Beyond Malnutrition Screening: Appropriate Methods to Guide Nutrition Care for Aged Care Residents

doi:10.1016/j.jada.2011.09.038

Journal of the Academy of Nutrition and Dietetics

Volume 112, Issue 3, March 2012, Pages 376-381

https://doi.org/10.1016/j.jada.2011.09.038 Get rights and content

Abstract

Background

Malnutrition is common in older adults and early and appropriate nutrition intervention can lead to positive quality of life and health outcomes.

Objective

The purpose of our study was to determine the concurrent validity of several malnutrition screening tools and anthropometric parameters against validated nutrition assessment tools in the long-term-care setting.

Study design

This work was a cross-sectional, observational study.

Participants/setting

Older adults (aged >55 years) from two long-term-care facilities were screened.

Main outcomes

Nutrition screening tools used included the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment-Short Form (MNA-SF), and the Simplified Nutritional Assessment Questionnaire. Nutritional status was assessed by Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), body mass index (BMI), corrected arm muscle area, and calf circumference. Residents were rated as either well nourished or malnourished according to each nutrition assessment tool.

Statistical analysis

A contingency table was used to determine the sensitivity and specificity of the nutrition screening tools and objective measures in detecting patients at risk of malnutrition compared with the SGA and MNA.

Results

One hundred twenty-seven residents (31.5% men; mean age 82.7±9 years, 57.5% high care) consented. According to SGA, 27.6% (n=31) of residents were malnourished and 13.4% were rated as malnourished by MNA. MST had the best sensitivity and specificity compared with the SGA (sensitivity 88.6%, specificity 93.5%, κ=0.806), followed by MNA-SF (85.7%, 62%, κ=0.377), MUST (68.6%, 96.7%, κ=0.703), and Simplified Nutritional Assessment Questionnaire (45.7%, 77.2%, κ=0.225). Compared with MNA, MNA-SF had the highest sensitivity of 100%, but specificity was 56.4% (κ=0.257). MST compared with MNA had a sensitivity of 94.1%, specificity 80.9% (κ=0.501). The anthropometric screens ranged from κ=0.193 to 0.468 when compared with SGA and MNA.

Conclusions

MST, MUST, MNA-SF, and the anthropometric screens corrected arm muscle area and calf circumference have acceptable concurrent validity compared with validated nutrition assessment tools and can be used to triage nutrition care in the long-term-care setting.

Section snippets

Study Design and Participants

A cross sectional, observational study was conducted in two long-term-care settings in southeast Queensland, Australia. Residents were excluded if they were younger than age 55 years or non-English speaking. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Human Research and Ethics Committees of the university and received approval from the industry partner. Written informed consent was

Results

Complete data were available on 127 residents. One long-term-care facility accommodated high-care residents only (n=34), and the other facility housed a mixture of high- (n=39) and low-care (n=54) residents. Residents in high care are more likely to experience physical and mental impairments that require assistance. There were no significant differences in age (80.3±8.8 years vs 83.8±9.9 years), sex (38% men vs 29% men), or malnutrition prevalence (32.4% vs 25.8%) between the two facilities.

Malnutrition Prevalence

According to SGA, malnutrition prevalence was just under 30%, which is lower than the 50% reported by other studies in long-term-care using the SGA (5, 6). Using the MNA, 13.4% of residents were malnourished, with a further 44.9% at risk. This compares with 28% to 90% prevalence of malnutrition and malnutrition risk using the MNA in international studies (30, 31, 32). The lower malnutrition prevalence in our study may be due to the proactive nutrition measures used by the facilities, including

Conclusions

This study found that malnutrition screening tools MST, MUST, and MNA-SF and the CAMA and calf circumference anthropometric screens had acceptable sensitivity and specificity when compared with the SGA and MNA nutrition assessments. Staff members conducting the screening, ease of use, training, and the resources available should be considered when implementing a screening procedure. There is further advantage in using the same nutrition screening tool across health care settings. Future

E. A. Isenring is a clinical academic fellow, Princess Alexandra Hospital, and conjoint Senior Lecturer, School of Human Movement Studies, University of Queensland, Brisbane, Australia, and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.

