Malnutrition Screening – Essential for detecting nutrition problems at an early stage

By Kaye Dennison - Dietitian

 

Malnutrition in New Zealand is a real problem, especially in the older population. National studies illustrate malnutrition affects 20 to 50 percent of older adults in the health care setting [1-5], and up to 31 percent in the community [6]. It is an issue that is often underrecognized and undertreated [7].

It is associated with many adverse outcomes including the loss of muscle mass, reduced strength, impaired immune function, longer length of hospital stay, higher treatment costs and increased mortality [7-9].

Nutrition screening is therefore an important and effective measure that can identify those with characteristics commonly linked with nutritional problems, who may require comprehensive nutrition assessment. Validated nutrition screening tools are effective and easily administered tools that can predict malnutrition risk using a quantitative score generated as a result of a series of questions and/or physical assessments [10], and can be performed by any trained health professional.

For malnutrition screening tools to be effective and valid, they need to possess certain characteristics, including having high sensitivity (ability to detect malnutrition in those who actually are malnourished), high specificity (ability to give a negative result in those who are not malnourished), quick and easy to administer, relevant in the appropriate setting (e.g. acute hospital or community) and specific to client group (e.g. older adults, people with kidney disease, children etc.) [11-14].

Malnutrition Screening Tools used in NZ

Many validated screening tools are used by hospitals and health care practices across NZ. Some of these tools are described below:

The Malnutrition Universal Screening Tool (MUST) [12]

Establishes malnutrition risk in adults in both acute and community settings. Includes three parameters around Body Mass Index (BMI), unintended weight loss and acute disease effect on nutrient intake.

Advantages: Establishes malnutrition risk in those whom weight and/or height cannot be measured. Can be administered within 5 minutes. Simple to use. Excellent reproducibility.

Mini-Nutritional Assessment-Short Form (MNA-SF) [13]

A single, rapid, six item questionnaire that assesses the nutrition status of older people, living in their own  homes or in residential level care facilities. This tool includes parameters around oral intake, weight loss, acute disease or psychological stress, neurological problems and BMI.

Advantages: High sensitivity and specificity. Can be administered within 5 minutes. Can be used in a range of settings. Can use a calf circumference measure in place of BMI.

Seniors in the Community: Risk Evaluation for Eating and Nutrition
(SCREEN II) [14]

A 14-item questionnaire assessing malnutrition risk status of older people in the community setting. It covers food intake and physiological, adaptive and functional nutrition factors.

Advantages: High sensitivity, specificity and acceptability. Can be self-administered or interviewer administered. No anthropometric or biochemical measures required.

What happens after being identified as ‘at risk of malnutrition’ or ‘malnourished’?

Those  identified as at risk of malnutrition would have a care plan put in place according to the facilities policy.  It is recommended for those identified as already having malnutrition to be  referred to a dietitian for further nutritional assessment and an appropriate fortified diet plan.

The dietitian will investigate the possible causes of malnutrition, then set aims and objectives for treatment. Typical treatment options include education and support around nutrient dense food choices and eating and drinking practices. Oral nutritional supplements, if nutritional requirements cannot be met through normal food and fluid intake alone.

InterRAI Long-Term Care Facilities (LTCF) Assessment

The InterRai LTCF Assessment is completed for all residents in long term care facilities.. It is a comprehensive electronic assessment tool used by health professionals to determine care needs of home based and residential care older adults in NZ. It collects a wide range of data on older people’s health, to support the monitoring and planning of long term care [15].

Although the InterRAI LTCF contains elements that examine known risk factors for malnutrition e.g. assesses disease presence, cognitive and functional health, it doesn’t suffice as replacement for a validated malnutrition screening tool. Facilities are encouraged to use internationally validated screening tools alongside the InterRAI assessment to monitor resident’s nutrition risk.

Conclusion

As malnutrition is prevalent in New Zealand’s older population, nutritional assessment and screening tools can be useful in highlighting individuals in need of nutritional support. Health care providers need to ensure appropriate protocols such as routine screening and follow-up of a more comprehensive assessment and plan of care, are put in place to successfully treat those at nutrition risk. As many malnutrition screening tools exist, the decision to use a particular tool should also be considered carefully. If in doubt as to what screening tool is right for your facility or service, check with your dietitian.

References:

  1. Popman A, Richter M, Allen J, Wham C. High nutrition risk is associated with higher risk of dysphagia in advanced age adults newly admitted to hospital. Nutr Diet 2017 Sep 15 doi: 10.1111/1747-0080.12385. [Epub ahead of print]
  2. Wham C, Fraser E, Buhs-Catterall J, Watkin R, Gammon C. Malnutrition risk of older people across district health board community, hospital and residential care settings in New Zealand. Australasian Journal on Ageing, 2017;36(3):205-211
  3. Goldstraw P. Nutrition: ignore it at your older patient’s peril. New Zealand Family Physician, 1998;25(4):27-29
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  5. Van Lill S. Audit on the nutritional status of patients over 65 years in the AT&R wards, Middlemore Hospital. Paper presented at the Conference of the New Zealand Dietetic Association, Palmerston North, New Zealand.
  6. Wham C, Carr R, Heller F. Country of origin predicts nutrition risk among community living older people. J Nutri Health Ageing, 2011;15(4):253-258
  7. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. Nutrition care practices in hospital wards: results from the Nutrition Care Day Survey 2010. Clinical Nutrition, 2011;31(6):995-1001
  8. Correia M.I., Waitzberg D.L. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through multivariate model analysis. Clinical Nutrition, 2003;22(3):235-239
  9. Saunders J, Smith T, Stroud M. Malnutrition and undernutrition. Medicine, 2010;39(1):45-50
  10. Green SM, Watson R. Nutritional screening and assessment tools for older adults: literature review. J Adv Nurs, 2006;54:477-490
  11. Cederholm T et al. Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clinical Nutrition, 2015;34:335-340
  12. Malnutrition Action Group. The ‘MUST’ explanatory booklet: A guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. England: Malnutrition Action Group, a Standing Committee of the British Association for Parenteral and Enteral Nutrition (BAPEN)
  13. Guigoz Y. The Mini Nutritional Assessment (MNA), review of the literature – what does it tell us? Journal of Nutrition, Health & Ageing, 2006;10:466-487
  14. Keller HH. Goy R. Validity and reliability of SCREEN II (Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II). European Journal of Clinical Nutrition, 2005 59(10):1149-1157
  15. Onder G et al. Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long Term care (SHELTER) study. BMC Health Surv Res, 2012 doi: 10.1186/1472-6963-12-5

 

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