Nutrition Screening

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Nutrition Screening Assessment of the Elderly
What tools are available?

• Patricia Anthony, MS, RD
• Manager, Clinical Services
• Nestlé Nutrition
• Vevey, Switzerland

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Elderly Demographics(gt 60 years)
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Malnutrition in the Elderly More common than
you would think

• 2 - 10 free-living elderly populations 1
• 30 - 60 institutionalized elderly 1
• 40 - 85 nursing home residents 2
• 20 - 60 home care patients 2
• (1) Vellas, B. et al, NNWS, 1999, Volume 1 (2)
  Nutr Screening Initiative

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Why the concern?

• Malnourished elderly are
• 2 times more likely to visit the doctor
• 3 times more likely to be hospitalized
• Infection is the most common disorder
• 2 - 10 times more likely to die if malnourished
• Diminished muscle strength
• Poor healing
• Malnutrition is a greater threat than obesity

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Complications and mortality Correia et al. Clin
Nutr 2003 22235-239
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Risk factors for complicationsMultiple logistic
regression analysisCorreia et al. Clin Nutr
2003 22235-239
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Risk factors for deathMultiple logistic
regression analysisCorreia et al. Clin Nutr
2003 22235-239
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Malnutrition Pressure Ulcers
Hudgens J, et al. JPEN 2004
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Malnutrition A vicious circle
Malnutrition

Apathy, depression Poor concentration
Reduced feeding capabilities
Poor Appetite
Reduced mobility
Loss of muscle strength
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Malnutrition increases costs

• 7.3 million per yr spent per 100,000
  malnourished in the community (BAPEN report 1999)
• Estimated cost savings in hospitals of 266
  million/year if nutritional support provided
  (Kings Fund report)

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Aging MalnutritionWhy is this an issue?

• Changes with aging
• Physical
• diminishing eye sight
• poor dentition
• taste changes
• poor swallowing
• Physiological
• Metabolic
• Psychosocial changes

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Frailty

• A condition in which at least 3 of the following
  5 symptoms are present
• Weakness
• Slow walking speed
• Low level of physical activity
• Unintentional Wt loss
• Exhaustion
• Malnutrition has been identified
• as one of the 4 causes of frailty

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So, how do we most effectively identify elderly
who are at risk of malnutrition?
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Nutrition Screening

• Purpose to quickly identify individuals
  nutritionally at-risk or who are malnourished
• Nutrition Assessment
• Purpose to identify early signs of malnutrition
  and prevent it from becoming a major co-factor in
  organ dysfunction and morbidity and mortality

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What is Screening?

• Separates those who are healthy from those at
  high risk for the condition
• Tests should be non-invasive, inexpensive, and
  have rapidly available results

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Screening Tools

• MNA Short Form
• Nutrition Screening Initiative
• DETERMINE checklist
• MUST (Malnutrition Universal Screening Tool)
• Nutrition Risk Screening (NRS) (ESPEN)

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• Developed in 1990
• Validated for ages 65
• Simple, reliable, non-invasive,
• quick
• Inexpensive
• Validated in hospital community setting
• For screening assessment

Guigoz et al., Nutr. Rev. 199654S59-65 Vellas
B et al., J Am Geriatr Soc 2000481300-1309c Rube
nstein LZ et al., J Gerontol 200156M366-M372
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Validation of MNA

• Nursing home, hospitalized free living elderly
• Sensitivity 96
• Specificity 98
• Predictive value 97
• Inter-observer MNA- Kappa 0.51

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• 4 sections
• Anthropometrics
• Diet questionnaire
• Global assessment
• lifestyle
• medications
• mobility
• Subjective assessment
• self perception of health
• nutrition

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MNA score interpretation

• maximum score 30 points
• ? 24 normal/well-nourished
• 17 - 23.5 border line/at risk of
  malnutrition
• lt 17 undernutrition

Guigoz et al., Facts Res. Gerontol. 1994
(suppl.2)15-70
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Predictive ability of MNA

• One-year Mortality
• lt17 - 48
• 17-23.5 - 24
• gt 23.5 - 0
• Correlates with functional level
• Good correlation with nutritional markers
• Dietary intake, vit.D, folate, prealbumin

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Mini Nutrition Assessment (MNA)Short Form

• Based on the original MNA
• Uses only 6 items
• MNA determined to be too time consuming to use
  as a screening tool
• Was further validated in ambulatory elderly
  patients

Cohendy et al. Aging 200113293-297
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MNA Screening Form (MNA-SF)
1. Body mass index (BMI) (kg/m2) 2. Weight loss
in past 3 months? 3. Acute illness or major
stress in past 3 months? 4. Mobility 5.
Dementia or depression 6. Has appetite food
intake declined in past 3 months?
Rubenstein LZ et al., J Gerontol 200156M366-M372
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www.mna-elderly.com
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The Nutrition Screening Initiative

• ADA, AAFP, NCA
• Designed to increase community dwelling elders
  awareness about health nutrition
• Self-administered checklist determines need for
  referral to a health care professional
• Not clinically validated

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MUST Malnutrition Universal Screening Tool