References (40)

M. Arvanitakis et al.
Nutrition in homes and home care: Recommendations—A summary based on the report approved by the Council of Europe
Clin Nutr
(2009)
M. Pirlich et al.
The German hospital malnutrition study
Clin Nutr
(2006)
S. Iizaka et al.
The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care
Clin Nutr
(2010)
J. Correia et al.
Efficiency of MST—Malnutrition Screening Tool—in elderly hospitalised patients
Clin Nutr
(2003)
M. Ferguson et al.
Development of a valid and reliable malnutrition screening tool for adult acute hospital patients
Nutrition
(1999)
M.M. Wilson et al.
Appetite assessment: Simple appetite questionnaire predicts weight loss in community dwelling adults and nursing home residents
Am J Clin Nutr
(2005)
J. Kondrup et al.
ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003)
S. Heymsfield et al.
Anthropometric measurement of muscle mass: Revised equations for calculating bone-free arm muscle area
Am J Clin Nutr
(1982)
D. Gaskill et al.
Maintaining nutrition in aged care residents with a train-the-trainer intervention and Nutrition Coordinator
J Nutr Health Aging
(2009)
S. Capra
Nutrition assessment or nutrition screening—How much information is enough to make a diagnosis in acute care?
Nutrition
(2007)

U. Soderhamn et al.

Self-care ability and sense of coherence in nutritional at-risk patients

Eur J Clin Nutr

(2008)

C. Watterson et al.

Evidence based guidelines for nutritional management of malnutrition in adult patients across the continuum of care

Nutr Diet

(2009)

A.M.M. Berkjout et al.

The relationship between difficulties in feeding oneself and loss of weight in nursing-home patients with dementia

Age Ageing

(1998)

M. Banks et al.

Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities

Nutr Diet

(2007)

D. Gaskill et al.

Malnutrition prevalence and nutrition issues in residential aged care facilities

Australas J Ageing

(2008)

J. Thomas et al.

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit

J Hum Nutr Diet

(2007)

R. Visvanathan et al.

Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes

Age Ageing

(2004)

H.H. Keller et al.

Body mass index (BMI), BMI change and mortality in community-dwelling seniors without dementia

J Nutr Health Aging

(2005)

Identifying patients at risk: ADA's definitions for nutrition screening and assessment

J Am Diet Assoc

(1994)

J.M. Jones

The methodology of nutrition screening and assessment tools

J Hum Nutr Diet

(2002)

Cited by (78)

