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Flashcards in Nutrition Screening Deck (18):
1

Physiological cause of undernutrition in hospitalised and older people

Reduced appetite
Reduced sell and taste
Dental health
GI changes
Swallowing disorders
Increased dependence
Reduced mobility
Polypharmacy
Prolonged or reported fasting for procedures
Dependence on others for eating

2

Psychological cause of undernutrition in hospitalised and older people

Depression
Delirium
Anxiety
Grief
Cognitive impairment

3

Social cause of undernutrition in hospitalised and older people

Social isolation
Inadequate knowledge about food, nutrition and food preparation
Poverty or food insecurity
Inability to access an adequate food upy
Inadequate assistance with meal set up or feeding
Mealtime interruptions in hospital/ rehab

4

Malnutrition

A state of nutrition in which a deficiency it excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/ body form (body shape, size, composition), body function and clinical outcome.
High prevalence in hospitals (35-43%)
Can be present prior to hospital admission, higher rates in people who have had falls- often due to deconditioning after prior hospitalisation.
Can develop in hospitals/ rehab/ residential care
Most not referred to dietitian

5

Consequence of malnutrition

Functional decline
Increased length of stay- slow wound healing, respiratory infections, poor food intake
Increased complications eg. Infections
Increased rehab time
Increased mortality

Poor nutrition status, low BMI and weight loss:
Decreased mobility and stability leading to falls
Bone loss and hip fractures
Increased risk of pressure ulcers
Increased disability

6

Elements of a system for effective surveillance and management of malnutrition screening

1. Screening
a. To identify those most at risk of malnutrition
2. Identification of those patients with malnutrition
a. Involves nutrition assessment- diagnosis
3. Systems and tools for treating malnutrition
a. Includes interventions such as oral nutritional supplements and enteral nutrition
b. Includes addressing the factors contributing to malnutrition
4. Evaluation and monitoring
a. Is the patients nutritional status improving over time?

7

Nutrition screening tool requirements

Simple
Quick to perform
Valid and reliable in target group for which it was developed:
High sensitivity: avoid false negatives (missed diagnosis)
High specificity: avoids false positives (unnecessary full assessment)
Acceptable to patients
Acceptable to health workers administering them - need to be simple enough to be used by range of workers
Feasible to conduct in sick, frail or confused patients
Eg wt and height cannot be measured in many ill patients

8

Nutrition screening vs nutrition assessment

Is an aid and should not replace clinical judgement and will not detect other nutrition problems
Range of staff can undertake (typically nurses in hospitals)
Recommended by ESPEN that all inpatients are screened
Results linked to action course - no action (low risk), resecreen eg in 1 week (moderates risk), nutrition assessment and plan (high risk)

Assessment is detailed and comprehensive
Undertaken by dietitian
Encompasses metabolic, biochemical, functional, anthropometric, dietary, social lifestyle data
Result (liked to nutrition care process)
- nutrition diagnosis
- individualised nutrition management plan
- monitoring of outcomes/ progress

9

Screening tool inclusions

Current weight for heigh status
Last changes in weight/ weight stability
Likely changes in future weight status- influenced by food intake, medical conditions
Impact on disease severity (in hospitalised patients)

10

MUST screening tool

Takes <10 mins
Easy, mid arm alternative to wt
Increased likelihood of complications in bed bound patients
1. BMI score >obese (0), 18.5-20 (1), <18.5 (2)
2. Unplanned weight loss in last 3-6 months <5% (0), 5-10 (1), >10% (2)
3. Acute disease effect score - is patient is ill and there has been or is like to be no nutritional intake for >5 days (2)
4. Add scores together 0- low risk, 1 medium risk, 2+ high risk
5. Management guidelines according to each risk level

11

How MUST performs

Sensitivity 89%
Specificity 82-88%
Advantages:
Good inter rate reliability
Does not need any lab tests
Alternatives for when height or weight cannot be taken
High sensitivity means few false negatives
Results clearly linked to an action plan

Limitations:
Not designed for sub acute or residential care setting
Show poor agreement with tools designated for those settings
Acute disease effect doesn't reflect chronic poor intake- may miss at risk patient with chronic disease
Use may be limited in those with communication difficulties although less reliant on subjective info than other tools

12

MST

Three questions- does not include anthropometric or biochemical measurements
Parameters selected were those correlated with SGA and objective measures (anthropometric and bulchdmical)
Takes <5 min
Easy to perform
Does not require objective ht and wt measurements
Sensitivity 93%
Specificity 93%
Advantages:
Good inter rater reliability
Does not need any lab tests
Not reliability on height or weight
High sensitivity means few false negs
Results clearly linked to action plan

Limitations
Not designed for sub acute or residential care settings
Show poor agreement with tools designed for those settings
Information hard to obtain if patient/ cater cannot provide- may lead to poor completion rates. Use may be limited in those with communication difficulties.

13

MNA- mini nutrition assessment

Development sponsored by nestle
Specifically designed for elderly population
Aims to identify malnutrition and risk of developing malnutrition
Screening (MNA-SF) plus assessment tool
Recommended by ESPEN
<10 mins
Easy
6 items max score of 14
Screening score then determines likely risk and recommended whether to proceed to 2nd part (assessment) of dietitian referral
12 or more- normal/ not at risk
11 or below- possible malnutrition, complete full MNA or refer to dietitian
Full MNA scored out of 30
>23.5 low risk
17-23.5 at risk
<17 malnourished
Sensitivity 90%, specificity 100%

14

MNA evaluation

Advantages
Good inter rater reliability
Does not need lab tests
Quick
Well accepted for use in older people across a range of settings

Limitations
Limited to elderly
Use may be limited to those with communication difficulties
Issues identified may be related to illness itself or psychosocial issues (not malnutrition), son may lead to own referrals or patients who do not actually have malnutrition
Required measurements to be taken- may be issue for some
Require higher level of training than other tools

15

NRS

Takes <10 mins
Easy
2 parts- if answer yes to any of first 3, proceed to table 2 for scoring
Advantages:
Good interrate reliability
High specificity
Majority of patients able to be screened
Good content validity
Captures weight loss or low BMI
Examples of disease severity given for limited range
Results linked to action plan

Limitations
Validation limited to hospitals
Use may be limited in those with communication difficulties
Disease severity may be subjectively interpreted
Lower sensitive than other tools
Not widely used in Aus

16

Common features of screening tools

Relatively small number of parameters to collate
Yield a score that guides actions
Give a range of risk assessments (low to high)
Incorporate BMI and/ or weight change, intake / appetite, and disease factor/ severity

Differences between various golds
Degree of complexity of info
Training and time to administer
Specific target groups v general use
Extent of validation, including evaluation of whether use of tool impacts on health outcomes

17

Common limitations

Effectiveness and cost effectiveness not well established for all tools: can they positively impact on outcome an/ or health care costs
Screening does not replace clinical judgement- still need to be able to initiate referral based on judgement or other indicator
Use of weight based indicator or BMI may fail to detect sarcopaenia
Some use lower BMI ranges than generally accepted for elderly
Nutrition risks and issues may be unique in certain diseases - require different approach to identifying risk

Requires cross disciplinary cooperation, may require cross campus cooperation, may be institutional barriers
Need to select tool best suited to target group
Resource and time intensive, training required
Requires resource for action plan

18

Future directions

Electronic screening systems and automated referrals
VNS for use in hospitals
Will be part of the national hospitals standard within the next few years
Purpose is to optimise nutrition status of patients whilst receiving care, with specific focus on the at risk patient