Nutrition screening in long-term care facilities : an evaluation of the methodological quality of available instruments

A variety of nutrition screening instruments have been developed and implemented for identifying the risk of undernutrition among community and hospitalized older adults. Despite the high prevalence of undernutrition amongst older adults in long-term care, few screening instruments have been developed or evaluated in this setting. This review aims to evaluate the validity, reproducibility and feasibility of nutrition screening instruments developed for use, or described as being used, with older adults in long-term care. Ten publications encompassing nine independent nutrition screening tools were identified using electronic databases and manual searches of reference lists. The Mini Nutritional Assessment-Short Form (MNA-SF) was the most widely evaluated nutrition screening instrument and met the requirements for a valid instrument (sensitivity and specificity >0.9) for use in the long-term care setting. Modified versions of the MNA for use in China and South Africa also demonstrated acceptable levels of sensitivity and specificity. Other nutrition screening instruments were found to have variable levels of sensitivity and specificity and while some demonstrated levels consistent with the MNA-SF, only two were evaluated across more than one study population, Body Mass Index (BMI)+weight loss and BMI+albumin. These same instruments reported the highest levels of inter-rater and test-retest reproducibility, although this was only tested in one other instrument (Chinese Nutrition Screen -modified MNA). In conclusion, it is evident from this review that further work in this area is needed. Based on validity, reproducibility and feasibility it appears that BMI+weight loss is the most suitable nutrition screening instrument for use in the long-term care setting at this time. MNA-SF is promising; however, there is currently no data for inter-rater or test-retest reproducibility in the long-term care setting.

A simple nutrition screening tool for hemodialysis nurses

Objective : To assess the reliability of a nurse-performed nutrition screening tool (NST) for hemodialysis (HD) patients to identify nutritionally at-risk patients.

Design : Tool reliability assessment.

Setting and Participants : The setting was nine non-hospital private (n = 3) and public (n = 6) HD units in Australia (two rural and seven metropolitan). Participants were 112 HD patients.

Results : A total of 112 HD patients (male = 65, female = 47) from 9 non-hospital HD units in Australia (seven metropolitan and two rural) were screened with the NST and the outcome of dietitian referral compared with Standard Dietitians Assessment. The mean age of patients was 57.6 years. Overall, the NST showed a sensitivity of 0.84 (range, 0.71 to 0.94; P < .05) and a specificity of 0.9 (range, 0.82 to 0.98; P < .05). The NST was more sensitive (sensitivity, 0.93 [range, 0.87 to 0.99; P < .05]) and was more specific for men (specificity, 0.92 [range, 0.85 to 0.99; P < .05]). Specificity was very strong in metropolitan patients (specificity, 0.94 [range, 0.87 to 1.01; P < .05]).

Conclusions : The tool was more sensitive and specific than the NST previously reported by the same investigators. The tool is particularly specific in that it screens those patients not requiring dietitian intervention. The use of this tool may benefit HD units that do not have on-site or regular dietetic support to prioritize patients needing dietitian intervention.

Nutrition screening by nurses in dialysis

Aims and objectives : To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients.

Background : People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise.

Design : Prospective cluster-randomised control trial.

Methods : Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined.

Results : There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months.

Conclusion : Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians.

Relevance to clinical practice : This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.

Nutrition screening of older people in a community general practice, using the MNA-SF

Background: Objective The study aimed to determine the prevalence of malnutrition risk in a population of older people (aged 75 years and over) attending a community general practice and identify characteristics of those classified as malnourished or at risk of malnutrition.

Design Cross-sectional study of nutritional risk screen conducted over a six month period.

Participants and setting Patients attending a general practice clinic in Victoria, Australia, who attended for the “75 plus” health assessment check.

Measurements The Mini Nutritional Assessment Short Form (MNA®-SF) was included as part of the health assessment. Information was collected on living situation, co-morbidities, independence with meal preparation and eating, number of medications. Height and weight was measured and MNA®-SF score recorded.

Results Two hundred and twenty five patients attending a general practice for a health assessment with a mean age of 81.3(4.3)(SD) years, 52% female and 34% living alone. Only one patient was categorised by the MNA®-SF as malnourished, with an additional 16% classified as at risk of malnutrition. The mean Body Mass Index (BMI) of the at-risk group was significantly lower than the well-nourished group (23.6 ± 0.8 (SEM) vs 27.4 ± 0.3; p=0.0001). However, 34% of the at-risk group had a BMI of 25 or more with only 13% in the underweight category.

Conclusion In this population of older adults attending their general practitioner for an annual health assessment, one in six were identified as being at nutritional risk which is an additional risk factor for a severe health issue. Importantly, one third of the at-risk group had a BMI in the overweight or obese category, highlighting that older people can be at nutritional risk although they may be overweight or obese.