• A practical, reliable, validated tool for
  nutrition screening
• Allows comparable nutritional screening across
  different care settings by different health
  professionals
• primary care, home, acute care, long term care
• Identifies individuals who are undernourished or
  obese
• Not specific for the elderly, but adults

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Step 5 Recommended Management Guidelines

• 0Low risk Routine care
• If obese / special diet local policy
• Hospital repeat screen every week
• Care homes repeat screen every month
• Community repeat screen annually for special
  groups e.g. gt75yr
• 1Medium risk Observe
• Help with food choices/ dietary advice
• Hospital Document dietary/fluid intake x 3d,
  repeat screen weekly
• LTC Document dietary/fluid intake x 3d, repeat
  screen monthly
• Community Repeat screen (2-3 monthly)
• 2High risk Treat
• Refer to Dietitian NST or implement local
  policy
• Improve nutritional intake
• Monitor and review care plan

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MUST ValidityMalnutrition Universal Screening
Tool

• Hospitals
• predicts Length of stay
• predicts discharge destination
• mortality
• Community
• predicts rates of hospitali admissions
• predicts rates of GP visits
• shows that appropriate intervention improves
  outcome

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NRS - Nutrition Risk Screen

• Developed in 2003 (Kondrup et al - ESPEN)
• Used retrospective analysis of RCT (adults)
• Nutritional criteria or characteristics
• Clinical outcome
• Assumption Indications for nutrition support are
  
• the severity of undernutrition
• the increase in nutritional requirements from the
  disease
• Screen includes measures of current potential
  undernutrition disease severity
• Validated vs RCT of NS to determine if it was
  able to distinguish those with a positive
  clinical outcome vs those with no benefit.

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NRS - Nutrition Risk Screen
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Indication for Nutritional Support

• Calculate the total score
• Score (0-3) for Impaired nutritional status (only
  one choose the variable with highest score)
• Score for Severity of disease (?
  stress-metabolism, i.e. increase in nutritional
  requirements).
• Add the two scores (? total score)
• If age ? 70 years add 1 to the total score to
  correct for frailty of elderly
• If age-corrected total ?3 Start Nutritional
  Support

Kondrup et al. Clin Nutr 2003 22 321-336
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NRS

• Is able to distinguish between RCTs with a
  positive effect on outcome those with no
  positive effect
• Is able to select patients who will have benefit
  from nutrition support

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Bauer JM, et al. Dtsch Med Wochenschr 2006

• MNA is especially applicable for a people who
  live independently for cooperative residents of
  nursing homes
• NRS is a valuable alternative for hospital
  patients and those unable to cooperate
• Screening for malnutrition should be a routine
  practice in the elderly population, especially
  those at high risk (i.e. hospitals nursing
  homes)

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Nutrition Assessment

• A comprehensive evaluation to define nutrition
  status
• Forms the basis for nutritional support in
  patients who require specific nutritional or
  metabolic evaluation, and perhaps special feeding
  techniques.
• An expert task.

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Nutrition AssessmentComponents

• Medical History
• Dietary History
• Body Composition
• Physical Exam
• Laboratory Analysis

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Nutrition AssessmentCommon tools

• Mini Nutritional Assessment (MNA)
• Subjective Global Assessment (SGA)

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Subjective Global Assessment (SGA)

• Highly standardized medical history PE
• History
• Weight change
• Changes in dietary intake
• Presence of GI symptoms
• Functional capacity
• Knowledge of the metabolic demands of the pts
  underlying disease state
• Physical Exam
• Loss of SQ fat
• Muscle wasting
• Edema in ankles
• Edema in sacral area
• Ascites

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Subjective Global Assessment (SGA)

• Based on features of history PE a SGA rank is
  chosen by the clinician
• A) Well nourished
• B) Moderate or suspected malnutrition
• C) Severe malnutrition
• No explicit numerical weighting scheme
• Ranking assigned on basis of subjective weighting
• Emphasis placed on weight loss, poor dietary
  intake, loss of SQ fat and muscle wasting
• Ranking is thought to be associated with risk of
  medical complications

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Subjective Global Assessment (SGA)

• Primarily validated in hospitalized patients
• Well correlated to anthropometric lab values
• Well correlated to morbidity indices (infection
  incidence, length of stay)
• Correlates well with other objective assessment
  techniques
• Predicts complications in patients with low
  ratings
• Poor interobserver reliability
• Not specifically validated in the elderly
• Requires skilled clinicians

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Nutrition is part of the Bigger Picture!

• Cognitive Mini Mental State Examination
  (MMS)
• Affective Geriatric Depression Scale (GDS)
  
• Gait Tinetti gait balances
  evaluation
• Autonomy Activities of Daily Living (ADL/ IADL)
• Nutrition Mini Nutritional Assessment
  (MNA)

Guigoz et al., Nutr. Rev. Nutr. Rev.
199654S59-65
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So what.....

• To prevent, minimize reverse malnutrition in
  the elderly there needs to be increased
  identification of nutritional status
  appropriate intervention
• To identify those at risk who might benefit
  from intervention the appropriate tool should be
  used
• inexpensive, practical, simple
• validated for the elderly population
• Research shows that nutrition intervention can be
  used effectively in patients who are at risk of
  malnutrition