The Mini Nutritional

Assessment (MNA) tool was used to determine the nutritional status of the UFCoDE and

RFCoDE while the Montreal Cognitive Assessment (MoCA) tool was used to measure the

cognitive function of the UFCoDE and RFCoDE. Data gathered were statistically analyzed using

the parametric inferential statistics. Informed consent was administered prior to the study.

Results: It was found out that most of Filipino elderly who are living in the community was at

risk of malnutrition (50% UFCoDE; 40% RFCoDE) and malnourished (15% RFCoDE). The

cognitive function of the UFCoDE and RFCoDE revealed that 65% had mild cognitive

impairment among the UFCoDE with mean score falling under same indicator, while 60% had

mild impairment among RFCoDE with mean score falling under moderate cognitive impairment.

The nutritional status among the UFCoDE and RFCoDE showed statistically related to their

cognitive function (p values <0.05). In addition, there was no significant difference among the

UFCoDE and RFCoDE in terms of their nutritional status, while there showed a significant

difference on their cognitive function. Conclusion: The nutritional status was significantly

related to the cognitive function among the UFCoDE and RFCoDE. Furthermore, intensive

research focusing on this subject must be done thereafter.

ACKNOWLEDGMENT

“Don’t count what you have for you may find an end. But rather let them count

for you and you will find no end.” Lucky P. Roaquin, RN

The success of this research proposal will not be possible without the few notable people

who supported, inspired, motivated and assisted me all-throughout my journey as I write the

concepts juggling in mind.

I would not come into a realization that this paper was greatly needed in the healthcare

industry without the people who will be part of it. To my elderly family, who had been my

greatest inspiration in the edifice of this research study, who continuously uplift and empower

themselves to be heard.

The teachings and words of encouragement I received from my most beloved mentor, Dr.

Eufemia Octaviano, who helped, is helping and will be helping me to exemplify the apposite

behavior of being a leader of change in our society.

Graduate school wouldn’t be this much fun, adventurous and challenging without my

companions, my friends, and my colleagues in the FEU - Institute of Graduate Studies, who have

been sharing a lot of knowledge and once in a lifetime personal experiences with them. They

have been one of my few inspirations to be more knowledgeable on my chosen field of expertise.

This paper wouldn’t be doable without the outstanding and honorary lecturers of the FEU

– Institute of Graduate Studies, especially to Dr. Rosalinda Salustiano, who made a huge

contribution in the fulfillment of this paper. They had been my ‘amino acids’ that served as the

building blocks of my advocacy to promote and protect our elderly in the community.

The numerous efforts of those people, who helped me with my study, Ms. Macy Monsod

of Nestle Philippines and Ms. Tina Brosseau of CEDRA for assisting in the approval of tools that

the researcher had utilized; and Mr. Roel Golimlim of Brgy. Bagumbuhay, Quezon City and Mr.

Castor Cayaba of Brgy. Dagupan Centro, Tabuk City for their approval in conducting the

researcher’s study.

And most importantly, I praise the Lord our God, the ultimate source of all wisdom, who

is the source of my refuge, my strength, my light, and my guide as I walk along the path of life.

- Lucky P. Roaquin, RN

DEDICATION

To My Dad

&

To My Mom

TABLE OF CONTENTS

Approval Sheet

PRELIMINARIES PAGE

Title Page ………………………………………………………………………………… i

Abstract …………..……………………………………………………………………… ii

Acknowledgement ………………………………………………………………………. iii

Dedication ……………………………………………………………………………….. v

Table of Contents ……………………………………………………………………….. vi

List of Tables ……………………………………………………………………………. viii

List of Figures …………………………………………………………………………… ix

CHAPTER

I THE PROBLEM AND ITS BACKGROUND

Introduction ……………………………………………………………………… 1

Significance of the Study ………………………………………........................... 3

Statement of the Problems ………………………………………………………. 5

Hypothesis ……………………………………………………………………….. 6

Theoretical Framework ………………………………………………………….. 6

Conceptual Paradigm ……………………………………………………………. 10

Scope and Limitation ……………………………………………………………. 12

Definition of Terms ……………………………………………………………… 13

II REVIEW OF LITERATURE

Review of Related Literatures

Facts and Figures about Elderly Nutrition and Cognition ………………. 14

Nutrition Plays a Definite Role …………………………………………. 15

The Culture in Nutrition ………………………………………………… 20

Nutrition on Cognition amongst the Elderly: Studies Revealed ………… 22

Synthesis ………………………………………………………………………… 26

III RESEARCH METHODOLOGY

Research Design ………………………………………………………………… 28

Population and Sample …………………………………………………………. 29

Research Locale ………………………………………………………………… 30

Research Instrument ……………………………………………………………. 31

Data Collection Procedure ………………………………………..…………….. 34

Statistical Treatment ……………………………………………………………. 35

Ethical Consideration …………………………………………………………… 38

IV RESULTS AND DISCUSSION ……………………………………………… 39

V SUMMARY, CONCLUSIONS AND RECOMMENDATION ……............. 50

REFERENCES

APPENDICES

A Letter of Request Seeking Permission to Conduct Study

A.1. Brgy. Bagumbuhay, Quezon City, Philippines

A.2. Brgy. Dagupan Centro, Tabuk City, Kalinga, Philippines

B Letter of Request Seeking Permission to Utilize Research Instruments

B.1. Nestle Philippines

B.2. Center for Diagnosis & Research on Alzheimer’s Disease

C Utilized Research Tools

C.1. Mini Nutritional Assessment (MNA) Tool

C.2. Montreal Cognitive Assessment (MoCA)Tool

D Informed Consent

D.1. For Urban Filipino Community-dwelling Elderly

D.2. For Rural Filipino Community-dwelling Elderly

E Raw Data of Gathered Information

F FCEPE: Focus Care Enhancement Program for Elderly

G Curriculum Vitae

LIST OF TABLES

TABLE PAGE

1 Nutritional Status of Urban Filipino Community ……………………. 39

Dwelling Elderly Based on Mini Nutritional

Assessement

2 Nutritional Status of Rural Filipino Community ……………………. 40

Dwelling Elderly Based on Mini Nutritional

Assessement

3 Detailed Results of Cognitive Function of Urban ……………………. 42

Filipino Community Dwelling Elderly by Areas

Based on Montreal Cognitive Assessment

Philippines (MoCA-P)

4 Summary Results of Cognitive Function of Urban ……………………. 43

Filipino Community Dwelling Elderly Based on

Montreal Cognitive Assessment


5 Detailed Results of Cognitive Function of Rural ……………………... 43

Filipino Community Dwelling Elderly by Areas

Based on Montreal Cognitive Assessment


6 Summary Results of Cognitive Function of Rural ……………………. 44

Filipino Community Dwelling Elderly Based on

Montreal Cognitive Assessment


7 Significant Relationship Between the Nutritional ……………………. 45

Status and Cognitive Function of Urban and

Rural Filipino Community Dwelling Elderly

8 Significant Difference Between the Urban and ………………………. 47


in terms of Nutritional Status

9 Significant Difference Between the Urban and ………………………. 48


in terms of Cognitive Function

LIST OF FIGURES

FIGURE PAGE

1 Maslow’s Hierarchy of Needs …………………………………………. 7

2 Leininger’s Sunrise Enabler Model ……………………………………. 8

3 The Relationship of Nutritional Health Status and ……………………. 10

Cognitive Function among Urban and Rural

Filipino Community-dwelling Elderly

4 Process of the Data Gathering Procedure ……………………………... 34

CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Introduction

The creation of this research study had been of influenced by the eagerness of the

researcher to uplift the health and wellness of Filipino elderly who are living in urban and rural

areas. Demographic shifting is dynamic. In this era, the paradigm of population may change and

that, population of the elderly might change its course. Inclusion of the care for our elderly

patients has been left behind, given the least priority and taking much less consideration in the

plan of and delivery of care.

As part of being a Filipino, it has been instilled in the society the importance of respect to

the elderly population. This trait had been an inspiration of the researcher to conduct such study.

The importance of nutrition among the elderly has been given emphasis by the researcher to

enhance the well-being of the elderly in the Philippines whether they are living in the urban areas

or the rural community.

To enhance the welfare the elderly in the society, the government had planned and

promulgated the so-called Republic Act 9994 or the “Expanded Senior Citizens Act of 2010”.

This Act includes benefits targeted not only to basic commodities which include availment of

food to sustain health and well-being but also educational assistance, as mandated on the law.

And from the 1987 Philippine Constitution, it was stated on Article XIII, Section 2 on

Health/Social Services likewise mandates: “The State shall adopt an integrated and

comprehensive approach to health development which shall endeavor to make essential goods,

health and other social services available to all people at affordable cost. There shall be priority

for the needs of the underprivileged sick, elderly, disabled, women and children.”

Furthermore, it has been of great importance that the researcher had chosen this topic to

promote additional working research on this field of expertise. Thus, there were little or less

studies that were established in the country especially with regards to the health and welfare of

the elderly population. There was a high prevalence of malnutrition among our elderly

population (BAPEN, 2007) and yet, awareness on this specific health issue in this population

was low (ENHA, 2005). In the Philippines alone, there was high prevalence of underweight as

well as overweight among Filipino elderly where undernutrition was a major problem among

elderly at 27.0% of the 70 years old and over and 17.7% of the 60 - 69 years old (Capanzana, et.

al., 2008).

Malnutrition has been associated with compromised cognitive capacity in the elderly

(Wells, et. al., 2006). According to Jernigan (2012), without the proper food, one’s biosystem

will become listless and disinterested, thus, elderly person suffering from malnutrition may

develop memory decline and answering simple questions will be impossible. Early detection of

malnutrition is important since it has been associated with diminished cognitive function,

mobility, and a diminished ability to care for one's self (Eriksson, et. al., 2005).

The elderly in our society, being one of the many recipients of care, attends to or holds to

different cultural practices acquired from his or her roots of generation. Thereby, including

culture care in the interventions rendered by professional caregivers is essential in order to

alleviate sufferings – disease-caused illnesses or psychological imbalances – thus, preserving,

maintaining and enhancing their way of living that includes health practices and self-care

regimens.

Significance of the Study

The study was conducted because the researcher wanted to investigate the relationship of

nutritional status and cognitive function of elderly as well as their differences among urban and

rural Filipino community-dwelling elderly. This will serve as a medium or a reference for

appropriate interventions in the nutritional and cognitive care for the elderly in the Philippines.

Nursing Practice

This study emphasized on the impact of nutrition to the cognition of the elderly. It will

provide details on how to give necessary plan of actions, series of interventions and the inclusion

of cultural care in the management of well and sick elderly. It will also give birth to different

strategic approach of nutritional care in the universality and diversity of gerontology nursing.

Furthermore, the study will strengthen and enhance the nutritional development programs

necessary to the promotion and support of the elderly well-being.

Nursing Service & Administration

On the other hand, the results of the study will hasten new and effective practice that will

help the entire healthcare team in the procurement of the delivery of care for the elderly. As

nurses and leaders, it is another responsibility to look for new and useful ways of intervening

care to our elderly patients with the integration of culture in our plan of care.

Nursing Education

This study will develop new and effective contribution to the body of knowledge that can

be taught to future leaders of the healthcare system. The information embodied in this research

will supplement students’ critical thinking, analysis, and adaptation of trans-cultural nursing in

the field of their practices. This study will abet the students to be more diligent, knowledge-

equipped and value-driven nurses towards the care for the elderly. Thus, improving the quality of

care rendered and the standards of practice encapsulated in the nursing curriculum and practice.

Nursing Research

The study will encourage other healthcare professionals in the investigation of culturally

competent care rendered to every individual across each nation. It will develop further

understanding on the concepts of care and culture in a multifarious society. This will widen the

horizon of evidence-based nursing research in the field of trans-cultural and gerontology nursing.

It will aide in the formation of effective and efficient tools in measuring cultural competencies of

nurses specifically in the care for the elderly.

Society

This study will give realization to the existence of the “known-yet-unknown” quandary

encountered by the elderly population. This study will give importance on the empowerment of

this vulnerable population through nutritional interventions, such as autonomy on food

preferences and choices, for sustainability and functionality. Moreover, this study will enable the

society to act as protectors of the elderly especially in terms of their right to adequate

nourishment and enhancement of optimum level of wellness.