Harmonization and standardization of malnutrition screening for all adults – A systematic review initiated by the Norwegian Directorate of Health
2022, Clinical Nutrition ESPEN
The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.
A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.
The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.
The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.
In Patients Admitted to a Home Rehabilitation Service, Is Remote Completion of the Patient-Generated Subjective Global Assessment Physical Examination Using Still Images Captured by Allied Health Assistants a Valid Alternative to an In-Person Physical Examination?
2022, Journal of the Academy of Nutrition and Dietetics
There is increasing provision of telehealth services, including nutrition services. However, remote nutrition assessments are challenging due to difficulties in conducting physical assessments remotely, a crucial component of assessing nutritional status.
The aim of this study was to evaluate whether remote completion of the Patient-Generated Subjective Global Assessment physical examination using still images captured by allied health assistants (AHAs) is a valid alternative to an in-person physical examination in patients admitted to a home rehabilitation service.
This study was cross-sectional in design.
This study involved 104 adults admitted to the home rehabilitation service at Southern Adelaide Local Health Network, Adelaide, Australia, over 2 sampling periods in 2019 and 2020 who were receiving home visits by an AHA and were engaged in rehabilitation activities.
Validity of the still image-based physical assessment was determined using still images collected by an AHA and an in-person physical assessment completed by a dietitian from each participant. A dietitian blinded to the in-person results later assessed the de-identified still images to determine the presence and extent of deficit at each anatomical site and overall physical examination component of the Patient-Generated Subjective Global Assessment.
Percentage agreement, weighted κ, sensitivity, and specificity between the still image based and in-person physical examinations were determined to assess agreement between the 2 methods of assessment.
The still image based physical examination achieved a percentage agreement of 75% against the in-person examination, with a weighted κ of 0.662 (95% confidence interval 0.516-0.808) and a sensitivity-specificity pair of 76.6% and 89.1%.
Physical examination using still images collected by AHAs achieved percentage agreement, κ, and sensitivity and specificity compared with an in-person physical examination that is consistent with or superior to commonly adopted nutrition screening and assessment tools. There is potential for implementation of this method to facilitate remote nutritional assessments by dietitians; however, further work is needed to ensure dietitians are able to assess still images reliably.
Reprint of: Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults
2022, Journal of the Academy of Nutrition and Dietetics
Citation Excerpt :
Ferguson and colleagues6 developed the MST to detect malnutrition or risk for malnutrition. Between 1999 and 2017, the MST was validated in acute, long-term, rehabilitation, and ambulatory care and oncology clinics in at least nine different countries.15-33 These studies revealed that the MST exhibited a moderate degree of validity, a moderate degree of agreement, and a moderate degree of inter-rater reliability in identifying malnutrition risk in adults (Figure 2).
It is the position of the Academy of Nutrition and Dietetics that, based upon current evidence, the Malnutrition Screening Tool should be used to screen adults for malnutrition (undernutrition) regardless of their age, medical history, or setting. Malnutrition (undernutrition) screening is a simple process intended to quickly recognize individuals who may have a malnutrition diagnosis. While numerous malnutrition screening tools are in use, their levels of validity, agreement, reliability, and generalizability vary. The Academy of Nutrition and Dietetics reviewed the body of evidence supporting malnutrition screening tools and determined a single tool for identifying adults in all settings who may have malnutrition, regardless of their age or medical history. The Nutrition Screening for Adults Workgroup conducted a systematic review of the most robust evidence to promote using the highest-quality malnutrition screening tool available.
Prospective validation of five malnutrition screening and assessment instruments among medical inpatients: Secondary analysis of a randomized clinical trial
2022, Clinical Nutrition
Screening for malnutrition upon hospital admission is the first crucial step for proper nutritional assessment and treatment. While several nutritional screening and assessment instruments exist, there is a lack of head-to-head validation of these instruments. We studied the ability of five different nutrition screening and assessment instruments to predict 1-year mortality and response to nutritional treatment in participants of the EFFORT randomized trial.
In this secondary analysis of a Swiss-wide multicenter, randomized clinical trial comparing individualized nutritional support with usual care nutrition in medical inpatients, we prospectively classified patients as low, intermediate, and high nutritional risk based on five nutritional screening and assessment instruments (NRS 2002, SGA, SNAQ, MNA and MUST).
Overall mortality at 1-year in the 1866 included patients was 30.4%. There were significant correlations and a significant concordance between all instruments with r-values ranging from 0.23 to 0.55 and kappa values ranging from 0.10 to 0.36. While high nutritional risk was associated with higher mortality in all instruments, SGA and MNA showed the strongest association with adjusted odds ratios of 3.17 (95%CI, 2.18 to 4.61, p < 0.001) and 3.45 (95%CI, 2.28 to 5.22, p < 0.001). When comparing mortality in intervention group patients to control group patients stratified by severity of malnutrition, there was overall no clear trend towards more benefit in patients with more severe malnutrition, with NRS 2002 and SGA showing the most pronounced relationship between the severity of malnutrition and reduction in mortality as a response to nutritional support.
Among all five screening and assessment instruments, higher nutritional risk was associated with higher risk for mortality and adverse clinical outcome, but not with more or less treatment response from nutritional support with differences among scores. Adding more specific parameters to these instruments is important when using them to decide for or against nutritional support interventions in an individual patient.
ClinicalTrials.gov NCT02517476.
Nutritional status and quality-of-life of older adults in aged care: A systematic review and meta-analysis
2022, Experimental Gerontology
The effect of malnutrition beyond morbidity and mortality has become a critical area of investigation in older people with an increased focus on quality-of-life (QoL), but as yet the relationship between malnutrition and QoL remains to be reviewed in older people from aged care settings. The current study conducted a systematic review and meta-analyses of studies published between the years 1995 and 2020 examining the relationship between nutritional status and QoL or the effects of a nutrition-based intervention on QoL in older people in residential aged care. Based on searches of the databases MEDLINE, PsycINFO, Emcare, and Embase, 21 studies were identified. Meta-analyses of the cross-sectional and quasi-experimental studies revealed a significant positive relationship between nutritional status and QoL and that nutritional intervention significantly improved QoL. By contrast, meta-analysis of randomised controlled trials revealed a non-significant but improved trend post-intervention in QoL. Although the effect sizes were small, the present findings indicate that nutrition-based interventions improve QoL in older people in residential aged care and align with previous reviews based on findings from other aged settings. Future research is needed to determine causality and to better identify and control for confounding factors which may influence both nutritional status and QoL.
Adult Malnutrition (Undernutrition) Screening: An Evidence Analysis Center Systematic Review
2020, Journal of the Academy of Nutrition and Dietetics
Citation Excerpt :
Summary: Twenty-two studies (15 positive quality31-33,38,43-53 and 7 neutral quality39,42,54-58) met inclusion criteria (Table 5). Study participants with various medical conditions ranged in age from 44.4±1748 to 82.7±9.0 years.31 Sixteen studies were conducted in the hospital,32,38,42,43,46-48,50-58 two in long-term care,31,45 three in ambulatory settings,39,44,49 and none in community settings.
Malnutrition screening relies on quick and easy-to-use tools that require minimal training of users. Valid and reliable tools should avoid under-referral of adults with a malnutrition diagnosis or over-referral of those without a malnutrition diagnosis to dietitians.
Our aim was to conduct a systematic review of adult malnutrition screening tools for validity, agreement, and reliability, and to determine the costs of the malnutrition screening procedure.
Following a structured process, a comprehensive search using PubMed, MEDLINE, EMBASE, and CINAHL was conducted for relevant research published between 1997 and 2017 that examined the validity, agreement, reliability, and costs of nutrition screening tools.
Sixty-nine studies met the inclusion criteria. The Malnutrition Screening Tool exhibited moderate validity, agreement, and reliability based on Grade I (Good/Strong) evidence. The evidence supporting the conclusions for the remaining tools was Fair (Grade II). The Malnutrition Universal Screening Tool exhibited high validity and moderate agreement and reliability. The Mini Nutritional Assessment–Short Form exhibited moderate validity and reliability and low agreement. The Short Nutritional Assessment Questionnaire and the Nutrition Risk Screening 2002 exhibited moderate validity and reliability and the Mini Nutritional Assessment–Short Form Body Mass Index exhibited high validity and moderate agreement. However, these last three tools were missing reliability or agreement data. Limited data were available to evaluate malnutrition screening costs.
This review provides an analysis of validity, agreement, and reliability of tools to screen adults for malnutrition, regardless of their age, medical history, or location. No tools were found with high validity, reliability, and strong supportive evidence. Tools most often achieved moderate validity, agreement, and reliability, and had large variations in individual results. The minimum validity and reliability of tools to screen adults for malnutrition should be established to shape future research. Cost data for the screening process should be obtained and examined.

