Comparison of nutritional risk screening tools in patients on admission to hospital

The application of the PDCA cycle in the nutritional management of patients with nasopharyngeal carcinoma

OBJECTIVE

This study is to explore the effect of the Plan-Do-Check-Act (PDCA) cycle on the nutritional management of patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 100 NPC patients were randomly divided into a control group and a PDCA group, with 50 patients in each group. The control group adopted a routine nutritional management strategy, and the PDCA group adopted a PDCA cycle management strategy. The body weight, body mass index (BMI), hemoglobin, serum prealbumin, serum albumin, the Patient-Generated Subjective Global Assessment (PG-SGA) score, the Nutrition Risk Screening 2002 (NRS-2002) score, the incidence rate of nutritional risk, the grade of malnutrition, and the grade of oral mucositis were compared between the two groups.

RESULTS

The body weight, BMI, and serum prealbumin in the PDCA group were higher than those in the control group, and the difference was statistically significant (p < 0.05). The NRS2002 score and PG-SGA score in the PDCA group were lower than those in the control group, and the differences were statistically significant (p < 0.05). The incidence of nutritional risk, the grade of malnutrition, and the grade of oral mucositis were less in the PDCA group than those in the control group (p < 0.05). There was no significant difference in hemoglobin and serum albumin between the two groups (p > 0.05).

CONCLUSION

The PDCA cycle can improve body weight, BMI, and serum prealbumin in NPC patients. It can reduce the NRS2002 score, the PG-SGA score, the incidence of nutritional risk, the severity of malnutrition, and the severity of oral mucositis in NPC patients.

Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.

Nutritional status and screening tools to detect nutritional risk in hospitalized patients with hepatic echinococcosis

Background: Echinococcosis is a chronic consumptive liver disease. Little research has been carried out on the nutritional status of infected patients, though liver diseases are often associated with malnutrition. Our study investigated four different nutrition screening tools, to assess nutritional risks of hospitalized patients with echinococcosis. Methods: Nutritional Risk Screening 2002 (NRS 2002), Short Form of Mini Nutritional Assessment (MNA-SF), Malnutrition Universal Screening Tool (MUST), and the Nutrition Risk Index (NRI) were used to assess 164 patients with alveolar echinococcosis (AE) and 232 with cystic echinococcosis (CE). Results were then compared with European Society for Clinical Nutrition and Metabolism (ESPEN) criteria for malnutrition diagnosis. Results: According to ESPEN standards for malnutrition diagnosis, 29.2% of CE patients and 31.1% of AE patients were malnourished. The malnutrition risk rates for CE and AE patients were as follows: NRS 2002 – 40.3% and 30.7%; MUST – 51.5% and 50.9%; MNA-SF – 46.8% and 44.1%; and NRI – 51.1% and 67.4%. In patients with CE, MNA-SF and NRS 2002 results correlated well with ESPEN results (k = 0.515, 0.496). Area-under-the-curve (AUC) values of MNA-SF and NRS 2002 were 0.803 and 0.776, respectively. For patients with AE, NRS 2002 and MNA-SF results correlated well with ESPEN (k = 0.555, 0.493). AUC values of NRS 2002 and MNA-SF were 0.776 and 0.792, respectively. Conclusion: This study is the first to analyze hospitalized echinococcosis patients based on these nutritional screening tools. Our results suggest that NRS 2002 and MNA-SF are suitable tools for nutritional screening of inpatients with echinococcosis.

Validity and Reliability of a Nutrition Screening Tool in Identifying Malnutrition Among Hospitalized Adult Patients

BACKGROUND

Malnutrition among hospitalized patients is closely associated with various medical complications. This study aimed to determine the validity and reliability of a 3-Minute Nutrition Screening (3-MinNS) tool in identifying the risk of malnutrition among hospitalized patients that can be administered by healthcare professionals.