Statement of the Problem

The study intended to investigate the relationship of nutritional status and cognitive

function of elderly as well as their differences among the urban and rural Filipino elderly who

are living within the community. Specifically, this study sought to answer the following

inquiries:

1. What is the nutritional status of urban and rural Filipino community-dwelling

elderly?

2. What is the cognitive function of urban and rural Filipino community-dwelling

elderly?

3. Is there a significant relationship between nutritional status and cognitive function

among urban and rural Filipino community-dwelling elderly?

4. Is there a significant difference in the nutritional status between urban and rural

Filipino community-dwelling elderly?

5. Is there a significant difference in the cognitive function between urban and rural

Filipino community-dwelling elderly?

6. Based on the study, what care enhancement program can be developed for the

elderly?

Hypothesis

From the problems of the study, the researcher’s assumptions are based on the following

hypotheses:

H01: There is no significant relationship between the nutritional status and cognitive

function of urban Filipino community-dwelling elderly.

H02: There is no significant relationship between the nutritional status and cognitive

function of rural Filipino community-dwelling elderly.

H03: There is no significant difference between urban and rural Filipino community-

dwelling elderly in terms of nutritional status.

H04: There is no significant difference between urban and rural Filipino community-

dwelling elderly in terms of cognitive function.

Theoretical Framework

The researcher based this study on two theories regarding nutrition and culture care.

These theories were Maslow’s Hierarchy of Human Needs and Leininger’s Theory of Culture

Care, Diversity and Universality.

Maslow’s Hierarchy of Human Needs

When physiologic and psychosocial changes among elderly are not appropriately

addressed, errors in management and poor

outcomes may ensue (Geist & Kahveci, 2012).

According to Smeltzer & Bare (2006),

human needs are addressed on the basis of priority that once essential needs are met, the person

experiences a need on a higher level. As explained further by Cherryb (2012), physiologic needs

such as nutrition, hydration, oxygenation, and sleep are the most basic and instinctive needs in

the hierarch; hence, it is essential for survival and growth.

Figure 1:

Maslow’s Hierarchy of Needs* *source:http://www.consciousaging.com/Transpersonal%20Psychology/Conscious%20Aging%20-

%20Maslow's%20Hierarchy%20of%20Needs.aspx

Maslow (Maslow, 1943) conceptualized human needs as a five-dimensioned pyramid that

is aligned according to its intrinsic and extrinsic human necessity. He explained that humans

need to attain all his basic requirements at the base level before attending to the higher form of

human fundamental needs. Age, being a part of human existence, does not influence the cyclical

nature of this theory. Physiologic needs, when met, unmet, or partially met, motivate all people,

regardless of age, gender, social and civic status, in aiming to meet basic necessities of vitality.

Leininger’s Theory of Culture Care, Diversity and Universality

The elderly in our society, being one of the many recipients of care, attends to or holds to

different cultural practices acquired from his or her roots of generation. Thereby, including

culture care in the interventions rendered by professional caregivers is essential in order to

alleviate sufferings – disease-caused illnesses or psychological imbalances – thus, preserving,

maintaining and enhancing their way of living that includes health practices and self-care

regimens.

Figure 2:

Leininger’s Sunrise Enabler Model* *source: http://leiningertheory.blogspot.com/2010/07/sunrise-enabler-l-eininger-developed.html

Nursing limited its scope into four metaparadigms: the concepts of person, environment,

nursing, and health. Leininger enhanced further the governing ideas that shape the practice of

nursing thus, not limiting only to the four metaparadigms of nursing. This then, gave birth to the

Theory of Culture Care, Diversity, and Universality. Furthermore, this theory is of great

importance as Leininger (2010) embedded in her theory that in order for a care to be competent,

she [the nurse] must take into account the cultural beliefs, caring behaviors, and values of

individuals, families, and groups. Nevertheless, environmental context was also defined as one of

her metaparadigms to be the “totality of an event, situation or particular interactions that give

meanings to human experiences, interpretations and social interactions in particular physical,

ecological, sociopolitical, and/or cultural settings (Leininger, 1991, as cited by Leininger &

McFarland, 2010). Therefore, the integration of culture as part of the environment in caring for

the elderly is necessary in order to render a proficient nursing care.

Kalinga is a vast area filled with hills, valleys, mountains and rice terraces. More than

half of the province’s area is suitable for agriculture and produces a bounty of rice, corn, cassava,

coffee, mangoes, pineapples, and legumes. Primarily, the people of Kalinga were farmers thus;

farming is the most common livelihood of the province. Rice is the main food staple among the

Kalingas. Most of the elderly were living with their respective families and their main source of

income mostly comes from agricultural business such as farming. There were only few Kalinga

elderly who were educated through college level. Most of the Kalinga elderly were high school

graduates and undergraduates.

Being the second largest city in Philippines, Quezon City has been a center for commerce

and industry. It has a large population of elderly. This urban area has a lot of infrastructures such

as shopping malls and amusement parks. The economy is greatly developed unlike in Kalinga

where it strives to be more developed. Most of the elderly were with their families and the main

source of their income comes from their children’s financial assistance or monthly premiums of

their retirement. They are more engaged to business like small sari-sari store. Elderly in this

urban area were well- educated comprising from college undergraduate to post-graduate level.

Conceptual Paradigm

The relationship of the concepts of the study can be further explained on Figure 3 as

depicted below.

Figure 3:

Assessment of Nutritional Status and Cognitive Function among

Urban and Rural Filipino Community-dwelling Elderly:

Basis for the development of

Focus Care Enhancement Program for Elderly

The fundamentals of this research study was deeply rooted in the concepts and ideas

made upon on the theory of Maslow and Leininger. As discussed earlier, a person should sustain

and fulfill the deficiency on the lower level before he or she attains his or her higher level of

need. And according to Leininger, healthcare professional should be known of the cultural

background and presentation of the population. The way people deal with their everyday struggle

is affected by the culture rooted in their existence.

The study was related in such a way that the research to be conduct will be based in the

nutritional and cognitive aspects of health, as it was discussed in the Hierarchy of Needs, and the

similarities and differences of cultural practices of the elderly in terms of their nutrition. In

addendum, the researcher will be conducting this research to investigate the relationship of

nutrition to the cognition of elderly, as well as the differences and similarities of nutritional

status of urban and rural Filipino community-dwelling elderly.

Adequate intake of nutrients and good hydration maintains and improves optimum well-

being, which includes enhanced cognitive functioning, of the elderly population. On the contrary,

deficiency of appropriate nutrients and minimal hydration of our elderly may impose great effect

on the mental health of this population, which includes mild cognitive impairment (MCI).

As part of human practices and way of living, nutrition has been actualized on the culture

of every individual in the society. Nutrition is greatly influenced by the cultural environment of

the elderly. Their nutritional preferences had been affected by the socioeconomic factors, social

norms and standards, and health-related beliefs.

Furthermore, the comparison of the urban and rural communities will then be the basis

for more culturally competent nursing skills on the nutritional aspect of the elderly. In addition,

the theory of Leininger was further elaborated in this study and not just encapsulated its

paradigms on the universality and diversity of the theory but, on the similarities and differences

of elderly on the same country but of different community.

The results of the study will then be centered on the enhancement of elderly nutrition and

cognition through different recommendations as further discussed on Chapter V of this study.

Scope and Limitations of the Study

The study focused on the relationship of nutritional status to cognitive function in the

elderly and the differences of urban and rural Filipino community-dwelling elderly. This study

aimed to explore the impact of nutrition to the cognition of elderly from both different

environments. Moreover, the study was confined on the nutritional health aspect of the elderly in

relation to their cognitive functioning. Well-being and fraility among the elderly are not included

in the scope of this study. In addition, elderly who were institutionalized or hospitalized situated

in the community was not included in the study, henceforth; those elderly who are engage in a

residential home care activity were not be included.

Definition of Terms

The following terms were operationally defined by the researcher in the intention to use it

according to the processes of the study.

Cognitive Function (CF) refers to the intellectual processes which involve memory, speech,

creativity, reasoning, analysis, and decision making. It is the ability of the elderly to perceive,

comprehend, and scrutinize concepts into a formation of pertinent ideas.

Community-dwelling Elderly (CoDE) refers to those old adults aging 60 and above who are

living in the community independently or with their respective families. They are not confined in

any geriatric facility or institutions.

Nutritional Status (NS) refers to the state of health among the elderly which involves dietary

intake, hydration and consumption of nutrients desirable for well-being and functioning.

Rural Filipino Community-dwelling Elderly (RFCoDE) refers to the old adults of 60 years

old and above who are naturally born citizen from the Philippines. At the same time, they are

living in the rural or municipality areas of the Philippines.

Urban Filipino Community-dwelling Elderly (UFCoDE) refers to the old adults of 60 years

old and above who are naturally born citizen from the Philippines. At the same time, they are

living in the urban or city areas of the Philippines.

CHAPTER II

REVIEW OF LITERATURE

This chapter presents the abundance of literature and research studies that were gathered

and collated from book, journals and articles, pertinent to the study. It has been categorized on

three interrelated concepts. First, it will give a brief and accurate summary on the concepts about

the role of nutrition, its source and importance among the elderly population. Second, it will give

a precise overview on the cultural aspect of nutrition based on the two distinct environments.

Third, it will give robust information about the relationship of nutrition to the cognition among

the elderly. And lastly, it will give a synthesis that will give explanation on the important factors

of this study as compared to other researches.

Facts and Figures about Elderly Nutrition & Cognition

Malnutrition is a state of nutrition (under or overnutrition) in which a lack of protein,

energy and other nutrients causes measurable adverse effects on tissue and/or body form,

composition, function or clinical outcome (Nestlé Health Science, 2012). Furthermore, Saava, et.

al. (2006) defined malnutrition as “an inadequate nutritional status or under-nourishment

characterized by insufficient dietary intake, muscle wasting and the weight loss leading to poor

health and the decreased quality of life, it might be precipitated by the loss of appetite,

loneliness, the chronic illness, physical and psychological elements that all together potentially

impact morbidity, mortality and the quality of life in the older age.”

There was a high prevalence of malnutrition among our elderly population (BAPEN,

2007). Of all the elderly aging 80 years and over, 35 percent of them were malnourished; 25 to

35 percent was 60 to 80 years of age; 25 percent of them were below 60 years of age.

Malnutrition is not just a problem among elderly in an institution – whether hospital or home

care (ENHA, 2005). It was also prominent among older people treated in the community. In the

conference paper of Wait (2005), 15 to 40 percent of older adults living in the community are

malnourished.

With the high prevalence of malnutrition among our elderly in the community, awareness

on this specific health issue in this population was low (ENHA, 2005). According to Bacon

(2005), a survey about the awareness of malnutrition among UK family doctors showed that 88

percent of the respondents were not aware of any nutritional screening tool designed to identify

patients at risk of malnutrition and 40 percent never provided dietary advice to patients at risk of

malnutrition prior to an elective admission to hospital (Nutricia Clinical Care/doctors.net.uk:

2005).

Nutrition Plays a Definite Role

As we age, there are changes within our body that occur inevitably. Ageing process

(Kirkwood, 2006 as cited by Denny, 2008) is the biological changes that result from a lifelong

accumulation of molecular damage in the cells and organs that constitute the human body,

eventually disrupting the cell’s ability to make the energy they need to function. According to

Brunner (2008), cellular changes of old age cause an alteration in the physical appearance and

functional decline. The body’s ability to maintain homeostasis becomes increasingly diminished

with cellular ageing, and organ systems cannot function at full efficiency because of cellular and

tissue deficits. These changes may lead to reduced appetite, body weight loss, malnutrition, and a

compromised immune system (Lichtenberg, 2010).

Dudek (2007) described that food nourishes the mind as well as the body broadens

nutrition to an art as well as a science. For most people, nutrition is not simply as food but rather

the quality, frequency and amount of food intake. Moreover, good eating habits established early

in life promote health maintenance throughout adulthood. And the development and progression

of degenerative diseases are influenced by lifelong eating habits.

Adequacy in the nutrient intake of the elderly has been in the topmost priority in the plan

of care; yet nutritional deficiencies and malnutrition occur frequently and are an area of major

concern (Ebersole, et. al., 2005). Malnutrition (Maher, et. al., 2012) is defined as an imbalance of

nutrients caused by either an excess intake of nutrients of nutritional deficits which causes ill-

effect on the health and well-being of an older adult and (Wells, et. al. 2006) has been associated

with compromised cognitive capacity of the elderly.