View all citing articles on Scopus

M. Banks is director of nutrition and dietetics, Royal Brisbane and Womens Hospital, Brisbane, Australia.

M. Ferguson is director of nutrition and dietetics, Princess Alexandra Hospital, Brisbane, Australia.

J. D. Bauer is manager, Department of Nutrition, The Wesley Hospital, Brisbane, Australia, and associate professor, School of Human Movement Studies, University of Queensland, Brisbane, Australia.

View full text

ResearchOriginal ResearchBeyond Malnutrition Screening: Appropriate Methods to Guide Nutrition Care for Aged Care Residents

Abstract

Background

Objective

Study design

Participants/setting

Main outcomes

Statistical analysis

Results

Conclusions

Section snippets

Study Design and Participants

Results

Malnutrition Prevalence

Conclusions

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Nutrition

Am J Clin Nutr

Clin Nutr

Am J Clin Nutr

J Nutr Health Aging

Nutrition

Self-care ability and sense of coherence in nutritional at-risk patients

Eur J Clin Nutr

Evidence based guidelines for nutritional management of malnutrition in adult patients across the continuum of care

Nutr Diet

The relationship between difficulties in feeding oneself and loss of weight in nursing-home patients with dementia

Age Ageing

Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities

Nutr Diet

Malnutrition prevalence and nutrition issues in residential aged care facilities

Australas J Ageing

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit

J Hum Nutr Diet

Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes

Age Ageing

Body mass index (BMI), BMI change and mortality in community-dwelling seniors without dementia

J Nutr Health Aging

Identifying patients at risk: ADA's definitions for nutrition screening and assessment

J Am Diet Assoc

The methodology of nutrition screening and assessment tools

J Hum Nutr Diet

Research
Original Research
Beyond Malnutrition Screening: Appropriate Methods to Guide Nutrition Care for Aged Care Residents