METHODS

A cross-sectional study was conducted between January and December 2012. A total of 350 adult patients in a teaching hospital were screened for risk of malnutrition using 3-MinNS and Subjective Global Assessment (SGA). To assess interrater reliability, each patient was screened for risk of malnutrition using 3-MinNS by 2 different nurses on 2 different occasions within 24 hours after admission. To assess the validity of 3-MinNS, the level of risk of malnutrition identified by the nurses using 3-MinNS was compared with the risk of malnutrition as assessed by a dietitian using SGA within 48 hours after the patients' enrolment into the study. The sensitivity, specificity, and predictive values were calculated in detecting patients at risk of malnutrition. Interrater reliability was determined using κ statistics.

RESULTS

Using SGA, the estimated prevalence of moderate to severe malnutrition was 36.3% (127/350). There was 94% proportional agreement between 2 nurses using 3-MinNS, and interrater reliability was substantial (κ = 0.79, P < .001). The analysis showed that 3-MinNS had moderate sensitivity (61.4%-68.5%) but high specificity (95.1%).

CONCLUSIONS

The 3-MinNS is a reliable and valid screening tool for use by healthcare professionals for identifying newly admitted medical and surgical patients who are at risk of malnutrition.

Assessment of nutritional status using anthropometric variables by multivariate analysis

BACKGROUND

Undernutrition is a serious health problem and highly prevalent in developing countries. There is no as such confirmatory test to measure undernutrition. The objective of the present study is to determine a new Composite Score using anthropometric measurements. Composite Score was then compared with other methods like body mass index (BMI) and mid-upper arm circumference (MUAC) classification, to test the significance of the method.

METHODS

Anthropometric data were collected from 780 adult Oraon (Male = 387, Female = 393) labourers of Alipurduar district of West Bengal, India, following standard instruments, and protocols. Nutritional status of the study participants were assessed by conventional methods, BMI and MUAC. Confirmatory factor analysis was carried out to reduce 12 anthropometric variables into a single Composite Score (C) and classification of nutritional status was done on the basis of the score. Furthermore, all the methods (BMI, MUAC and C) were compared and discriminant function analysis was adopted to find out the percentage of correctly classified individuals by each of the three methods.

RESULT

The frequency of undernutrition was 45.9% according to BMI category, 56.7% according to MUAC category and 51.8% according to newly computed Composite Score. Further analysis showed that Composite Score has a higher strength of correct classification (98.7%), compared to BMI (95.9%) and MUAC (96.2%).

CONCLUSION

Therefore, anthropometric measurements can be used to identify nutritional status in the population more correctly by calculating Composite Score of the measurements and it is a non-invasive and relatively correct way of identification.

Nutritional Considerations of Cardiovascular Diseases and Treatments

Nutritional considerations of many chronic diseases are not fully understood or taken into consideration in everyday clinical practice. Therefore, it is not surprising that high proportion of hospitalized patients with cardiovascular diseases remains underdiagnosed with malnutrition. Malnourished patients have increased risk of poor clinical outcomes, complications rate, prolonged hospital stay, more frequent rehospitalizations, and lower quality of life. The purpose of this review is to recapitulate recent data on nutritional considerations in cardiovascular medicine.

Malnutrition Predicts Clinical Outcome in Patients with Neuroendocrine Neoplasia

Malnutrition is a common problem in oncological diseases, influencing treatment outcomes, treatment complications, quality of life and survival. The potential role of malnutrition has not yet been studied systematically in neuroendocrine neoplasms (NEN), which, due to their growing prevalence and additional therapeutic options, provide an increasing clinical challenge to diagnosis and management. The aim of this cross-sectional observational study, which included a long-term follow-up, was therefore to define the prevalence of malnutrition in 203 patients with NEN using various methodological approaches, and to analyse the short- and long-term outcome of malnourished patients. A detailed subgroup analysis was also performed to define risk factors for poorer outcome. When applying malnutrition screening scores, 21-25% of the NEN patients were at risk of or demonstrated manifest malnutrition. This was confirmed by anthropometric measurements, by determination of serum surrogate parameters such as albumin as well as by bioelectrical impedance analysis (BIA), particularly phase angle α. The length of hospital stay was significantly longer in malnourished NEN patients, while long-term overall survival was highly significantly reduced. Patients with high-grade (G3) neuroendocrine carcinomas, progressive disease and undergoing chemotherapy were at particular risk of malnutrition associated with a poorer outcome. Multivariate analysis confirmed the important and highly significant role of malnutrition as an independent prognostic factor for NEN besides proliferative capacity (G3 NEC). Malnutrition is therefore an underrecognized problem in NEN patients which should systematically be diagnosed by widely available standard methods such as Nutritional Risk Screening (NRS), serum albumin assessment and BIA, and treated to improve both short- and long-term outcomes.