Nutrition, as other physiologic needs, is of great importance in every individual’s vitality.

According to Nordqvist (2009), nutrition is the supply of materials – food – required by

organisms to stay alive. It also focuses on how diseases, condition, and problems can be

prevented or lessened with a healthy diet. Therefore, nutrition status is fundamental to the quality

of life in the ageing person as it is closely associated with an older person’s functionality and

ability to remain independent (Lichtenberg, 2010).

According to Resnick (2007), nutrition is important among elderly because it has an

impact on their functional performance, thus, inadequacy of food intake can result to weight loss

and loss of muscle mass interfering mobility and ambulation.

Having enough amount of nutrient intake is essential at any age population especially our

vulnerable residents in our society, the older adults. From the article of Beattie (2012), a 1990

survey by Ross Laboratories found that 30 percent of seniors skip at least one meal a day, while

another study found that 16 percent of seniors consume fewer than 1000 calories a day, which is

insufficient to maintain adequate nutrition. There are many reasons why a senior may skip a

meal, from forgetfulness to financial burden, depression to dental problems, and loneliness to

frailty.

For the older adults in our society, nutrition is of great beneficial in their vitality. In the

article of Segal & Kemp (2012), the benefits of healthy eating include increased mental alertness,

resistance to illness and disease, higher energy levels, faster recuperation times, and better

management of chronic health problems.

According to Baker (2007), there are at least 45 chemical compounds and elements found

in foods that are essential to human cells. They were classified into five main groups:

carbohydrates, proteins, fats, minerals, and vitamins. These nutrients have their specific roles in

maintaining a healthy body among the elderly. Carbohydrate (Rutherford, 2011) serves as the

source of energy for the body through the conversion of sugar into glucose. Protein (Paddon-

Jones & Rasmussen, 2009) is important in the diet of the elderly since it preserves the skeletal

mass in ageing. Aside from storing energy, fat (Tchkonia, et. al., 2010) is important in immune

and endocrine function, thermoregulation, mechanical protection, and tissue regeneration.

Vitamins and minerals (Saibil, 2011) are essential among the elderly since they keep the bones

and teeth strong, promote health blood circulation and wound healing, maintains the function of

the kidney, preserve normal skin integrity, and provides adequate immunity.

Nutrition is a broad concept especially that it is not focused on what food we eat but

rather what we eat aside from food. According to Cartz, et. al. (2012), water is essential to health

but is often overlooked. This can result to inadequate level of hydration among the elderly

population. Inadequate hydration (Byles, et. al., 2009) is associated with many adverse

consequences including poor oral health, poor skin integrity, constipation, urinary tract infection,

and confusion, and may contribute to reduced food intake and malnutrition. Furthermore,

sufficient hydration may bring well-being, better quality of life, and improved outcomes for

every older adult (Cartz, et. al., 2012).

According to Jéquier & Constant (2010), water, a vital nutrient, has numerous critical

roles in the human body such that it acts as a building material; as a solvent, reaction medium,

reactant and reaction product; as a carrier for nutrients and waste products; in thermoregulation

and as a lubricant and shock absorber. Consequently, the optimal functioning of our body

requires a good hydration level. The regulation of water balance is very precise and is essential

for the maintenance of health and life.

According to Benton, et. al. (2012), the brain requires adequate nutrition for optimum

growth, development and maturation. Protein, fatty acids (specifically, long-chain fatty acids)

and many micronutrients are essential for the proper structure of brain tissue, healthy

neurochemistry, and the overall growth and maturation of the brain.

On the other hands, oral nutritional supplementation (Milne, Avenell & Potter, 2006) can

improve nutritional status and seem to reduce mortality and complications for under-nourished

elderly. It has been used widely prescribed for older adults both in the hospital and community

settings. Supplements can improve the nutritional status of older people resulting to small but

consistent weight gain. According to Suter (2006), an adequate intake of different vitamins is not

only of importance for the prevention of the development of deficiencies, but also the control of

chronic disease risk. Vitamins may play a role in prevention of the pathogenesis of most chronic

diseases of aging such as decreased cognitive function, cardiovascular diseases, and cancer.

Pharmacology is another factor that influences the intake of necessary nutrients needed

by the optimal functioning of the body, as we reach the age of 65 and older. According to Biggs

(2007), medications play a role in poor nutrition causing anorexia and after taste sensation,

making food tastes bitter, metallic, or sour. The adverse consequences of drug-nutrient

interactions in elderly people can include nutritional deficiency, drug toxicity, loss of drug

efficacy and disease control, and unwanted changes in body weight (Couris, et. al., 2006).

Nutrition greatly affects the functionality of our life especially as we get older. Good and

adequate nutrient intake may improved bone density thus decreasing falls (Bischoff-Ferrari, 2009

through ESPEN Congress), increased muscular strength with exercise (van Loon, 2009 through

ESPEN Congress), and stimulate immune system and sustain mental health (Traister, 2011).

The Culture in Nutrition

Nutrition plays a great role in the society especially in the elderly. And as part of the

health care team, it is our duty to fulfill a role that manages the nutritional intake of every elderly

in the society. As culture influences the nutritional intake of the elderly, every individual who

takes the responsibility in the care for our elderly should have social awareness in this field of

the heath care industry. The holistic approach in the care for the elderly involves the culture care

encapsulated in the paradigms of nursing. The amount of food needed by our elderly is

influenced by how the way of their living, beliefs, practices, and customs.

Physiological changes may be the common denominator of every elderly in the society

across the globe but the uniqueness in their needs, especially in terms of their nutritional health,

made them different from every old ager in the world.

According to Grodner, et.al. (2012), lifestyle and behavior are central to the maintenance

of health and wellness. In order to influence the way of one’s living, healthcare professional

should take into account the values, attitudes, culture, and life circumstances of every individual.

This is then will affect the nutrition and diet intake of every individual especially the elder

populations. Thus, diet and nutrition assessment is imperative to provide culturally competent

care.

As further explained by Giger (2013), nutritional preferences include habits and patterns

that were develop during the childhood as a result of family lifestyle, and ethnic or cultural,

social, religious, geographical, economic, and psychological components. Food also has

symbolic meaning, in some cultures, that has nothing to do with nutritional value. In these

cultures eating becomes associated with sentiments and assumptions about oneself and the

world. In addition food becomes symbolic to people because it can be used as a reward.

Eating habits (Luggen, Bernstein & Touhy, 2008) are influenced by ethnicity which

determines if traditional foods are preserved, and religion where it affects possible food choices.

A variety of reasons including taste, convenience, cost, weight management, disease prevention,

culture, religion, food contents, food accessibility and many more contribute to food selection

(Ree, et. al., 2008). Furthermore, Ree, et.al. (2008) identified that individuals with higher literacy

and income levels were expected to make healthier food choices as compared to their lower

counterparts.

The intake of food has been influenced by the culture that was originated in the roots of

our existence. The selection of what food to eat is governed by forces which include preferences,

choices and likings (Grodner, 2012). As further explained by Grodner (2012), food preferences

are foods we choose to eat when all foods are available at the same time and in the same amount.

Environment greatly affects the preferences of food intake that is usually the result of cultural

and socioeconomic influences. We often adjust our choices to match those that are around us.

Food choices (Grodner, 2012) concern the specific foods that are convenient to choose

when we are actually ready to eat. It is confined by convenience and nutritional value may not be

a prime concern that affects food choice. On the other hand, food liking (Grodner, 2012)

considers which foods we really like to eat.

Food habits in elderly people are not only influenced by the lifetime preferences and by

physiological changes according to aging but also by social aspects such as loneliness, economic

situations or living conditions and disability (Saeidlou, 2011). Furthermore, according to Tomé

(2011), socioeconomic status affects food choices and dietary quality. Food price is among the

many factors that influence old people's food choices. Consequently, it affects energy intake and

nutrient quality of diets.

According to the study of Tanchoco (2011), distinction to the general pattern on food

pattern, consumption, preferences, and preparation had been brought about by the augmentation

of diverse ethnic groups in the different parts of the Philippines. On the other hand, the use of

rice is still the major staple across the land. Vegetables had been in a scant amount in servings, as

well as fruits and dairy products due to their high cost.

Nutrition on Cognition Amongst the Elderly: Studies Revealed

Malnutrition has been associated with compromised cognitive capacity in the elderly

(Wells, et. al., 2006). According to Jernigan (2012), without the proper food, one’s biosystem

will become listless and disinterested, thus, elderly person suffering from malnutrition may

develop memory decline and answering simple questions will be impossible. Early detection of

malnutrition is important since it has been associated with diminished cognitive function,

mobility, and a diminished ability to care for one's self (Eriksson, et. al., 2005).

Nutrition plays a very important role in the promotion of well-defined cognitive

functioning of the elderly. Studies on the effect of nutrients had been established that there is a

connection between the nutritional status and cognitive function among the elderly population.

The intake of nutrients is greatly affected by the culture of every elderly. The dietary intake and

food choices are influenced by historical and cultural factors which include dietary habits, food

preparations and cooking methods (James, 2004).

As the brain is dependent upon a constant supply of nutrients and oxygen for optimum

function, it is not surprising that poor nutrition can be linked with disturbances in the blood

supply to the brain, and hence neurological impairment (Clark, in press as cited by Denny,

2008). Adequate nutrition is critical to preserving the health of older people and an integral part

of health, happiness, independence, quality of life, and physical and mental functioning

(Ebersole, et. al., 2005).

According to Benton, et. al. (2012), cognitive decline and functional disability are clinical

symptoms of dementia, a series of syndromes that reflect damaged and malfunctioning neurons.

There are as many as fifty other causes that include head injury, drugs, alcohol, and specific

nutritional deficiencies. Nutrition may modulate cognitive processing. For example, nutrients

such as folate and vitamin B-12 are required for genome maintenance, and iron or copper

overload can exacerbate homeostatic imbalance in redox pathways.

Adequate water intake (Holdsworth, 2012) is a fundamental part of a balanced diet and in

addition to its importance for physical performance and mental function. Dehydration affects

health, wellbeing and performance, which includes cognitive function and motor control, as well

as contributing to morbidity in several chronic disease processes.

As part of nutrition, hydration is vital in the cognitive functioning of the brain. According

to the article of Norman (2012), nutrition and hydration are part of a foundation for healthy

learning. Water is essential for optimal brain health and function. It enhances circulation and aids

in removing wastes. Water keeps the brain from overheating, which can cause cognitive decline

and even damage.

From the study of Seamans, et. al. (2010), women were appearing to be at a higher risk of

vitamin D insufficiency than men thus, it was associated with reduced capacity of spatial

working memory.

The evidence reviewed suggests that, whereas studies involving supplementation with

single vitamins, or restricted ranges of vitamins, have demonstrated equivocal results, evidence

from studies involving the administration of broader ranges of vitamins, or multivitamins,

suggest potential efficacy in terms of cognitive and psychological functioning (Kennedy &

Haskell, 2011).

According to the study made by Vizuete, et. al. (2010), the greater consumption of

cereals, vegetables, eggs, and fish would certainly supply essential nutrients that might facilitate

the maintenance of cognitive capacity.

From the study of Morley & Banks (2010), lipids may affect cognition in a number of

diseases and conditions but the effect of cholesterol and triglycerides were negative. On the

contrary omega-3 fatty acids such as DHA were supportive with the cognition among elderly.

Therefore, cholesterol, omega-3 fatty acids and triglycerides have implications for Alzheimer’s

disease and conditions associated with dyslipidemia and cognitive impairments such as obesity.

Roberts, et. al. (2010) discussed that higher intake of mono- and polyunsaturated fats

were associated with a reduced likelihood of mild cognitive impairment among elderly persons

in the population-based setting. Furthemore, Roberts, et. al. (2010) stated that polyunsaturated

fats may reduce the risk of thrombosis, cardiovascular risk, and stroke, and may also inhibit

inflammation.

There are associations between nutrition and dementia disorders but they are complex

(Irving, 2003). A few intervention studies with liquid supplements in demented elderly people

resulted in improved nutritional status. More studies are needed to evaluate not only the effects

on nutritional parameters, but also the effects on cognitive performance, ADL functions and

quality of life.

Synthesis

Malnutrition among the elderly population had been prevalent yet; assessment and

interventions centered on nutrition had been in the least priority of the health care professionals.

Malnutrition may cause detrimental effects on the wellbeing of the elderly. Such outcomes may

interfere directly on the functionality of the elderly particularly the cognitive aspect of health.