A haemodialysis nutritional screening tool for nurses : a pilot study

The purpose of the study was to pilot a nurse-performed nutritional screening tool (NST) for dialysis patients in order to identify nutritionally at-risk patients. Haemodialysis (HD) patients are at risk of nutritional-related problems. Nutritional screening by nurses may assist in the early recognition of and response to these problems. An NST was developed using 9 screening parameters. (BMI, weight change, poor appetite, GI symptoms, albumin, pre-dialysis urea, K+, PO4++, HbA1c). The NST was compared with Standard Dietitian Assessment (SDA). 44 HD patients were screened with the NST and then with SDA. The tool showed sensitivity of 0.7 (95%CI+/- 0.21) and a specificity of 0.77 (95%CI+/-0.16). Reliability was low (alpha = .18). Alpha increased to 0.32 if pre-dialysis urea was removed from the tool and increased to 0.48 if weight loss, appetite, K+ and PO4++ were used alone. The pilot study showed a low reliability of the NST compared with SDA. With further analysis and modifications, the NST has the potential to assist nutritional screening by nurses in dialysis centres that have limited dietetic access.

Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients

Objective: To determine the prevalence of malnutrition in a population of elderly hospitalised patients and to explore health professionals' perceptions and awareness of signs and risks of malnutrition and treatment options available.

Subjects and design: One hundred elderly patients and 57 health professionals from medical wards of a tertiary teaching hospital. Quantitative and qualitative study design using a validated malnutrition assessment tool (Mini Nutritional Assessment) and researcher-designed questionnaire to assess health professionals' knowledge of nutrition risk factors.

Main outcome measures: Mini Nutritional Assessment score, nutrition risk category and themes in health professionals' knowledge and awareness of malnutrition and its risk factors.

Results: Thirty per cent of patients were identified as malnourished while 61% were at risk of malnutrition. Documentation by health professionals of two major risk factors for malnutrition—recent loss of weight and appetite—were poor with only 19% and 53% of patients with actual loss of weight or appetite, respectively, identified by staff and only 7% and 9% of these patients, respectively, referred for dietetic assessment. While health professionals' knowledge of important medical risk factors for malnutrition was good, their knowledge of malnutrition risk factors such as recent loss of weight and loss of appetite was poor. Medical staff focused on biochemical factors when assessing nutrition status, while nursing staff focused on skin integrity and turgor.

Conclusion: Malnutrition in elderly hospitalised patients remains a significant problem with low rates of recognition and referral by medical and nursing staff. Considerable scope exists to develop training and education tools and to implement an appropriate nutrition screening policy to improve referral rates to dietitians.

Hospital malnutrition : prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

In vitro and in situ screening systems for morphological and phytochemical analysis of Withania somnifera germplasms

We report, for the first time for Withania somnifera, the use of a modified in vitro system for morphological and phytochemical screening of true to type plants as compared with those grown in a conventional in situ system. Eleven germplasms of cultivated W. somnifera from different regions of India were collected to examine chemotypic variation in withaferin A (WA). Methods were developed to optimize WA extraction. The maximum concentration of WA was extracted from manually ground leaf and root material to which 60 % methanol was added followed by sonication in a water bath sonicator. Variation in WA concentration in whole plants was observed amongst the different germplasms. In the in vitro system, the concentration of WA ranged between 0.27 and 7.64 mg/g dry weight (DW) and in the in situ system, the range in concentration was between 8.06 and 36.31 mg/g DW. The highest amount of WA found in leaves was 7.37 and 41.42 mg/g DW in the in vitro and the in situ systems respectively. In roots, the highest WA concentration was 0.27 mg/g DW in the in vitro and 0.60 mg/g DW in the in situ system. There are distinct advantages in using the in vitro grown plants rather than those grown in the in situ system including the simplicity of design, efficient use of space and nutrition and a system which is soil and contaminant free. The proposed in vitro system is therefore ideal for utilization in molecular, enzymatic and biochemical studies.

Profile of European adults interested in internet-based personalised nutrition: the Food4Me study

PURPOSE: Personalised interventions may have greater potential for reducing the global burden of non-communicable diseases and for promoting better health and well-being across the lifespan than the conventional "one size fits all" approach. However, the characteristics of individuals interested in personalised nutrition (PN) are unclear. Therefore, the aim of this study was to describe the characteristics of European adults interested in taking part in an internet-based PN study. METHODS: Individuals from seven European countries (UK, Ireland, Germany, The Netherlands, Spain, Greece and Poland) were invited to participate in the study via the Food4Me website ( http://www.food4me.org ). Two screening questionnaires were used to collect data on socio-demographic, anthropometric and health-related characteristics as well as dietary intakes. RESULTS: A total of 5662 individuals expressed an interest in the study (mean age 40 ± 12.7; range 15-87 years). Of these, 65 % were female and 97 % were Caucasian. Overall, 13 % were smokers and 47 % reported the presence of a clinically diagnosed disease. Furthermore, 47 % were overweight or obese and 35 % were sedentary during leisure time. Assessment of dietary intakes showed that 54 % of individuals reported consuming at least 5 portions of fruit and vegetables per day, 46 % consumed more than 3 servings of wholegrains and 37 % limited their salt intake to <5.75 g per day. CONCLUSIONS: Our data indicate that individuals volunteering to participate in an internet-based PN study are broadly representative of the European adult population, most of whom had adequate nutrient intakes but could benefit from improved dietary choices and greater physical activity. Future use of internet-based PN approaches is thus relevant to a wide target audience.