Prevalence and Association of Undernutrition with Quality of Life among Swedish People Aged 60 Years and Above: Results of the SNAC-B Study

OBJECTIVES

This study aimed to assess the prevalence of undernutrition among elderly and to investigate the association of risk of undernutrition with health-related quality of life and life satisfaction controlling for age, gender, marital status, economic status, housing arrangement, education level, functional ability, and diseases.

DESIGN

A cross-sectional study design was used for this study. The baseline data (2001-2003) of "The Swedish National Study of Aging and Care-Blekinge (SNAC-B)" was used.

SETTING

This population-based study focused on both home-living and special-housing residents.

PARTICIPANTS

The participants (n=1402) were randomly selected and included both males and females 60-96 years of age residing in a municipality of south-east Sweden.

MEASUREMENTS

The risk of undernutrition was estimated by the occurrence of at least one anthropometric measure (body mass index, mid-arm circumference, and calf circumference) below cut-off, in addition to the presence of at least one subjective measure (declined food intake, weight loss, and eating difficulty). The dependent variables, health-related quality of life and life satisfaction, were measured by the validated short form health survey (SF-12) and Liang's life satisfactions index A (LSIA), respectively.

RESULTS

According to the criterion, 8.5% of the participants were at risk of undernutrition, and subjects at nutritional risk were significantly older, female, unmarried/widowed/divorced, residing in special housing, and functionally impaired. The risk of undernutrition was significantly associated with poor health-related quality of life, both in the physical (OR 2.31, 95% CI 1.18-4.52) and mental (OR 2.34, 95% CI 1.22-4.47) dimensions. However, no significant association was observed between nutritional status and life satisfaction (OR 1.30, 95% CI 0.70-2.40).

CONCLUSION

The risk of undernutrition significantly increases the risk of poor physical and mental health-related quality of life but has negligible impact on life satisfaction. This study also highlights the importance of functional ability both for the prevention of undernutrition and promotion of quality of life. However, more studies are needed to validate the tool used here for undernutrition risk assessment before it can be used in clinical or population settings.

Comparison of Nursing Records and the Catholic Medical Center Nutritional Risk Screening as a Nutrition Screening Tool for Intensive Care Unit Patients

In the present study, we aimed to compare the results from nutritional risk screening based on nursing records with those using the Catholic Medical Center Nutritional Risk Screening (CMCNRS) tool. A cross-sectional study was performed involving 91 patients aged ≥ 18 years from an intensive care unit. We collected general characteristics of the patients and nutrition screening was conducted for each patient by using computerized hospital program for the nursing records as well as the CMCNRS conducted by clinical dietitians. The subjects were aged 64.0 ± 17.5 years, and 52 (57.1%) patients had a NPO (nothing by mouth) status. Neurological disease was the most common diagnosis (25.3%). Compared with the CMCNRS results from the clinical dietitians, the results for the nursing records had a sensitivity of 40.5% (95% CI 32.0-40.5) and a specificity of 100.0% (95% CI 92.8-100.0). The agreement was fair between the CMCNRS results obtained by clinical dietitians and the nursing records (k = 0.423). Analysis of the errors from the screening using the nursing records revealed significant differences for all subjective indicators (p < 0.001), compared with the CMCNRS by the clinical dietitians. Thus, after assessing the methods used for nutrition screening and the differences in the search results regarding malnourished status, we noted that the nursing records had a lower sensitivity than the screening by the CMCNRS.