Nutrition is important across lifespan. But the greater amount of it demands on the needs

of the unborn as well as the elderly. Adequacy on diet intake and hydration is important as we

age. Enough supplementation of essential vitamins and minerals may aid in maintaining a

healthy body of an elderly. Furthermore, as we age, certain degenerative diseases may arise due

to insufficiency of nutrient intake.

Factors affecting decrease intake of nutrient and hydration may include pharmacology

(certain medications that may suppress appetite), socio-economic status (deficient sources of

income), educational attainment (lacking information about nutrition), and cultural determinants.

Personal factors may also affect intake of nutrients such as food preferences, food choices and

food likings.

Furthermore, studies revealed that there is a relationship of inadequate nutrient intake on

the cognitive functioning among elderly. Cognitive dysfunction such as mild cognitive

impairment, dementia, and Alzheimer’s disease may take place if there is an evident

insufficiency on the levels of certain compounds in our body that regulates the brain functioning.

In addition, an increase of harmful substances in our body such as triglycerides and cholesterol

may initiate the progress of cognitive impairment among the elderly.

CHAPTER III

RESEARCH METHODOLOGY

This chapter discusses the research methods used by the researcher. It talks about the

design utilized by the researcher, the selection of participants and locale, the instruments that was

employed to the participants, and the how data collection and statistical treatment. It also

includes a discussion on ethical principles.

Research Design

The researcher will be using a descriptive-correlational-comparative non-experimental

research design. Here, the researcher intends to describe and compare the relationship of

nutritional health status and the cognitive function of Filipino and Indonesian community-

dwelling elderly. According to Nieswiadomy (2008), descriptive-correlational-comparative

studies enable the researcher to describe or explain the relationship between variables in a given

phenomena and examines the strength of relationships between variables by determining how

changes in one variable are associated with changes in another variable at the same time,

scrutinizes the differences between intact groups on some dependent variable of interest. As

further explained by Sousa, Driessnack & Mendes (2007), the researcher observes, describes,

and documents various aspects of a phenomenon. There is no manipulation of variables or search

for cause and effect related to the phenomenon. From Baac (2010), descriptive research design

provides further insight into the research problem by describing the variables of interest of the

research. From an anonymous document, competent description can challenge accepted

assumptions about the way things are and can provoke action. On the contrary, correlational

studies can suggest that there is a relationship between two variables but they cannot prove that

one variable causes a change in another variable. In other words, correlation does not equal

causation (Cherryb, 2012). It is then, therefore that a comparative research is important in this

study to allow the researcher employ research in an objective and statistical valid way (Verial,

2012).

Population and Sample

The participants of this research were male and female Filipino elderly who are living

within the community (urban and rural) with their families. The elderly were 60 years old and

above and were not clinically diagnosed with depression, dementia and Alzheimer’s disease

before the research. Exclusion criteria includes were those elderly who were hospitalized or

underwent any major surgery of the lower gastrointestinal tract for the past 12 months, who were

taking medications (e.g. chemotherapeutic drugs) that may suppress appetite, who are enrolled in

any fitness management sessions, who have diseases that may affect their amount of food intake

(e.g. neoplasms, liver and kidney disease, biliary diseases, gastrointestinal diseases), who were

currently joining activities in a residential care facility, and who were currently institutionalized

or hospitalized.

The participants were selected through a non-probability purposive sampling technique.

This method is based on the assumption that the researcher or the chosen expert has enough

knowledge about the population of interest to select specific subjects for the study

(Nieswaidomy, 2008). Furthermore, the participants were chosen that the researcher believes are

typical, or representative, of the accessible population, or someone who is believed to be an

expert may be asked to select the subject. In addition, purposive sampling (Wadsworth Cengage

Learning, 2005) targets a particular group of people. The major problem with purposive

sampling was that the type of people who are available for study may be different from those in

the population who can't be located and this might introduce a source of bias. On the other hand,

according to Trochim (2006), the researcher samples with a purpose in mind. This technique is

useful for situations where you need to reach a targeted sample quickly and where sampling for

proportionality is not the primary concern. With a purposive sample, you are likely to get the

opinions of your target population, but you are also likely to overweight subgroups in your

population that are more readily accessible.

Research Locale

The researcher conducted the study in Metro Manila and the Cordillera Administrative

Region, Philippines. According to Ericta (2012), 6.76 percent or 6.23 million comprises of

elderly aging from 60 and above, and 10.9 percent of which are elderly of the Metro Manila and

6.9 percent of which are elderly of the Cordillera Administrative Region. In addition, the

researcher had chosen these two regions due to availability and richness of urban and rural

community-dwelling elderly.

Research Instrument

According to Nieswiadomy (2008), research instruments are the devices used to collect

data that will facilitate observation and measurement of the variables of interest. For this study,

the researcher utilized the Mini Nutritional Assessment (MNA) tool from Nestle Health Institute

and Montreal Cognitive Assessment (MoCA) tool from Center for Diagnosis & Research on

Alzheimer’s Disease.

Nutritional Status

Nutritional status of the elderly will be assessed by the Mini Nutritional Assessment

(MNA) tool that comprises 18 items that were grouped into four rubrics: anthropometric

assessment (BMI calculated from weight and height, weight loss, and arm and calf

circumferences; items B, F, Q and R) general assessment (lifestyle, medication, mobility and

presence of signs of depression or dementia; items C, D, E, G, H and I); short dietary assessment

(number of meals, food and fluid intake, and autonomy of feeding; items A, J, K, L, M and N);

and subjective assessment (self perception of health and nutrition; items O and P) (Guigoz,

2006).

Scores of 24-30 (none decrease in food intake, none weight loss, none restricted mobility,

none psychological stress or acute disease in the past three months, none neuropsychological

problems, BMI of 23 or greater, lives independently, doesn’t take more than 3 prescribed drugs,

no pressure sore, eats three meals, consumes one serving of dairy product, two or more servings

of legumes or egg per week and eats fish, meat or poultry everyday, consumes two ore more

servings of fruits and vegetables per day, drinks more than 5 cups of water in a day, self-fed

without problem, views self with no nutritional problem, has better health status than same age

group, MAC of 22 or greater and CC of 31 or greater) are considered normal nutritional status;

17-23.5 (moderate decrease in food intake, weight loss between one and three kilograms, can go

out to bed or chair but does not go out, none psychological stress or acute disease in the past

three months, with mild dementia, BMI of 19 to less than 23, lives in nursing home or hospital,

takes more than three prescribed drugs, has pressure ulcer or skin ulcer, eats two meals per day,

consumes at least two of the protein intake markers, doesn’t consume fruit, or vegetable in a day,

drinks 3-5 cups per day, self-fed with some difficulty, uncertain of nutritional status, views

health status as good or doesn’t know of the same age group, MAC of 21 to 22, and CC less than

31) indicate at risk of malnutrition; 0-17 (severe decrease of food intake, weight loss of greater

than three kilograms or does not know if there was weight loss, none ambulatory, with severe

dementia or depression, BMI of less than 19, lives in nursing home or hospital, takes more than

three prescribed drugs, has pressure ulcer or skin ulcer, eats one meal per day, consumes one of

the protein intake markers, doesn’t consume fruit, or vegetable in a day, drinks less than three

cups per day, self-fed with difficulty, views self as being malnourished, views health status as

not good of the same age group, MAC of less than 21, and CC less than 31) indicates

malnutrition. An advantage of the tool is that no laboratory data are needed (Guigoz, 2006).

An in-depth assessment and physical exam should be performed when patients are

identified to be malnourished or at nutritional risk. A review of symptoms and objective clinical

findings should be assessed in addition to the patient’s cultural factors, preferences, social

needs/desires surrounding meals (DiMaria-Ghalili, et. al., 2012). Older adults who are residing in

the community are at risk of malnutrition and represent a group that should be targeted for

nutrition screening, thus MNA-SF is necessary following a full MNA if score is ≤11 on the short

form (Charlton, 2010). The sensitivity, specificity and positive predictive values according to the

clinical status were 96%, 98% and 97%.

Cognitive Function

Cognitive function will be assessed using the Montreal Cognitive Assessment (MoCA)

(Nasreddine, et. al., 2005). It is a brief 30-item questionnaire use to assess the cognitive ability of

the elderly which includes orientation, short-term memory, executive function, language ability,

and visuospatial ability. Scores of ≥26 indicates normal cognitive function while ≤25 indicates

mild cognitive impairment. The MoCA is a relatively simple, brief test that helps health

professionals determine quickly whether a person has abnormal cognitive function and may need

a more thorough diagnostic work-up for Alzheimer's disease though the disadvantage of using

MoCA is that conclusions regarding its validity can only be made in memory clinic settings

(Rosenzweig, 2010). Nasreddine, et.al. (2005) tested the reliability examining the internal

consistency (Cronbach’s alpha = 0.83) and the test-retest reliability (r = 0.9) which indicates

excellent result. Validity of MoCA was measured correlating to Mini Mental Status Examination

(MMSE) yielding to excellent (r = 0.87) result.

Data Collection Procedure

The research study will be undergoing five steps for the data collection procedure. The

process will be based on the concepts that are described and further be explained on Figure 2 as

shown below.

Figure 4:

Process of the Data Gathering Procedure

Prior to the data collection, the researcher gave a letter to the Barangay Captain of the

two locales asking permission to conduct the study.

The researcher did a house-to-house visit for the possible participants who will join the

research. In-depth explanation of the study was conducted for both the participants and his/her

next to kin.

After an in-depth explanation about the research, the researcher then gave an informed

consent to the research participants stating the purpose of the study as well as the confidentiality

of all the details submitted by the participants.

After the administration of informed consent to the research participants, the researcher

utilized the Mini Nutritional Assessment (MNA®) tool (Guigoz, et. al. 2006). The researcher

Step 1:

Identification of Research

Participants

Step 2:

Informed Consent

Step 3:

Untilization of MNA® tool

Step 4:

Utilization of MoCA® tool

Step 5:

Collation and Evaluation

took the body mass index (BMI) using a bathroom scale to determine the weight of the

participants which was measured by kilograms (kg), and a tape measure to determine the height

of the participants which was measured in centimeters (cm) then converted to meter-square (m2).

After taking the BMI of the participants, the researcher proceeded with the interview using the

MNA® tool (Guigoz, et. al. 2006). This is a 30-item questionnaire that lasted for five to 10

minutes. This tool helped the researcher to determine the nutritional status of urban and rural

Filipino community dwelling elderly.

After taking the nutritional status of the elderly, the researcher utilized the Montreal

Cognitive Assessment (MoCA®) tool (Nasreddine, 2005). This is a 30-item questionnaire that

lasted for 10 to 15 minutes. This tool helped the researcher to determine the cognitive function of

Filipino urban and rural community dwelling elderly.

After taking the nutritional status and cognitive function of both urban and rural elderly,

the researcher collated all the information provided by the participants and evaluated further for

missing data. After didactic collation and evaluation of the information laid by the participants,

this then gave lee-way for the statistical analysis needed in order to test the hypothesis.

Statistical Treatment

All data was computed and analyzed using the parametric inferential statistics wherein

the information gathered from the sample will be used to estimate the corresponding figures for a

population and make comparisons between samples and population, stating the level of

confidence in each result (Watson, et. al., 2006). To determine to the nutritional health status of

UFCoDE and RFCoDE, the researcher used the frequency distribution. Frequency distribution

(Jackson, 2012) is a table in which all scores are listed along with the frequency with which each

occurs.

To determine the cognitive function of UFCoDE and RFCoDE, the researcher had chosen

to use the mean. According to Jackson (2012), mean is the most commonly used measure of

central tendency; the arithmetic average of a group of scores. Most important, the mean

(Steinberg, 2012) is the place where the numerical distances of scores on one side of the mean

balance the numerical distance of scores on the other side of the mean. This is mathematically

represented by:

where

μ represents population mean;

Σ represents the sum;

X represents the individual score; and,

N represents the number of scores in the distribution.

To calculate the mean (μ), we sum up (Σ) all the scores of the individuals (X) and divide

by the total number (N) of scores in the distribution.

To determine the relationship of nutritional health status and cognitive function among

UFCoDE and RFCoDE, the researcher used Pearson’s Product Moment Correlation (represented

by rho, ρ). This is used to determine if there is a linear relationship between two continuous

variables (Evans & Rooney, 2011). Pearson’s ρ is the most commonly used correlation

coefficient when both variables are measured on an interval or ratio scale (Jackson, 2012).

