8 Chapter 7: Nutritional Assessment and Screening
Tracy Everitt; Megan Davies; and Sayuri Omori
Chapter 7 Learning Objectives
At the conclusion of this chapter, students will be able to:
Learning Objectives
- Describe what nutrition screening is and why it is important for older adults.
- Identify the nutrition screening instruments and how they are used.
- Explain the difference between nutrition assessment and nutrition screening.
- Describe the key elements of nutritional assessment and diagnosis.
Introduction
Age-related changes in physiology and appetite may affect an older adult’s nutritional intake. Older adults are at higher risk for malnutrition, which refers to deficiencies, excesses or imbalances in energy intake and nutrients. Malnutrition detrimentally impacts health, cognitive and physical functioning and quality of life. Given these adverse health outcomes in an aging population, screening and assessing malnutrition among older adults is an important health priority.
7.1 Importance of Nutrition
A well-balanced and varied diet full of nutritious foods such as fruits and vegetables, whole grains, legumes, nuts and lean proteins and limited in sugar, salt, saturated or solid fats, and alcoholic beverages is critical to good health in aging (Geirsdóttir & Bell, 2021). A nutritious diet can support the maintenance of a healthy body by managing weight, blood sugar and arthritis, lowering blood pressure, reducing the risk of chronic diseases, slowing the progression of eye disease, keeping bones and muscles strong, and helping to support brain health. Good nutrition can optimize overall health, add vitality, reduce the risk of illness, and increase people‘s health spans – the number of years a person lives in good health.
The human body cannot stay healthy, fight disease, or deal with illnesses without adequate nutrition. Poor nutrition weakens the immune system, leaving people vulnerable to infections and delaying recovery and healing. It can also cause unhealthy weight changes and muscle loss, leading to frailty, falls, broken bones, disability, loss of independence and disease complications. Poor nutrition can also lead to nutrition-related diseases and conditions like malnutrition, sarcopenia, and osteoporosis.
Older adults are at particular risk as nutritional needs and physiology change with age. Changes to taste and swallowing, medical conditions and medications that impact appetite, decreased ability to shop and prepare meals, declines in the thirst sensation, social isolation, and other physical and environmental changes can all impact nutrition. Engaging older adults and all those who care for them is important to providing high-value nutrition care for older adults.
Up to two-thirds of Canadian adults are at high nutrition risk, predisposing them to frailty, hospitalization and death later in life. Nutrition risk occurs in up to 70% of Canadian community-dwelling older adults and is associated with hospitalization, reduced health-related quality of life, and mortality (Capicio, et al., 2022). Common barriers to adequate food intake among older adults increase their vulnerability to nutrition-related health issues. Identifying nutritional risks and interventions to reduce them in community-dwelling older adults might help prevent malnutrition.
7.2 Malnutrition
Malnutrition broadly refers to deficiencies, excesses or imbalances in a person’s intake of energy and nutrients. Undernutrition includes energy, macronutrient and micronutrient deficiencies or insufficiency, while overnutrition is routinely associated with overweight, obesity, and diet-related non-communicable disease.
Malnutrition in older people is increasing in prevalence as the population ages. The prevalence of undernutrition in older people living in the community is about one in five (Geirsdóttir & Bell, 2021). Poor nutritional status is well established as a negative prognostic indicator among older adults, leading to functional decline, lower quality of life, and increases in complications, morbidity, and mortality. It also leads to increased length of hospital stays, unplanned readmissions, institutionalization, and increased health care costs. Malnutrition can more than double the risk of dying in older adults. Figure 7.2.1 visually represents the intersecting components that may put an older adult at increased risk of malnutrition. This pyramid identifies the significance of social determinants of health and how they can build on biological, physiological and environmental factors to create an increased risk for malnutrition.
Figure 7.2.1: Determinants of Malnutrition Pyramid, specific to older adults.
Malnutrition in older adults is challenging for policymakers and the health care system. Although there are many reasons why older people may become malnourished, there are also many practical ways of dealing with the problem. Suppose an older adult is experiencing malnutrition or unintentional weight loss. In that case, the best first step is to see the doctor, who may be able to diagnose an underlying condition or alter a medication regime that may be contributing to the problem. A doctor can also provide a referral to a registered dietitian, who can design a personalized eating plan. The problem is that malnutrition and unintentional weight loss are not always recognized. Strategies to identify people who are malnourished or at risk of becoming malnourished are important for reducing the prevalence of malnutrition, especially among older people. These strategies can include nutrition screening and nutritional assessment to assess risk.