Improvement of nutritional support strategies after surgery for benign liver tumor through nutritional risk screening: a prospective, randomized, controlled, single-blind clinical study

OBJECTIVE

The rising of individualized therapy requires nutritional risk screening has become a major topic for each particular disease, yet most of the screenings were for malignancies, less for benign diseases. There is no report on the screening of patients with benign liver tumors postoperatively. We aim to evaluate the nutritional support strategies post operation for benign liver tumors through nutritional risk screening.

METHODS

In this prospective, randomized, controlled study, 95 patients who underwent hepatectomy for benign tumors were divided into two groups. Fifty patients in the control group were given routine permissive underfeeding nutritional supply (75 kJ/kg/d), and 45 patients in the experimental group were given lower energy (42 kJ/kg/d) in accordance of their surgical trauma. Routine blood tests, liver/kidney function were monitored before surgery and at the day 1, 3, 5, 9 after surgery, patients were observed for the time of flatus, complications, length of hospitalization (LOH), nutrition-related costs, and other clinical parameters. This completed study is registered with Clinicaltrials.gov, number NCT01292330.

RESULTS

The nutrition-related expenses (494.0±181.0 vs. 1,514.4±348.4 RMB, P<0.05) and the total hospital costs (18,495.2±4735.0 vs. 21,432.7±8,291.2 RMB, P<0.05) for patients in the experimental group were significantly lower than those in the control group. Meanwhile, the lowered energy supply after the surgeries did not have adverse effects on clinical parameters, complications, and LOH.

CONCLUSIONS

Patient with benign liver tumors can adopt an even lower postoperative nutritional supply that close to that for mild non-surgical conditions, and lower than the postoperative permissive underfeeding standard.

Effects of an intervention on nutrition consultation for cancer patients

We assessed whether cancer patients given a nutritional consultation by dietitians when discharged from the hospital experienced more health benefits than those not given a nutritional consultation. The McNemar test and the general linear model were used to examine the effect of nutrition intervention. A bubble chart was plotted to show the comparison between cancer groups. A total of 537 cancer patients discharged from a 1200-bed medical centre in Taiwan in 2011 were randomly divided into experimental and control groups. In the experimental group, nutritional status [evaluated using the Subjective Global Assessment (SGA) Classification technique], weight loss, and food intake recovery were significantly affected and returned to their usual levels, but in the control group, only food intake recovery was significantly affected. The effect of nutrition consultation intervention for cancer patients is thus evident. Significant positive effects were cancer-stage-dependent but not cancer-type-dependent. Future studies are recommended using the present study's methods to see whether the nutrition intervention effect occurs in cancer patients discharged from other hospitals throughout the world.

Using a nutritional screening tool to evaluate the nutritional status of patients with colorectal cancer

We assessed which nutrition evaluation method [subjective global assessment (SGA); malnutrition universal screening tool (MUST); nutritional risk index (NRI)] provided the most efficacious combination of high validity, low cost, and ease of use to examine and improve the status of malnutrition for colorectal cancer (CRC) patients. The SGA, MUST, and NRI scales were used to analyze the preoperative status of malnutrition for 45 CRC patients in a medical center in Taiwan. Differences in the reliability of the 3 methods were compared using the kappa (κ) coefficient of agreement. Lengths of hospital stays were compared using the Mann-Whitney U test to examine the effect of malnutrition in CRC patients. The SGA κ coefficient was higher with the MUST than with the NRI. Preoperative and postoperative weight losses were significantly different on the NRI, and the longer the length of the hospital stay, the greater was the weight loss. Although the SGA had a higher validity and lower cost than the NRI, we recommend using the MUST method for a routine nutrition evaluation because it is easier to use and is less expensive than the SGA and the NRI.

Malnutrition as assessed by nutritional risk index is associated with worse outcome in patients admitted with acute decompensated heart failure: an ACAP-HF data analysis

Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) in patients admitted with acute decompensated heart failure (ADHF). Serum albumin levels and lymphocyte counts were retrospectively determined at hospital admission in 1740 consecutive patients admitted with primary and secondary diagnosis of ADHF. The Nutrition Risk Score (NRI) developed originally in AIDS and cancer populations was derived from the serum albumin concentration and the ratio of actual to usual weight, as follows: NRI = (1.519 × serum albumin, g/dL) + {41.7 × present weight (kg)/ideal body weight(kg)}. Patients were classified into four groups as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between nutritional risk category and LOS.