To determine if there are differences between UFCoDE and RFCoDE in terms of their

nutritional health status and cognitive function, the researcher utilized the z-test. According to

Steinberg (2011), z-test is used to determine the probability of obtaining a sample mean that is

known to the population. This is then represented by:

where

represents the sample mean;

μ represents the population mean; and,

represents the standard error of the mean.

Ethical Consideration

The researcher observed the different ethical code during the course of the study. These

include the following as enumerated and further explained below:

Informed Consent. The participants of the study were given informed consent stating the

purpose, procedure and intension of the study. The researcher discussed the intent of the study

thoroughly to the participants and their next of kin. Inquiries were answered with full knowledge

by the researcher.

Confidentiality. Given with all the information as submitted by the participant of the study, the

researcher treated all facts with utmost confidentiality. Important information from the

participants, such as name, was not exposed to other participant. Participants’ anonymity was

preserved by the researcher. Tools that had information of the participants were kept securely by

the researcher.

Respect & Non-malificence. Since the participants of this study were elderly and was included as

vulnerable population, the researcher treated the participants with due respect. The researcher

avoided embarrassing, offensive, and foul words. During the data gathering, the researcher

looked into the safety of the participants. Such safety measures include quiet environment, use of

lay-man’s terms and assistance during the data gathering.

Honesty. The researcher properly cited articles, journals, and books from all related researches

used in this study. In addition, permission to use tools and to conduct study was addressed by the

researcher.

CHAPTER IV

RESULTS AND DISCUSSION

This chapter shows the presentation, analysis and interpretation of data gathered

according to the sequence of problems as stated on Chapter I. Furthermore, the study intends to

investigate the relationship of nutritional health status to the cognitive function as well as their

differences among the Filipino elderly who are living in an urban and rural community.

Presentation is according to the specific problems of the study.

Specific Problem

Problem No. 1. What is the nutritional status of urban and rural Filipino community

dwelling elderly?

Table 1

Nutritional Status of Urban Filipino Community Dwelling Elderly Based on

Mini Nutritional Assessment (MNA)

Screening

Score

N % Assessment

Score

N % Total

Assessment

N % Malnutrition

Indicator

Score

12 – 14 10 50% 13 – 16 4 20% 24 – 30 10 50% Normal

Nutritional

Status

8 – 11 10 50% 10 – 12.5 14 70% 17 – 23.5 10 50% At Risk of

Malnutrition

0 – 7 < 10 2 10% < 17 Malnourished

Total 20 100 Total 20 100 Total 20 100

Table 1.1 shows the result of the nutritional status (NS) of urban Filipino community

dwelling elderly as based on the Mini Nutritional Assessment (MNA) tool. As shown above, the

result of the MNA of the participants (N=20) fell under normal nutritional status and at risk of

malnutrition where N=10 or 50% were normal nutritional status and N=10 or 50% were at risk of

malnutrition. In addition, the screening scores of the participants (N=20) fell under normal

nutritional status and at risk of malnutrition where N=10 or 50% were normal nutritional status

and N=10 or 50% were at risk of malnutrition. On the other hand, the assessment scores of the

participants (N=20) were distributed in the indicators. N=4 or 20% of the participants had normal

nutritional status, N=14 or 70% were at risk of malnutrition, and N=2 or 10% were

malnourished.

Table 2

Nutritional Status of Rural Filipino community Dwelling Elderly Based on

Mini Nutritional Assessment (MNA)

Screening

Score

N % Assessment

Score

N % Total

Assessment

N % Malnutrition

Indicator

Score

12 – 14 10 50% 13 – 16 3 15% 24 – 30 9 45% Normal

Nutritional

Status

8 – 11 8 40% 10 – 12.5 13 65% 17 – 23.5 8 40% At Risk of

Malnutrition

0 – 7 2 10% < 10 4 20% < 17 3 15% Malnourished

Total 20 100 Total 20 100 Total 20 100

Table 1.2 shows the result of the nutritional status (NS) of rural Filipino community

dwelling elderly as based on the Mini Nutritional Assessment (MNA) tool. As shown above, the

result of the MNA of the participants (N=20) were distributed in all the indicators where N=9 or

45% were normal nutritional status, N=8 or 40% were at risk of malnutrition, and N=3 or 15%

were malnourished. In addition, the screening scores of the participants (N=20) fell in all the

indicators where N=10 or 50% were normal nutritional status, N=8 or 40% were at risk of

malnutrition, and N=2 or 10% were malnourished. On the other hand, the assessment scores of

the participants (N=20) were distributed in the indicators. N=3 or 15% of the participants had

normal nutritional status, N=13 or 65% were at risk of malnutrition, and N=4 or 20% were

malnourished.

From the study of Capanzana, et. al. (2008), there was high prevalence of underweight as

well as overweight among Filipino elderly. Body Mass Index (BMI) values indicated that

undernutrition was a major problem among elderly at 27.0% of the 70 years old and over and

17.7% of the 60 - 69 years old. On the other hand, overweight was also prevalent among 60-69

years old and 70 years old and over at 20.0% and 14.0%, respectively. In addition, Jenkins, et. al.

(2007) reported that 30% of the elderly were underweight and is more common people over 70.

According to the 2008 National Nutrition Survey, 21.1% of adults age 60 and above have BMI

of less than 18.5 while 18.0% and 3.8% were overweight and obese respectively. On the other

hand, 57% of adults age 60 and above have a normal BMI(18.5 to <25.0).

Problem No. 2. What is the cognitive function of urban and rural Filipino community

dwelling elderly?

Table 3

Detailed Results of Cognitive Function of Urban Filipino Community Dwelling Elderly by Areas

Based on Montreal Cognitive Assessment Philippines (MOCA-P)

Visouspatial

(5)

Naming

(3)

Attention

(6)

Language

(3)

Abstraction

(2)

Recall

(5)

Orientation

(6)

S* N % S* N % S* N % S* N % S* N % S* N % S* N %

5 10 50 3 17 85 5 7 35 3 1 5 2 4 20 5 1 5 6 15 75

4 6 30 2 3 5 4 9 45 2 7 35 1 10 50 4 8 40 5 5 25

3 3 15 3 3 15 1 12 60 0 6 30 3 6 30

1 1 5 1 1 5 2 4 20

1 1 5

AVERAGE SCORE

4.2 2.85 4.05 1.45 0.9 3.2 5.75 *S=score

Table 2.1 shows the percentage and mean score results of the cognitive function (CF)

among the UFCoDE as based on the seven areas of the Montreal Cognitive Assessment-

Philippines (MoCA-P) tool. As shown on the table, 50% or N=10 had the highest score in

visuospatial/executive ability and the mean score was 4.2 where 5 being the highest score and 0

being the lowest. 85% or N=17 had the highest score in naming and the mean score was 2.85

where 3 being the highest and 0 being the lowest. 45% or N=9 had score of 4 in attention and the

mean score was 4.05 where 5 being the highest and 0 being the lowest. 60% or N=12 had score

of 1 in language and the mean score was 1.45 where 3 being the highest and 0 being the lowest.

50% or N=10 had score of 1 in abstraction and the mean score was 0.9 where 2 being the highest

and 0 being the lowest. 40% or N=8 had score of 4 in delayed recall and the mean score was 3.2

where 5 being the highest and 0 being the lowest. 75% or N=15 had the highest score in

orientation and the mean score was 5.75 where 6 being the highest and 0 being the lowest.

Table 4

Summary Results of Cognitive Function of Urban Filipino Community Dwelling Elderly


Total Score N % Interpretation

26 – 30 6 30% Normal Cognitive Function

18 – 25 13 65% Mild Cognitive Impairment

10 – 17 1 5% Moderately Cognitive Impairment

<10 Severe Cognitive Impairment

Total 20 100

Table 2.1.1 shows the frequency of the summary results of the cognitive function (CF)

among the UFCoDE based on Montreal Cognitive Assessment-Philippine (MoCA-P) tool. As

shown above, 65% or N=13 had mild cognitive impairment while 30% or N=6 had normal

cognitive function and 5% or N=1 had moderate cognitive impairment. The total mean score of

the UFCoDE as shown on Table 2.1 was 22.4 with verbal interpretation of mild cognitive

impairment according to MoCA-P tool.

Table 5

Detailed Results of Cognitive Function of Rural Filipino Community Dwelling Elderly by Areas


Visouspatial

(5)

Naming

(3)

Attention

(6)

Language

(3)

Abstraction

(2)

Recall

(5)

Orientation

(6)

S* N % S* N % S* N % S* N % S* N % S* N % S* N %

5 9 45 3 14 70 4 5 25 2 1 5 2 1 5 4 2 10 6 15 75

4 1 5 2 6 30 3 8 40 1 16 80 1 6 30 3 7 35 5 3 15

3 5 25 2 2 10 0 3 15 0 13 65 2 3 15 4 2 10

2 2 10 1 3 15 1 4 20

0 3 15 0 2 10 0 4 20

AVERAGE SCORE

3.4 2.7 2.55 0.9 0.4 1.95 5.65 *S=score

Table 2.2 shows the percentage and mean score results of the cognitive function (CF)

among the RFCoDE as based on the seven areas of the Montreal Cognitive Assessment-

Philippines (MoCA-P) tool. As shown on the table, 45% or N=9 had the highest score in

visuospatial/executive ability and the mean score was 3.4 where 5 being the highest score and 0

being the lowest. 70% or N=14 had the highest score in naming and the mean score was 2.7

where 3 being the highest and 0 being the lowest. 40% or N=8 had score of 3 in attention and the

mean score was 2.55 where 5 being the highest and 0 being the lowest. 80% or N=16 had score

of 1 in language and the mean score was 0.9 where 3 being the highest and 0 being the lowest.

65% or N=13 had the lowest in abstraction and the mean score was 0.4 where 2 being the highest

and 0 being the lowest. 35% or N=7 had score of 3 in delayed recall and the mean score was 1.95

where 5 being the highest and 0 being the lowest. 75% or N=15 had the highest score in

orientation and the mean score was 5.65 where 6 being the highest and 0 being the lowest.

Table 6

Summary Results of Cognitive Function of Rural Filipino Community Dwelling Elderly


Total Score N % Interpretation

26 – 30 Normal Cognitive Function

18 – 25 12 60% Mild Cognitive Impairment

10 – 17 5 25% Moderately Cognitive Impairment

< 10 3 15% Severe Cognitive Impairment

Total 20 100

Table 2.2.1 shows the frequency of the summary results of the cognitive function (CF)

among the UFCoDE based on Montreal Cognitive Assessment-Philippine (MoCA-P) tool. As

shown above, 60% or N=12 had mild cognitive impairment while 25% or N=5 had moderate

cognitive function and 15% or N=3 had severe cognitive impairment. The total mean score of the

UFCoDE as shown on Table 2.1 was 17.55 with indicator of moderate cognitive impairment

according to MoCA-P tool.

According to Glisky (2007), older adults show significant impairments on attentional

tasks that require dividing or switching of attention among multiple inputs or tasks. Many older

adults complain of increased memory lapses as they age although they believe that their

memories for remote events are better than their memories for recent events. From Deary, et. al.

(2009), there is little age-associated decline in some mental functions—such as verbal ability,

some numerical abilities and general knowledge—but other mental capabilities decline from

middle age onwards, or even earlier. The latter include aspects of memory, executive functions,

processing speed and reasoning. Morganti & Riva (2011) explained further that the ability to

orient in space declining with age and it constitute one of the main signs of cognitive impairment

in neurological patients.

Problem No. 3. Is there a significant relationship between the nutritional status and

cognitive function among the urban and rural Filipino community dwelling elderly?

Table 7

Significant Relationship between the Nutritional Status and the Cognitive Function of

Urban and Rural Filipino Community Dwelling Elderly

Variable

Computed

Value

(Urban)

Computed

Value

(Rural)

Tabular

Value at 0.05 Decision Interpretation

Nutritional

Status and

Cognitive

Function

ρ = 0.4320 ρ = 0.50 ρ = 0.2573

Reject the

Null

Hypothesis

Significant

*ρ=Pearson rho

Table 3.1 presents the significant relationship between the nutritional status and cognitive

function of urban and rural Filipino community-dwelling elderly. Based on the table, the

computed Pearson r value for urban and rural elderly was 0.4320 and 0.50 respectively and the

tabular Pearson r value at 0.05 level of significance was 0.2573. Since the computed values were

greater than the tabular value, therefore the null hypothesis, that there is no significant

relationship between the nutritional status and cognitive function of urban and rural Filipino

community-dwelling elderly, therefore was rejected. It means that the nutritional status and

cognitive function of urban and rural Filipino community-dwelling elderly was interrelated or

interconnected. It concludes further that the nutritional status was affected or related to the

cognitive function or vice versa.