7.3 Nutritional Screening
Malnutrition risk screening has multiple aims, including identifying nutritional status, the need for nutritional intervention, and identifying those at risk of adverse outcomes, such as infections, prolonged healing, or death, due to their nutrition status (Lee & Frongillo, 2001). Malnutrition risk screening should be performed on all patients needing health care services, whether in a hospital, community, long-term care, or home setting. The screening process allows health care providers to quickly target the prevention and treatment of malnutrition in their patients. The most important prevention method for the negative consequences of malnutrition is to commence nutritional therapy as early as possible. The greater the unintentional weight loss, the greater the risk of negative outcomes; in older adults, regaining lost muscle is difficult and unachievable in many cases. The primary goal of screening for older adults is to lengthen their health span, helping to keep them at home and in community-based settings rather than being institutionalized.
Malnutrition screening tools consider weight loss, reduced food intake and disease activity. When targeting community-dwelling older adults, physical and functional status, nutrition intake, and chronic conditions may be prioritized in addition to current nutritional status, whereas in a hospital patient, acute disease should also be considered in combination with the above (Geirsdóttir & Bell, 2021). Unintentional weight loss is routinely included in screening tools regardless of setting and is used by itself in the primary detection of malnutrition. Although helpful, no nutritional screening tool is perfect. Healthcare providers who screen for malnutrition must apply critical thinking and clinical judgment.
Nutrition Screening Tools
The following validated tools are suggested for screening clients for malnutrition or at risk of malnutrition. They can be quickly and easily performed by untrained professionals and sometimes by clients or caregivers. A dietitian should further assess clients identified as malnourished. Screening Tools specifically for older adults living in institutional settings include the Mini Nutrition Assessment Short Form (MNA-SF), the Malnutrition Screening Tool (MST), and the Malnutrition Universal Screening Tool (‘MUST‘). Screening tools for community–dwelling older adults include the Mini-Nutritional Assessment (MNA), Seniors in the Community: Risk Evaluation for Eating and Nutrition tool (SCREEN) and the ‘MUST‘ tool. Table 7.3.1 briefly describes each of these tools and how they are used to screen for malnutrition in older adults.
Table 7.3.1: Summary Table of Nutrition Screening Tools for Older Adults
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Screening Tool
|
Description
|
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Mini Nutrition Assessment Short Form
(MNA-SF) |
MNA-SF is a screening scale used to assess nutritional status. It includes queries regarding other senior issues, including cognitive impairment and depression, mobility, acute disease or psychological stress, weight loss, and food intake.
MNA-SF is the recommended version of MNA for clinical use. It requires BMI or calf circumference when BMI is not calculable. If a risk of malnutrition is found, it requires follow-up with full MNA.
A link to this tool can be found here: MNA-SF |
|
Malnutrition Screening Tool
(MST) |
Developed in Australia. A health professional, client or caregiver can administer it. Asks two questions:
With a score of 2 or more, action is required. Usually, a referral to a dietitian is recommended.
A link to this tool can be found here: MST |
|
Malnutrition Universal Screening Tool
(‘MUST’) |
Designed by the British Association for Parental and Enteral Nutrition. A 5-step screening tool to identify adults who are malnourished, at risk of malnutrition, or obese. It also includes management guidelines which can be used to develop a care plan. It requires anthropometric measurements for BMI calculations, but can use alternative anthropometric measurements for height and weight.
It is for use in hospitals, communities and other care settings and can be used by all care workers.
A link to this tool can be found here: MUST |
|
Mini Nutritional Assessment (Self-MNA)
|
The Self-MNA is a simple tool that can be used by adults 65 years of age and older or their caregivers.
This new tool has been scientifically validated and is as effective as the MNA in identifying malnutrition.
A link to this tool can be found here: Self-MNA |
|
Senior in the Community: Risk Evaluation for Eating and Nutrition Tool
(SCREEN) |
Available validated screens:
1) SCREEN II. Can be administered by the client or interviewer.