Three hundred and eighty-one patients (34%) were at moderate or severe nutritional risk by NRI score. This cohort had lower BMI (24 ± 5.6 kg/m²), albumin (2.8±0.5 g/dL), mean NRI (73.5±9) and lower eGFR (50±33 mL/min per 1.73 m²). NRI for this cohort, adjusted for age, was associated with LOS of 10.1 days. Using the Multiple Logistic regression module, NRI was the strongest predictor for LOS (OR 1.7, 95% CI: 1.58–1.9; P=0.005), followed by TIMI Risk Score [TRS] (OR 1.33, 95% CI: 1.03–1.71; P=0.02) and the presence of coronary artery disease (OR 2.29, 95%CI: 1.03–5.1; P=0.04). Moderate and severe NRI score was associated with higher readmission and death rates as compared to the other two groups.

Nutritional depletion as assessed by Nutritional Risk Index is associated with worse outcome in patients admitted with ADHF. Therefore; we recommend adding NRI to further risk stratify these patients.

Undernutrition in hospitalized older adults: patterns and correlates, outcomes, and opportunities for intervention with a focus on processes of care

Undernutrition in hospitalized older adults is increasingly being recognized as a serious problem with implications for both patient care and outcomes and health service utilization and costs. This article presents an overview of research that has been conducted examining undernutrition in hospitalized older adults. First, findings from observational studies examining patterns and predictors of undernutrition in hospitalized older adults will be described, with a focus on methodological challenges. Second, clinical outcomes and costs associated with undernutrition in hospitalized older adults will be presented, both while in the hospital and subsequent to discharge. Third, a description of interventions that have already been implemented in hospitalized older adults will be described. Finally, future areas of inquiry and opportunities for evidence-based nutritional interventions targeted at older adults during and following hospitalization will be suggested. The emphasis of the discussion on interventions will focus on processes of care and the hospital environment.

Defining malnutrition: mission or mission impossible?

OBJECTIVE

Although screening for malnutrition in health care has expanded enormously, a gold standard for the optimal definition and operationalism of malnutrition is still lacking. This report reflects expert opinions on the elements of the definition and operationalism of malnutrition and is meant to trigger further debate within the nutritional societies.

METHODS

A Delphi study was performed consisting of three phases. After a literature review (phase 1), questions for a semistructured interviews (phase 2) were formulated. Subsequently, the results of these semistructured interviews were used to develop the final list of elements (for defining and operationalism of malnutrition). In phase 3 (final phase), experts were asked to provide written feedback regarding the ranking of elements concerning the importance of these elements.

RESULTS

Twenty-two experts (response 73.3%) were included in the final phase of this Delphi study. No overall agreement could be reached. The elements deficiencies of energy or protein and decrease in fat-free mass were most often mentioned to be particularly important in defining malnutrition. Elements mentioned to be important in operationalism of malnutrition were involuntary weight loss, body mass index, and no nutritional intake. Opinions on cutoff points regarding these elements differed strongly among experts.

CONCLUSION

This study shows that there is no full agreement among experts on the elements defining and operationalism of malnutrition. The results of this study may fuel the discussion within the nutritional societies, which will most ideally lead to an international consensus on a definition and operationalism of malnutrition.

Who will become malnourished? A prospective study of factors associated with malnutrition in older persons living at home

OBJECTIVES

To describe the nutritional status of older persons living at home, to investigate factors of importance for nutritional status, and to describe possible relationships between nutritional status and health-related quality of life (HRQoL).

DESIGN

A longitudinal study using data from older persons born between 1916 and 1925. Data were collected at three occasions separated by four-year intervals.

SETTING

Data collection was carried out in the participants' own homes. An experimenter administered all tests and conducted the interviews.