According to Denny (2008), diet plays a key role in the development of cognitive decline

in older age. Furthermore, Benton (2012) stated that specific nutritional deficiencies may cause

cognitive decline among the elderly. In addition to nutrition, adequate hydration (Holdsworth,

2012; Norman, 2012; Jéquier & Constant, 2010) is fundamental in diet and it is important in

optimal brain health. From the study of Roberts, et. al. (2010), mono- and polyunsaturated fatty

acids may be beneficial the promotion on healthy brain function thus, reducing the risk of

thrombosis, cardiovascular risk, and stroke that may lead to cognitive impairment. Vizuete, et. al.

(2010) further concluded that greater consumption of cereals, vegetables, eggs, and fish would

certainly supply essential nutrients that might facilitate the maintenance of cognitive capacity.

Vitamin B12 (Bozoglu, et. al., 2010) may also help improve the cognitive status and maintain the

functional status among the geriatric population.

Problem No. 4. Is there a significant difference in the nutritional status between the urban

and rural Filipino community dwelling elderly?

Table 8

Significant Difference between the Urban and Rural Filipino Community Dwelling Elderly in

terms of Nutritional Status

Variable Computed

Value

Tabular Value

at 0.05 Decision Interpretation

Urban and Rural

Community

Elderly

z = 1.14 z = 1.96 Accept the Null

Hypothesis Not Significant

*z=z-test value

Table 4.1 presents the significant difference between the urban and rural Filipino

community-dwelling elderly in terms of nutritional status. Based on the table, the computed

Pearson r value for urban and rural Filipino community-dwelling elderly was 1.14 and the

tabular z-test value at 0.05 level of significance was 1.96. Since the computed value was lesser

than the tabular value, therefore the null hypothesis, that there is no significant relationship

between the nutritional status and cognitive function of urban and rural Filipino community-

dwelling elderly, therefore was accepted. It means that the nutritional status of urban and rural

Filipino community-dwelling elderly was not diverse form each other. It concludes further that

the nutritional status of urban and rural Filipino community-dwelling elderly was similar and has

no distinct differences.

From the study of Risonar, et. al. (2009), community living elderly suffer from lack of

both macronutrient intake as compared with energy requirements, and micronutrient intake as

compared with the standard dietary recommendations. Their energy intakes are ~65% of the

amounts required based on their total energy expenditure. Though their intakes decrease with

increasing age, so do their energy expenditure, making their relative insufficiency of food intake

stable with age.

Problem No. 5. Is there a significant difference in the cognitive function between the urban

and rural Filipino community dwelling elderly?

Table 9

Significant Difference between the Urban and Rural Filipino Community Dwelling Elderly in

terms of Cognitive Function

Variable Computed

Value

Tabular Value

at 0.05

Decision Interpretation

Urban and Rural

Community

Elderly

z = 3.28 z = 1.96 Reject the Null

Hypothesis Significant

*z=z-test value

Table 4.2 presents the significant difference between the urban and rural Filipino

community-dwelling elderly in terms of cognitive function (CF). Based on the table, the

computed z-test value for urban and rural Filipino community-dwelling elderly was 3.28 and the

tabular z-test value at 0.05 level of significance was 1.96. Since the computed value was greater

than the tabular value, therefore the null hypothesis, that there is no significant relationship

between the nutritional status and cognitive function of urban and rural Filipino community-

dwelling elderly, therefore was rejected. It means that the cognitive function of urban and rural

Filipino community-dwelling elderly differs from each other.

From the study, 55% or N=11 of the UFCoDE had more than 11 years of education while

30% or N=6 of the RFCoDE had more than 11 years of education. Since there was higher rate of

literacy among the UFCoDE than of the RFCoDE, higher educational attainment is associated

with greater levels of cognitive performance as well as with a reduced risk of dementia and

Alzheimer’s disease (Parisi, et. al., 2012). From the study of Alley, et. al. (2007), years of

education were positively related to higher baseline scores on each of the cognitive tests; the

effect of an additional year of education was large, particularly relative to the effect of an

additional year of age.

CHAPTER V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Summary

This research study was conducted to determine the relationship of nutritional status and

cognitive function among urban and rural Filipino community-dwelling elderly. This study was

rooted on two important theories in Nursing: (1) Maslow’s Hierarchy of Human Needs where it

identified that nutrition and cognition are part of human needs in order to survive; and (2)

Leininger’s Theory of Culture Care, Diversity, and Universality where it discusses the

importance of culture as part of nursing care. In addition, this study explored the differences of

urban and rural Filipino community-dwelling elderly in terms of their nutritional status and

cognitive function.

The total population of this study was forty (40) elderly which was divided equally

according to their locale – twenty elderly for urban and twenty elderly for rural. The participants

were chosen based on the criteria set by the researcher using non-probability purposive sampling.

The data needed for the study were obtained through the use of Mini Nutritional Assessment

(MNA®) tool to determine the nutritional status of the elderly which was adapted from the

Nestle Nutrition Institute, and the use of Montreal Cognitive Assessment (MoCA®) tool to

determine the cognitive function of the elderly which was adapted from Montreal Cognitive

Assessment organization. The collection of data was done from December 2012 to January 2013.

The data gathered was statistically computed analyzed using inferential non-parametric

statistics. Frequency distribution was used to determine the nutritional status and cognitive

function of urban and rural Filipino community-dwelling elderly. Pearson’s Product Moment

Correlation was utilized to determine the relationship of nutritional status and cognitive function

among urban and rural Filipino community-dwelling elderly. Z-test was used to determine the

difference between the UFCoDE and RFCoDE in terms of their nutritional status and cognitive

function.

Findings

The findings of the study revealed the following:

1. The nutritional status of the UFCoDE gathered from the results of the MNA® according

to the indicators as follows:

1.1. The screening score indicated that 50% or N=10 had normal

nutritional status and 50% or N=10 were at risk of malnutrition.

1.2. The assessment scored indicated that 20% or N=4 had normal

nutritional status, 70% or N=14 were at risk of malnutrition, and 10% or

N=2 were malnourished.

1.3 The total assessment score indicated that 50% or N=10 had normal

nutritional status and 50% or N=10 were at risk of malnutrition.

2. The nutritional status of the RFCoDE gathered from the results of the MNA® according

to the indicators as follows:

2.1. The screening score indicated that 50% or N=10 had normal



2.2. The assessment scored indicated that 15% or N=3 had normal



2.3. The total assessment score indicated that 45% or N=9 had normal



3. The cognitive function of the UFCoDE gathered from the results of the MoCA®

according to the indicators as follows:

3.1. The total score indicated that 30% or N=6 had normal cognitive

function, 65% or N=13 had mild cognitive impairment, and 5% or N=1

had moderate cognitive impairment.

3.2. The mean scores per areas were 4.2 for visuospatial/executive ability

(0-5), 2.85 for naming (0-3), 4.05 for attention (0-6), 1.45 for language (0-3),

0.9 for abstraction (0-2), 3.2 for delayed recall (0-5) and 5.75 for orientation

(0-6).

4. The cognitive function of the RFCoDE gathered from the results of the MoCA®

according to the indicators as follows:

4.1. The total score indicated that 60% or N=12 had mild cognitive

impairment, 25% or N=5 had moderate cognitive impairment, and 15% or

N=3 had severe cognitive impairment.

4.2. The mean scores per areas were 3.4 for visuospatial/executive ability

(0-5), 2.7 for naming (0-3), 2.55 for attention (0-6), 0.9 for language (0-3), 0.4

for abstraction (0-2), 1.95 for delayed recall (0- 5) and 5.65 for orientation (0-

6).

5. The result on the relationship of nutritional status and cognitive function among UFCoDE

and RFCoDE as follows:

5.1. That the computed ρ-values for UFCoDE and RFCoDE were 0.4320

and 0.50 respectively.

5.2. That the computed ρ-valued for UFCoDE and RFCoDE was higher

than the tabular ρ-value at 0.05 level of significance where ρ was 0.2573.

6. The result on the difference in the nutritional status between the UFCoDE and RFCoDE

where the tabular z-test value at 0.05 level of significance is 1.96 as follows:

6.1. That the computed z-test value for nutritional status among the

UFCoDE and RFCoDE was 1.14.

6.2. That the computed z-test value of the UFCoDE and RFCoDE in terms

of their nutritional status was lower than the tabular z-test value at 0.05 level of

significance where z was 1.96.

7. The result on the difference in the cognitive function between the UFCoDE and RFCoDE

where the tabular z-test value at 0.05 level of significance is 1.96 as follows:

7.1. That the computed z-test value was for cognitive function among the

UFCoDE and RFCoDE was 3.28.

7.2. That the computed z-test value of the UFCoDE and RFCoDE in terms

of their cognitive function was higher than the tabular z-test value at 0.05

level of significance where z was 1.96.

Conclusions

On the basis of findings of the study, the following conclusions are drawn:

1. That fifty percent of the UFCoDE population was either at risk of malnutrition or

have a normal nutritional status.

2. That the population of RFCoDE falls under normal nutritional status or at risk of

malnutrition since the percentage is not far from each other.

3. That the majority of UFCoDE and RFCoDE population had mild cognitive

impairment.

4. That the mean score of UFCoDE according to the different areas of the MoCA®

tool was 22.4 indicating that there is an incidence of mild cognitive impairment

among the elderly who are residing in an urban community.

5. That the mean score of RFCoDE according to the different areas of the MoCA®

tool was 17.55 indicating that there is an incidence of moderate cognitive

impairment among the elderly who are residing in an rural community.

6. That there is a significant relationship of nutritional status and cognitive function

among the UFCoDE and RFCoDE.

7. That there is no significant difference between the UFCoDE and RFCoDE in

terms of their nutritional status.

8. That there is significant difference between the UFCoDE and RFCoDE in terms

of their cognitive function.

Recommendations

The results of this study highlighted the relationship between nutritional status and

cognitive function among urban and rural community-dwelling elderly as well as their

differences. From the findings and conclusions drawn from this study, the following

recommendations are given by the researcher:

1. Nursing Practice, Educations, Service & Administration

1.1. Nurses who practice in the community should do a nutritional health

screening and assessment every six months to determine the status of those

elderly who are living in urban and rural community.

1.2 Nurses should create a nutritional teaching module for Filipino elderly

that focuses on the nutritional needs, food preferences, cooking methods and

food preparation.

1.3 Nurses should include culture in their plan of care as nutrition is greatly

affected by the way of living, beliefs, practices, and traditions.

1.4 Nurses should have social awareness on this field of nursing in order

to deliver an effective nursing care across different cultural orientation.

2. Nursing Research

2.1 Future nurse researcher should conduct a study comparing Filipino

elderly and other elderly in a worldwide perspective.

2.2 Nurses should develop tools to determine the nutritional status and

cognitive function of Filipino elderly.

2.3 Nurses should do didactic researches on elderly nutrition and

cognitive function on a worldwide perspective with the inclusion of

culture as basis of the study.

2.4 Future researcher should include 24-hour diet recall that includes intake

of medical supplements and alcoholic beverages to assess further the nutritional

status of the elderly.

3. Society

3.1 The growing number of elderly in the country reminds the population

about demographic shifting of the society. It is imperative that this

population is in need of quality care. Government implements the provision of

the Senior Citizens Act to enhance the quality of life among our urban and

rural community-dwelling elderly. The government should create

programs for the elderly that focuses on nutrition and cognition

enhancement.

3.2 Family of an elderly should respect and accept the nutritional

preferences and food choices of their elderly as it is rooted in their

culture. Families should serve healthy and complete meals for the elderly

focusing on nutritional needs.