2) SCREEN-AB. Abbreviated from SCREEN II. A link to this tool can be found here: SCREEN |
| Dietitians of Canada Nutrition Sample Dietitian Referral Form and Nutrition Assessment Form
Best Practices for Nutrition, Food Service, and Dining in LTC Homes |
Screening, assessment and monitoring guidelines for Residents in Long Term Care.
A link to this tool can be found here: Best Practices for Nutrition, Food Service, and Dining in LTC Homes |
|
NCP Data Collection and Reassessment
NCP Initial Assessment Long-Term Care NCP Toolkit
|
The Nutrition Care Process is a systematic approach which includes four steps: nutrition assessment and reassessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation. Developed by the Academy of Nutrition and Dietetics’ Nutrition Care Model Workgroup
**Special permission required to reproduce/publish
A link to this tool can be found here: NCPT |
Source: Dietitians of Canada. Nutrition Screen Tools. https://www-pennutrition-com.libproxy.stfx.ca/calculators/nutrition_screening_tools.aspx
7.4 Nutritional Assessment
In some cases, nutrition screening does not provide the whole picture of health and nutrition issues. An expansion of nutrition screening is a nutritional assessment. A nutritional assessment will acquire sufficient information about nutrition impact symptoms (NIS), body composition and function, stress metabolism, psychological and psychosocial parameters, as well as nutrition requirements to inform nutritional diagnosis(es), goal setting, and care planning (Geirsdóttir & Bell, 2021). Continuous assessment is also used to monitor the effectiveness of nutrition interventions. The components of a nutritional assessment include anthropometric measures, biochemical parameters, clinical evaluation and dietary history.
Nutritional assessment in many older adults is further complicated by multi-morbidity, acute illness, hospitalizations, and disabilities in combination with nutrition-related problems such as dysphagia, decreased appetite, fatigue, and muscle weakness. The crossover between malnutrition, physical dysfunction, sarcopenia, frailty, and cachexia in aging further contributes to diagnostic difficulties. The nutrition impact symptoms assessment aims to detect, reduce, or remove barriers to eating and ensure that the nutrition plan can consider physiological, psychosocial, and environmental changes related to eating. Further investigation and treatment should be initiated in response to modifiable NIS factors detected. A systematic approach to the nutrition care process and assessing NIS is recommended to understand the greater picture of individual nutrition intake disturbances. There are many determinants of malnutrition and different tools for assessment. For example, the NIS Score for symptoms impacting food intake is built on PG-SGA, one of the best validated NIS instruments for cancer patients (Fernandez, H., et al., 2008).
Components of Nutritional Assessment
Table 7.4.1: Summary of each component of nutritional assessment.
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Anthropometric Measurements
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Non-invasive quantitative measurements of the body.
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Biochemical Parameters
|
Used to assess nutritional status by measuring: albumin, creatinine, lipid profile, hemoglobin, ferritin, and electrolytes.
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Clinical Assessment
|
A systematic way to obtain and document information about an individual’s medical and psychiatric conditions and symptoms, function, behaviour, personal history, values, preferences, goals, and other relevant information, which is then analyzed using clinical reasoning to identify underlying conditions.
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Dietary History
|
Structured interview method consisting of questions about habitual intake of foods from the core food groups and dietary behaviours.
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References
Capicio, M., et al. (2022). Nutrition Risk, Resilience and Effects of a Brief Education Intervention among Community-Dwelling Older Adults during the COVID-19 Pandemic in Alberta, Canada. Nutrients, 14(5), 1110.
Geirsdóttir, Ó., & Bell, J. (2021). Interdisciplinary Nutritional Management and Care for Older Adults: An Evidence-Based Practical Guide for Nurses (p. 271). Springer Nature.
Fernandez, H., et al. (2008) House staff member awareness of older inpatients’ risks for hazards of hospitalization. Arch Intern Med 168(4):390–396
Lee, J., Frongillo, E. (2001) Factors associated with food insecurity among U.S. elderly persons: importance of functional impairments. Journal of Gerontology Behavioural Psychology Sciences Society Sci 56(2):S94–S99
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