PARTICIPANTS

A randomized selection from the Swedish Twin Register included 258 persons, all still living at home.

MEASUREMENTS

Nutritional status was assessed using the Mini Nutritional Assessment (MNA), cognitive function using the Mini-Mental State Examination (MMSE) and HRQoL using the Nottingham Health Profile (NHP). Questions covering physical, psychological and social factors that may have an impact on nutritional status were also posed.

RESULTS

Approximately 17% of participants were assessed as being at risk for malnutrition or as being malnourished. Cognitive impairment, reduced perceived health, recent hospital stay and receiving meals-on-wheels were factors associated with being at risk for malnutrition.

CONCLUSION

Being at risk for malnutrition is common in older persons living at home, and many factors related to frailty increase this risk in later life. Making use of knowledge of these factors when giving care to older persons may be important in preventing nutritional problems.

Parenteral and enteral nutrition in the management of neurosurgical patients in the intensive care unit

The iatrogenic malnutrition of neurosurgical patients in intensive care units (ICU) is an underestimated problem. It may cause a decrease in plasma albumin and oncotic pressure, leading to an increase in the amount of water entering the brain and increased intracranial pressure (ICP). This study was conducted to test the hypothesis that combined high-protein parenteral and enteral nutrition is beneficial for neurosurgical patients in ICU. A total of 202 neurosurgical patients in ICU (mean age+/-standard deviation, 56 years+/-16 years; male:female=1.2:1) were studied. Two consecutive 1-year time periods were compared, during which two different nutritional regimens were followed. In the first time period (Y1) patients were given a low-protein/high-fat formulation parenterally, followed by a standard enteral regimen. In the second time period (Y2) a protein-rich, combined parenteral and enteral diet was prospectively administered. The Glasgow Outcome Score was measured at 3-6 months after discharge. The following clinical parameters were recorded during the first 2 weeks after admission: ICP; albumin; cholinesterase (CHE); daily hours of ICP > 20 mmHg and cerebral perfusion pressure<70 mmHg; and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. It was found that overall albumin (32.4 g/L+/-4.1g/L vs. 27.5 g/L+/-3.6g/L) and CHE was higher during Y2, although the total energy supply, glucose and fat intake was lower. Higher GOS scores were seen when patients had lower APACHE II scores and received the Y2 nutritional regimen. During Y2, the total hours of ICP > 20 mmHg were fewer. With the Y2 nutrition, maintenance of adequate cerebral perfusion required less catecholamine medication and colloidal fluid replacement. Therefore, adequate nutrition is an important parameter in the management of neurosurgical patients in ICU.

The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery

BACKGROUND

Malnutrition in gastrointestinal (GI) surgery is associated with increased morbidity. Therefore, careful screening remains crucial to identify patients at risk for malnutrition and consequently postoperative complications. The aim of this study was to evaluate the ability of 3 established score systems to identify patients at risk of developing postoperative complications in GI surgery and to assess the correlation among the score systems.

METHODS

We evaluated prospectively 200 patients admitted for elective GI surgery using (1) nutrition risk index, (2) nutrition risk score, and (3) bioelectrical impedance analysis. Complications were assessed using a standardized complication classification. The findings of the score systems were correlated with the incidence and severity of complications. Parametric and nonparametric correlation analysis was performed among the different score systems.

RESULTS

All 3 score systems correlated significantly with the incidence and severity of postoperative complications and the duration of hospital stay. Using multiple regression analysis, only nutrition risk score and malignancy remained prognostic factors for the development of complications with odds ratios of 4.2 (P = .024) and 5.6 (P < .001), respectively. The correlation between nutrition risk score and nutrition risk index was only moderate (Pearson coefficient = 0.54). Bioelectrical impedance analysis displayed only weak to trivial correlation to the nutrition risk index (0.32) and nutrition risk score (0.19), respectively.

CONCLUSION

The nutrition risk score, nutrition risk index, and bioimpedance analysis correlate with the incidence and severity of perioperative complications in GI surgery. The nutrition risk score was the best score in predicting patients who will develop complications in this study population. The correlation between the individual scores was only moderate, and therefore, they do not necessarily identify the same patients.