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Appendix A

Letter of Request Seeking Permission to Conduct Study

FAR EASTERN UNIVERSITY Institute of Nursing Graduate Studies

N. Reyes, Sr. St., Sampaloc


4 December 2012

Hon. ROEL T.GOLIMLIM

Brgy. Captain

Brgy. Bagumbuhay, Proj. 4

Quezon City, Philippines

LETTER OF REQUEST SEEKING PERMISSION TO CONDUCT STUDY

Dear Hon. Golimlim:

My name is Lucky P. Roaquin, and I am a graduate student at the Far Eastern University –

Institute of Graduate Studies. I wish to conduct a research for my graduate thesis which involves

the relationship of nutritional status and cognitive function among Filipino urban and rural

community-dwelling elderly. This study will be conducted under the supervision of Dr. Eufemia

Octaviano, a faculty of the aforementioned University.

I am hereby seeking your consent to approach a number of elderly people (aging ≥60 years) who

are currently residing within the area of your jurisdiction particularly in Barangay Bagumbuhay,

Project 4, Quezon City.

If you require any further information, please do not hesitate to contact me. Thank you for your

time and consideration in this matter.

Yours sincerely,


FEU - Institute of Nursing Graduate Studies

Cell. No.: +63 9163593508

E-mail: [email protected]

Supervised by:

Dr. Eufemia Octaviano, RN, MAN

Adviser, FEU – IN Graduate Studies

mailto:[email protected]




14 January 2013

Hon. CASTOR CAYABA

Brgy. Captain

Brgy. Dagupan Centro

Tabuk City, Kalinga, Philippines

LETTER OF REQUEST SEEKING PERMISSION TO CONDUCT STUDY

Dear Hon. Cayaba:

My name is Lucky P. Roaquin, and I am a graduate student at the Far Eastern University –

Institute of Graduate Studies. I wish to conduct a research for my graduate thesis which involves

the relationship of nutritional status and cognitive function among Filipino urban and rural

community-dwelling elderly. This study will be conducted under the supervision of Dr. Eufemia

Octaviano, a faculty of the aforementioned University.

I am hereby seeking your consent to approach a number of elderly people (aging ≥60 years) who

are currently residing within the area of your jurisdiction particularly in Barangay Dagupan

Centro, Tabuk City, Kalinga.

If you require any further information, please do not hesitate to contact me. Thank you for your

time and consideration in this matter.

Yours sincerely,


FEU - Institute of Nursing Graduate Studies

Cell. No.: +63 9163593508

E-mail: [email protected]

Supervised by:

Dr. Eufemia Octaviano, RN, MAN

Adviser, FEU – IN Graduate Studies


Appendix B

Letter of Request Seeking Permission to Utilize Research Instruments

APPENDIX B.1.

Letter of Request Seeking Permission to Utilize Research Instrument – Nestle Philippines

From: kit roaquin [mailto:[email protected]]

Sent: Tuesday, September 25, 2012 12:31 PM

To: Monsod,MaCristina,MAKATI,HEALTHCARE NUTRITION

Cc: Malimet,Jewel,MAKATI,HCN / BTNMS - Contractual

Subject: Re: Permission to Borrow MNA® Tool for Research

Good day!

Thanks for letting me use your tool. Thi will be of great help on me. And as soon as I will finish

this study, I will send you a copy of it.

Best Regads

Lucky P. Roaquin, RN, MANc



Manila City, 1008 Philippines

On Sep 25, 2012, at 10:00 AM, "Monsod,MaCristina,MAKATI,HEALTHCARE NUTRITION"

<[email protected]> wrote:

Dear Lucky,

Thank you for your interest in Nestlé Nutrition’s MNA. We are willing to give you some forms for your

use. Please send us your mailing address.

In case you have inquiries, please do not hesitate to get in touch with me.

Regards,

Macy

Macy Ochoa Monsod

Nutrition Marketing Manager

<image001.jpg>

Email: [email protected]

Add: #31 Plaza Drive, Rockwell Center

Makati City, Philippines 1200

Tel: +632 8980001 loc 7512

From: Cheung,Lorena,HONGKONG,HealthCare Nutrition

Sent: Tuesday, September 25, 2012 12:43 AM



To: Monsod,MaCristina,MAKATI,HEALTHCARE NUTRITION

Subject: Fwd: Permission to Borrow MNA® Tool for Research

Hi Macy,

FYI.

Regards,

Lorena

Begin forwarded message:

From: Janet Skates <[email protected]>

Date: 2012年9月25日GMT+08:00上午12時32分07秒

To: 'kit roaquin' <[email protected]>

Cc: "Cheung,Lorena,HONGKONG,HealthCare Nutrition" <[email protected]>

Subject: RE: Permission to Borrow MNA® Tool for Research

Dear Lucky,

Thank you for your interest in Nestlé’s Mini Nutritional Assessment (MNA®). No special permission is

required to use the MNA® in your graduate research and thesis - Nutritional Health Status and Cognitive

Function of Filipino and Indonesian Community-Dwelling Elderly. If you decide later to publish your

research, you will need to request permission to reprint the MNA® when you submit your manuscript

for publication. You may send the request [email protected].

Good luck in your studies and research. Please let me know if you have further questions.

Kind regards,

Janet Skates

Nestlé Health Sciences Consultant

MNA® Mini Nutritional Assessment Application

1 (423) 239-7176

[email protected]

From: kit roaquin [mailto:[email protected]]

Sent: Wednesday, September 19, 2012 2:50 AM

To: [email protected]

Subject: Permission to Borrow MNA® Tool for Research

Importance: High

To Whom It May Concern:







Sir/Madam,

Good day!

As a part of the health care professionals that endeavors in the care for the population especially our

older adults, I came into a realization that the world is inevitably changing thus, it affects the trends

within our society. Due to the effect of rapid advancement in the modern technologies, it has uplifted the

value of health in terms of medicine and nutrition. Our elderly in our society is as vulnerable as the

unborn that needed to be given immediate interventions to promote health and wellness at the same

time prevent occurrences of illnesses and diseases.

Nutrition plays the most important role in this venture of success of every health care professional. The

proper and accurate assessment of elderly especially with regards to their nutritional status is very much

important in the establishment of an effective and efficient plan of care. Furthermore, as a nurse, it is my

duly responsibility to maintain the integrity of every elderly across the globe.

Thereby, I would to ask for your permission to allow use your comprehensive assessment tool for elderly

nutrition - the Mini Nutritional Assessment (MNA) tool. This is in regards to my graduate thesis -

Nutritional Health Status and Cognitive Function of Filipino and Indonesian Community-Dwelling Elderly.

Your tool, just like the success of every research I have read, has been of great help in clarifying the

relationship of nutrition in the holistic domain of the elderly.

And as a return of your greatness, I will be sending you a copy of the outcomes from this research study.

I am Lucky P. Roaquin, a registered nurse and advocate of the elderly. Currently, I am enrolled in a

Master's Degree Program from the Far Eastern University - Manila, Philippines.

Thank you very much and I am looking forward for your favorable response.

Respectfully yours,

Lucky P. Roaquin, RN, MANc



Manila City, Philippines

APPENDIX B.2.

Letter of Request Seeking Permission to Utilize Research Instruments –

Center for Diagnosis & Research on Alzheimer’s Disease (CEDRA)

From: Info-MoCA ([email protected])

Sent: Monday, September 17, 2012 3:29:27 PM

To: 'kit roaquin' ([email protected])

Cc: [email protected]

Good morning,

All available languages are posted on the website www.mocatest.org

Tina Brosseau Projects & Development Manager Center for Diagnosis & Research on Alzheimer's disease (CEDRA) Phone: (450) 672-9637 / Fax: (450) 672-1443 www.cedra.ca

From: kit roaquin [mailto:[email protected]] Sent: 13 septembre 2012 7:14


Subject: Re: Permission to Borrow MoCA

Thanks a lot, Tina.

And lastly, do you have any Bahasa (Indonesian) version of your MoCA?

Lucky P. Roaquin, RN, MANc Institute of Graduate Studies Far Eastern University Manila City, Philippines

On Sep 13, 2012, at 11:22 PM, "Info-MoCA" <[email protected]> wrote: You are welcome to use the MoCA in your study as described below with no further permission requirements if it is not industry funded. Any modification to the MoCA ©/ Instructions, requires prior written approval by copyright owner. Shall any industry funding become available, a licencing agreement to use the MoCA will be required. All the best, Tina

http://www.mocatest.org/

http://www.cedra.ca/


http://sn126w.snt126.mail.live.com/mail/PrintMessages.aspx?cpids=726b28e6-00dc-11e2-8a1f-002264c1d724,m&isSafe=true&FolderID=00000000-0000-0000-0000-000000000001


To: [email protected] Subject: RE: Permission to Borrow MoCA

Hi Tina, Good day! Thank you for the quick positive response. With regards to the queries below, here are my response: - 'Nutritional Health Status and Cognitive Function of Filipino and Indonesian Community-dwelling Elderly' - I don't have numbers yet of the participants since I will using a purposive sampling design (50 Filipino & 50 Indonesian-tentative number) - My study is not funded by any institution. This is a self-initiative study for my graduate thesis. Hopefully I provided you with enough information. For further clarifications, you may ask me in your convenience. Thank you so much! Lucky P. Roaquin, RN, MANc Institute of Graduate Studies Far Eastern University Manila City, Philippines

From: [email protected]

To: [email protected] CC: [email protected]

Subject: RE: Permission to Borrow MoCA Date: Mon, 10 Sep 2012 10:38:06 -0400

Good morning, Thank you for your interest in the MoCA. In order to grant permission to use the MoCA test, we need more information.

- What is the title of your study? - How many subjects will participate in the study and how many times will the MoCA be

administered? - Is the study industry funded? If so, a licensing agreement must be completed.

Thank you, Tina Brosseau Projects & Development Manager Center for Diagnosis & Research on Alzheimer's disease (CEDRA) Phone: (450) 672-9637 / Fax: (450) 672-1443 www.cedra.ca / www.mocatest.org







http://www.cedra.ca/

http://www.mocatest.org/


Subject: Permission to Borrow MoCA

Importance: High

To Whom It May Concern:

Sir/Madam:

Good day!

As a part of the health care professionals that endeavors in the care for the population especially our older adults, I came into a realization that the world is inevitably changing thus, it affects the trends within our society. Due to the effect of rapid advancement in the modern technologies, it has uplifted the

value of health in terms of medicine and nutrition. Our elderly in our society is as vulnerable as the

unborn that needed to be given immediate interventions to promote health and wellness at the same time prevent occurrences of illnesses and diseases.

Cognitive function plays the most important role in this venture of success of every health care professional. The proper and accurate assessment of elderly especially with regards to their cognitive

function is very much important in the establishment of an effective and efficient plan of care. Furthermore, as a nurse, it is my duly responsibility to maintain the integrity of every elderly across the

globe.

Thereby, I would to ask for your permission to allow use your comprehensive assessment tool for elderly

nutrition - the Montreal Cognitive Assessment (MoCA) tool. This is in regards to my graduate thesis - Nutritional Health Status and Cognitive Function of Filipino and Indonesian Community-Dwelling Elderly.

Your tool, just like the success of every research I have read, has been of great help in clarifying the relationship of nutrition in the holistic domain of the elderly.

And as a return of your greatness, I will be sending you a copy of the outcomes from this research study.

I am Lucky P. Roaquin, a registered nurse and advocate of the elderly. Currently, I am enrolled in a Master's Degree Program from the Far Eastern University - Manila, Philippines.

Thank you very much and I am looking forward for your favorable response.

Respectfully yours, Lucky P. Roaquin, RN, MANc Institute of Graduate Studies Far Eastern University Manila City, Philippines

Appendix C

Utilized Research Tools

Appendix D

Informed Consent

APPENDIX D.1.

Informed Consent for Urban Filipino Community-dwelling Elderly




Informed Consent Form for Filipino Urban Community-Dwelling Elderly

Date:

Dear Mr/Mrs. ,

Greetings of peace and joy!

I am Lucky P. Roaquin, a graduate student of the Far Eastern University – Institute of Graduate

Studies. I am doing a research on the relationship of nutritional and cognitive function among

urban and rural Filipino community-dwelling elderly.

Please ask me to clarify about the information and I will take time to explain.

The purpose of this study is to improve nursing profession and to serve the Filipino people

especially the elderly population. Rest assured that the results of this study will be treated with

utmost confidentiality.

Very truly yours,


I, , understand fully the purpose of this study and that all of my

questions were answered. Therefore, I am willing to participate in this study with my full

knowledge and cooperation.

Name:

Signature:

Date:

APPENDIX D.2.