Do the malnutrition universal screening tool (MUST) and Birmingham nutrition risk (BNR) score predict mortality in older hospitalised patients?

BACKGROUND

Undernutrition is common in older hospitalised patients, and routine screening is advocated. It is unclear whether screening tools such as the Birmingham Nutrition Risk (BNR) score and the Malnutrition Universal Screening Tool (MUST) can successfully predict outcome in this patient group.

METHODS

Consecutive admissions to Medicine for the Elderly assessment wards in Dundee were assessed between mid-October 2003 and mid-January 2004. Body Mass Index (BMI), MUST and BNR scores were prospectively collected. Time to death was obtained from the Scottish Death Register and compared across strata of risk.

RESULTS

115 patients were analysed, mean age 82.1 years. 39/115 (34%) were male. 20 patients were identified as high risk by both methods of screening. A further 10 were categorised high risk only with the Birmingham classification and 12 only with MUST.80/115 (67%) patients had died at the time of accessing death records. MUST category significantly predicted death (log rank test, p = 0.022). Neither BMI (log rank p = 0.37) or Birmingham nutrition score (log rank p = 0.35) predicted death.

CONCLUSION

The MUST score, but not the BNR, is able to predict increased mortality in older hospitalised patients.

Triagem nutricional em adultos hospitalizados

Em hospitais, o objetivo de um procedimento de triagem nutricional é identificar indivíduos desnutridos ou em risco de desnutrição, possibilitando intervenção nutricional precoce e melhor alocação de recursos. Diferentes métodos são apresentados na literatura para esta finalidade: Malnutrition Screening Tool, Short Nutritional Assessment Questionnaire, Nutritional Risk Index, Nutrition Risk Score, Nutritional Risk Screening, Mini Nutritional Assessment, Malnutrition Universal Screening Tool, Nutritional Screening Tool, Nutritional Screening Equation. No entanto, o emprego de muitos destes instrumentos está limitado pela inadequada metodologia empregada na derivação e/ou validação, pela seleção de grupos específicos de pacientes, pela pouca praticidade ou por necessidade de um especialista para seu emprego. Na ausência de um padrão de referência para emitir o diagnóstico nutricional, desfechos clínicos relevantes devem balizar a derivação e a validação de novos instrumentos. Este trabalho descreve os instrumentos de triagem nutricional acima referidos e apresenta considerações quanto ao seu emprego para adultos hospitalizados não selecionados.

How important is malnutrition? A prospective study in internal medicine

BACKGROUND/OBJECTIVE

Data about the prevalence of malnutrition on hospital admission vary and follow-up data are scarce. We assessed the nutritional status of unselected patients on admission and discharge.

SUBJECTS/METHODS

A total of 430 consecutively admitted patients were assessed and 168 patients hospitalized > or =6 days were reassessed on discharge. Assessment was carried out by the Mini Nutritional Assessment (MNA), weight and anthropometric measurements, bioelectrical impedance analysis, biochemical markers and a subjective clinical assessment by the physicians in charge.

RESULTS

On admission, 47% of all patients were overweight (body mass index, BMI >25 kg m(-2)) and 8% underweight (BMI<18.5 kg m(-2)). In terms of the MNA 70% were adequately nourished, 20% were at risk for malnutrition and 10% were malnourished. By clinical judgment alone 18 (4.3%) malnourished patients according to MNA were missed. The 44 malnourished patients according to the MNA had significantly lower values for BMI, fat-free mass, fat mass, waist circumference, triceps skinfold thickness, hemoglobin, albumin, prealbumin, total cholesterol but higher values for C-reactive protein. Of the 168 patients staying > or =6 days in hospital, 57% lost and 39% gained weight. Only 1.9% of all patients (8 of 430) were malnourished and lost further weight during hospitalization.

CONCLUSIONS

We found a low prevalence (10%) of malnourished patients on admission. Clinical judgment and to some extent anthropometrical measurement were helpful for assessing the nutritional status, laboratory values were not.