Informed Consent for Rural Filipino Community-dwelling Elderly

FAR EASTERN UNIVERSITY

Institute of Nursing Graduate Studies



Informed Consent Form for Rural Filipino Community-Dwelling Elderly

Date:

Dear Mr/Mrs. ,

Greetings of peace and joy!

I am Lucky P. Roaquin, a graduate student of the Far Eastern University – Institute of Graduate

Studies. I am doing a research on the relationship of nutritional and cognitive function among

urban and rural Filipino community-dwelling elderly.

Please ask me to clarify about the information and I will take time to explain.

The purpose of this study is to improve nursing profession and to serve the Filipino people

especially the elderly population. Rest assured that the results of this study will be treated with

utmost confidentiality.

Very truly yours,


I, , understand fully the purpose of this study and that all of my

questions were answered. Therefore, I am willing to participate in this study with my full

knowledge and cooperation.

Name:

Signature:

Date:

Appendix E

Raw Data of Gathered Information

Appendix E

Raw Data on Gathered Information

A. Demographic Profile

Urban Rural

Age Gender Years of Education Age Gender Years of Education

63 M 11-14 years 73 F 0-6 years

66 M 11-14 years 65 F 11-14 years

62 F 11-14 years 60 M 11-14 years

68 F More than 14 years 65 F 0-6 years

60 M 11-14 years 71 F 7-10 years

71 M 7-10 years 85 F 7-10 years

66 F 11-14 years 86 M 7-10 years

77 M 0-6 years 61 F 11-14 years

80 M 7-10 years 67 M 7-10 years

60 F 11-14 years 64 M 0-6 years

68 M 0-6 years 60 F 7-10 years

70 M 7-10 years 76 M 11-14 years

74 M More than 14 years 62 F 11-14 years

79 F More than 14 years 63 M 0-6 years

60 F 11-14 years 68 M 7-10 years

60 F 7-10 years 71 M 0-6 years

69 M 7-10 years 76 M 7-10 years

65 F 0-6 years 69 F 7-10 years

63 F 7-10 years 80 M 11-14 years

70 F 11-14 years 60 M 7-10 years

Appendix E


B. Mini Nutritional Assessment (MNA) Tool

Urban Rural

TOTAL

(30)

Screening

(14)

Assessment

(16)

TOTAL

(30)

Screening

(14)

Assessment

(16)

28 13 15 24 12 12

17.5 10 7.5 25 13 12

19 10 9 27.5 14 13.5

24 11 13 24.5 14 10.5

26 14 12 17 10 7

22 11 11 24.5 13 11.5

22 10 12 13.5 6 7.5

20 10 10 19 9 10

20.5 9 11.5 28 14 14

24 12 12 21.5 11 10.5

26 14 12 27.5 13 14.5

24 13 11 22 11 11

22 12 10 23 12 11

22 11 11 26 14 12

28 14 14 18 8 10

24.5 13 11.5 16 8 8

26 12 14 22.5 10 12.5

23.5 11 12.5 20 10 10

26.5 14 12.5 12.5 7 5.5

21 11 10 26.5 14 12.5

Appendix E


C.1. Montreal Cognitive Assessment (MoCA) Tool – Urban

TOTAL

(30)

Visuo

(5)

Naming

(3)

Attention

(6)

Language

(3)

Abstraction

(2)

Recall

(5)

Orientation

(6)

25 5 3 5 1 1 4 6

21 5 3 4 1 0 2 6

20 3 3 3 1 1 3 6

24 5 3 4 1 2 3 6

26 5 3 4 2 2 4 6

18 3 3 3 1 0 3 5

24 4 3 5 2 0 4 6

19 4 3 3 1 0 2 6

11 1 2 1 1 0 1 5

27 5 3 5 3 1 4 6

26 5 3 5 1 1 5 6

22 4 3 4 2 0 3 6

26 5 3 5 2 1 4 6

27 5 3 5 2 2 4 6

26 5 3 4 2 2 4 6

20 4 3 4 1 1 2 5

20 3 2 4 2 1 3 5

19 4 2 4 1 1 2 5

23 5 3 4 1 1 3 6

24 4 3 5 1 1 4 6

Appendix E


C.2. Montreal Cognitive Assessment (MoCA) Tool – Rural

TOTAL

(30)

Visuo

(5)

Naming

(3)

Attention

(6)

Language

(3)

Abstraction

(2)

Recall

(5)

Orientation

(6)

16 3 2 3 1 0 1 6

21 4 3 4 1 2 1 6

21 5 3 3 1 0 3 6

14 2 2 4 1 0 0 5

17 2 3 2 1 0 3 6

8 0 2 1 1 0 0 4

13 3 2 2 1 0 1 4

20 5 3 3 1 0 2 6

22 5 3 4 1 0 3 6

7 0 2 0 0 0 0 5

22 5 3 3 1 1 3 6

18 3 3 4 1 0 2 5

22 5 3 3 1 1 3 6

24 5 3 4 1 1 4 6

22 5 3 3 1 1 3 6

13 3 3 1 0 0 0 6

20 5 3 1 1 1 3 6

18 3 3 3 1 0 2 6

9 0 2 0 0 0 1 6

24 5 3 3 2 1 4 6

Appendix F

FCEPE: Focus Care Enhancement Program for Elderly

APPENDIX F:


FAR EASTERN UNIVERSITY INSTITUTE OF NURSING

GRADUATE STUDIES


By: Lucky P. Roaquin, RN

Title : “Kumain ng Masustansya para Pagtanda’y ay Sumigla”

Description : Focus Care Enhancement Program for Elderly (FCEPE) is

designed to promote the well-being of elderly in the Philippines

particularly on their nutritional health and cognitive functioning.

Malnutrition has been a great quandary among the elderly

population. The enhancement of proper nutrition among the

elderly population is essential in the promotion of a better cognitive functioning in

the later life. It is said to be that cognitive impairment is affected by poor

intake of nutrients. This program will help the elderly to

prepare healthy and affordable meals that will improve not only their

cognitive capacity but also to their total well-being. With good nutritional status, elderly

will be able to perform activities of daily living independently.

Benefits : The elderly will gain knowledge, skills, and attitude towards

healthy ageing with respect to:

1. The understanding of malnutrition, its incidence, risk

factors and effects to health;

2. The importance of good and proper nutrition, its sources

and role to elderly well-being; and

3. The value of cooking methods, food preparation and

healthy meal planning.

General Objectives : After two days of didactic health teaching and motivational

activities, the elderly will be able to :

1. Comprehend the meaning of malnutrition and its

detrimental effect to ageing;

2. Appreciate the essence of having a good and proper

nutrition; and,

3. Create a functional and complete meal plan at affordable

among the elderly.

Learning Objectives Learning Topics Motivational Activities Evaluation

After the end of the

lecture, the elderly

are expected to:

Day 1: 9 AM - 12

PM

Know the

information about

malnutrition, its

incidence, the

different risk

factors, and its

effect to the

elderly.

State the meaning

of good nutrition

and its importance

to healthy ageing.

Enumerate the

different

techniques in food

preparation and

cooking methods.

Develop a

personalized one-

day complete

meal plan

enumerating the

different food

groups

Day 2: 9 AM – 12

PM

Definition of

malnutrition,

incidence of

malnutrition, risk

factors, effect of

malnutrition to

elderly

Definition of good

nutrition,

importance of good

nutrition, major

food groups,

importance &

sources of vitamins

and minerals

Importance of food

preparation,

techniques on good

food handling,

different cooking

methods, tips on

food storage and

refrigeration

Discussion of the

Food Guide

Pyramid

Recommended for

Filipino Elderly,

sample meal

planning

techniques

Participative

learning discussion

Participative

learning discussion

Demonstration,

video playing

Participative

discussion,

demonstration

Demonstration

Recitation

Pen and paper

Return

demonstration,

recitation

Pen & paper,

return

demonstration

Follow-up

nutritional

screening and

assessment

Follow-up

nutritional

screening and

assessment

Create meals

focusing on the

nutrients, proper

cooking

techniques and

resourcefulness of

available food

sources

Sample cooking

demonstration

(malunggay

porridge, hi-protein

ampalaya mix)

Appendix G

Curriculum Vitae

Lucky P. Roaquin

#4 North Sikap St., Brgy. Plainview,

Mandaluyong City, Philippines

Contact numbers: (+63) 915 359 3508; (+63) 932 208 9922 E-mail address: [email protected]

Personal Profile Highly astute, energetic, and team-spirited with a strong work ethics to fill numerous general roles. Accurate, precise and highly ethical in all work-related assignments. Comprehensive experience in environments with problem resolution and business function, all in time-critical, fast-paced and high-volume settings. Fast learner with high energy and a drive to exceed expectation, in the management of a private investment portfolio. Outstanding comprehension on health assessment & management, reports analysis, leadership management and staff development. Summary of Qualifications

Experienced in balancing priorities for a short-term and long-range goals

Able to coordinate multiple projects and meet deadlines under pressure

A strong history of completing projects on time

Equally effective working in self-managed projects or as a team member

Ability to adapt quickly to challenges and challenging environments

Energetic, optimistic, and self-motivated

Enthusiastic, resourceful, and willing to assume increase responsibility Professional Experience 2011 HR Manager / Education Business Manager GROP International Services, Inc.

Manages people in the company

Handling recruitment process and representative of English tutors

Provides educational and self-enhancement training to newly hired English tutors

Prepares efficient topics given to Chinese students for learning and capacity building

2011 English as Spoken Language Tutor Korean Private English Tutor – Antipolo City

Teaches English to Koreans and helps them to speak English fluently, construct sentences accurately, and create high-quality English essays.

Helps builds and boosts confidence of Korean students in a competitive way.

Prepares functional lesson plans and time sheets for the students.

Creates a conducive learning environment for the students

Provides necessary activities for the improvement of learning capacity of the students.

2008-2010 Account Receivables Analyst

Accenture, Inc., Makati City

Reconcile, researches and resolves discrepancies between payments and

customer invoice.

Solves problems largely by precedent with referral to detailed instructions/procedures.

Interacts largely with own workgroup but may interact with users around first line queries/requests for information.

Communicates & coordinates discrepancies to onshore counterparts to resolve outstanding issues.

Shares knowledge and experience with either members of team.

May assist less experience or temporary staff where appropriate

Sufficient familiarity with/exposure to a number of straightforward processes and standardized work routines to execute them.

Professional Development

Trainings Attended 2011 Nurse Associate Home Health Care – Quezon City October 17, 2011 – January 20, 2012

Responsible for overall health assessment of patients.

Assists colleagues in the accomplishment of some nursing tasks.

In-charge in the plan of care of patients

Accountable in the implementation of plan of care to patients towards wellness.

Provides assistance to patients in the performance of activities of daily living.

Documents profound reports and findings. Seminars Attended 2012 Resource Speaker “Care of the Chronically Ill and the Older Person” St. Paul University – Quezon City January 17, 2012 2011 Resource Speaker “In the Limelight: Nurses Amidst Modernity” Colegio de San Juan de Letran – Calamba City October 4, 2011 2011 Attendee “Palliative Care Symposium on Symptom Management” UP-Philippine General Hospital – Manila City November 4, 2011 2011 Attendee “Essentials of Dementia Care” Manila Doctors Hospital – Manila City October 20, 2011 2011 Attendee “Wound Care Management” Home Health Care – Quezon City August 24, 2011 2011 Attendee “Care of Terminally Ill”

Home Health Care – Quezon City August 13, 2011 2011 Attendee “Taking Care of Lola and Lola Congress” Home Health Care – Quezon City July 29, 2011 Areas of Strength

Strong communication skills, analytical problem solver and proficient in financial analysis.

Time management skills and driven to learn-apply new ideas

Dedicated, self-motivated, highly professional and proven leadership capabilities

Complete command of:

Excel

PowerPoint

Word Formal Education 2010 to present Master of Arts Nursing major in Medical-Surgical Graduate Student Far Eastern University – Manila City 2008 Bachelor of Science Nursing Graduate Far Eastern University – Manila City 2004 High School Graduate St. Theresita’s School – Tabuk City Character References Mariebel Doris Camagay, MD, FPGM Medical Director Home Health Care – Quezon City Tel# (+632) 920 1445 Stephen Borrega, RN Unit Head Nurse Home Health Care – Quezon City Tel# (+632) 433 1715 I hereby certify that all information above is based on my knowledge.

Respectfully yours,

_____________________ Lucky P. Roaquin, RN

Lic#506882