Nutritional assessment

Hospital-based malnutrition continues to be an important comorbidity affecting clinical outcomes. Knowledge of performing an appropriate nutrition assessment and implementing a rational nutrition therapy should be part of any patient's hospital plan of care. Familiarity with nutrition assessment scoring systems and nutrition assessment tools should be part of any gastroenterologist's expertise. Assessment of a patient's caloric and protein needs should be part of any hospital patient's clinical evaluation.

A local nutritional screening tool compared to malnutrition universal screening tool

OBJECTIVE

The aim of the study was to compare the Glasgow Nutritional Screening Tool with the Malnutrition Universal Screening Tool (MUST) recently recommended for use by the British Association for Parenteral and Enteral Nutrition.

DESIGN

Comparison-validation study.

SETTING

Four adult acute hospitals in Glasgow, UK.

SUBJECTS

All 242 in-patients from a variety of specialties.

METHODS

Two investigators independently interviewed 202 in-patients for the comparison-validation study. Each used a single tool with each patient, using each tool in turn. Investigators were not aware of each other's assessments. Forty other patients were interviewed by both raters separately using the local tool to evaluate inter-rater reliability.

RESULTS

When compared with MUST as a 'gold standard', the local tool had a sensitivity of 95.3% and a specificity of 64.9%, with moderate agreement between the two tools using kappa test (kappa=0.57). Agreement between the raters was substantial (kappa=0.69) with 85% of patients classified the same by both raters.

CONCLUSION

The Glasgow Nutritional Screening Tool is a valid and reliable tool that can be used on admission for nutritional screening.

Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients

Nutrition is an important determinant of health in persons over the age of 65. Malnutrition in the elderly is often underdiagnosed. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. The purpose of this article is to provide clinicians with an educational overview of this essential but often underecognized aspect of geriatric assessment. This article will review some common issues in nutrition for the elderly in both hospital and community settings. The complexity and impact of multiple comorbidities on the successful nutritional assessment of elderly patients is highlighted by using case scenarios to discuss nutritional issues common to elderly patients and nutritional assessment tools. Three case studies provide some context for an overview of these issues, which include the physiology of aging, weight loss, protein undernutrition, impaired cognition, malnutrition during hospitalization, screening procedures, and general dietary recommendations for patients 65 years of age and older.

Comparison of tools for nutritional assessment and screening at hospital admission: a population study

INTRODUCTION

This population study aimed to test the sensitivity and specificity of nutritional risk index (NRI), malnutrition universal screening tool (MUST) and nutritional risk screening tool 2002 (NRS-2002) compared to subjective global assessment (SGA) and to evaluate the association between nutritional risk determined by these screening tools and length of hospital stay (LOS).

METHODS

Patients (n=995) were assessed at hospital admission by four screening tools (SGA, NRI, MUST and NRS-2002). Sensitivity, specificity and predictive values were calculated to evaluate NRI, MUST and NRS-2002 compared to SGA. Multiple logistic regressions, adjusted for age, were used to estimate odds ratios (OR) and confidence interval (CI) for medium and high, compared to low risk in patients hospitalized >11, compared to 1-10 days LOS.

RESULTS

The sensitivity was 62%, 61% and 43% and specificity was 93%, 76% and 89% with the NRS-2002, MUST and NRI, respectively. NRS-2002 had higher positive (85%) and negative predictive values (79%) than the MUST (65% and 76%) or NRI (76% and 66%, respectively). Patients who were severely malnourished or at high nutritional risk by SGA (OR 2.4, CI 1.5-3.9), MUST (OR 3.1, CI 2.1-4.7) and NRS-2002 (OR 2.9, CI 1.7-4.9) were significantly more likely to be hospitalized >11 days, compared to 1-10 days, than patients assessed as low risk.

CONCLUSION

NRS-2002 had higher sensitivity and specificity than the MUST and NRI, compared to SGA. There was a significant association between LOS and nutritional status and risk by SGA, NRS-2002, MUST and NRI. Nutritional status and risk can be assessed by SGA, NRS-2002 and MUST in patients at hospital admission.