Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study

Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery

OBJECTIVES

The aim of this study was to assess the prognostic value of different nutritional screening tools in patients undergoing cardiopulmonary bypass, with regard to adverse clinical outcome.

METHODS

This prospective cohort study analysed 1193 adult patients who underwent cardiopulmonary bypass. Patients were screened using five nutritional screening tools: Subjective Global Assessment (SGA), Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), Mini-Nutritional Assessment (MNA) and Short Nutritional Assessment Questionnaire (SNAQ). In-hospital mortality, postoperative complications, length of stay in intensive care unit and length of hospitalization were analysed. Multivariate backward logistic regression analysis was used to assess the independent predictive value of the studied screening tools.

RESULTS

In accordance with univariate analysis, malnutrition detected by SNAQ, MUST, NRS-2002 and MNA was associated with postoperative complications (odds ratio [OR] 1.8, 95% confidence interval [95% CI] 1.3-2.4; OR 1.9, 95% CI 1.4-2.6; OR 1.8, 95% CI 1.2-2.9 and OR 1.9, 95% CI 1.4-2.6). Malnutrition detected by MUST, NRS-2002, MNA and SGA was associated with intensive care unit stay >2 days (OR 1.5, 95% CI 1.1-2.1; OR 2.3, 95% CI 1.5-3.7; OR 1.7, 95% CI 1.2-2.2 and OR 2.7, 95% CI 1.6-4.6). Prolonged hospitalization (>20 days) was predicted by SNAQ, MUST and MNA (OR 1.4, 95% CI 1-1.9; OR 1.6, 95% CI 1.2-2.2 and OR 1.6, 95% CI 1.2-2.2). In accordance with multivariate analysis, only MUST and MNA independently predicted postoperative complications (OR 1.6, 95% CI 1.1-2.3 and OR 1.6, 95% CI 1.1-2.2). Other independent factors influencing postoperative complications were well-known logistic EuroSCORE (OR 1.06, 95% CI 1-1.1) and the duration of cardiopulmonary bypass in minutes (OR 1.01, 95% CI 1-1.01).

CONCLUSIONS

MUST and MNA both have independent predictive values with regard to postoperative complications. Taking into account simplicity, MUST is preferable for the cardiac surgical population.

Evaluation of nutritional screening tools for patients scheduled for cardiac surgery

OBJECTIVE

The aim of this study was to assess the prognostic value of different nutritional screening tools in patients undergoing cardiopulmonary bypass with regard to an adverse clinical course.

METHODS

This prospective cohort study analyzed 894 adult patients who underwent cardiopulmonary bypass. Patients were screened using four nutritional screening tools: Nutritional Risk Screening 2002 (NRS-2002), the Malnutrition Universal Screening Tool (MUST), the Mini-Nutritional Assessment (MNA), and the Short Nutritional Assessment Questionnaire (SNAQ). Nutritional status was assessed using the Subjective Global Assessment. In-hospital mortality, postoperative complications, length of stay in the intensive care unit, and length of hospitalization were analyzed.

RESULTS

The sensitivities of the SNAQ, MUST, and NRS-2002 to detect the malnutrition confirmed by the Subjective Global Assessment were 91.5%, 97.9%, and 38.3%, respectively, and the MNA showed a sensitivity of 81.8% for the elderly. Malnutrition detected by the SNAQ, MUST, and NRS-2002 was associated with postoperative complications (odds ratios [ORs] 1.75, 1.98, and 1.82, respectively) and a stay in the intensive care unit longer than 2 d (ORs 1.46, 1.56, and 2.8). Malnutrition as detected by the SNAQ and MUST was also associated with prolonged hospitalization (ORs 1.49 and 1.59). According to multivariate logistic regression analysis, postoperative complications were independently predicted by the European System for Cardiac Operative Risk Evaluation (OR 1.1, P < 0.0001), cardiopulmonary bypass time (OR 1.01, P < 0.0001), and malnutrition identified by the MUST (OR 1.2, P = 0.01).

CONCLUSION

The MUST independently predicts postoperative complications. The SNAQ and MUST have comparable accuracy in detecting malnutrition. Whether preoperative nutritional therapy would improve the outcome in malnourished patients needs to be studied.

Validity of a questionnaire for the semi-quantitative evaluation of dietary intake of hospitalised patients compared to weighed records

BACKGROUND

Malnutrition in hospitalised patients is often underestimated. The present study aimed to evaluate the validity of a questionnaire for the semi-quantitative evaluation of food intake compared to weighed records in patients who were hospitalised for the rehabilitation of neurological disorders.

METHODS

Food intake at breakfast, lunch and dinner was evaluated in 319 in-patients, by weighing the meals and the residuals, and using a semi-quantitative questionnaire, during five consecutive days. The questionnaire represented, for each offered food, the pictures of the nonconsumed quantities. The consumption of each food was determined by weighing foods that were served and the residuals after the meal. As a measure of validity of the questionnaire, the agreement over chance (kappa statistic) between the questionnaire and the weight was calculated. Considering the weight as the gold standard, the sensitivity and specificity of the questionnaire in detecting patients who consumed <50% or 75% of the meals was calculated.

RESULTS

The agreement between the two measures was satisfactory (κ ≥ 0.70) or almost satisfactory (0.60 < κ < 0.70) for most of the foods, with the exception of fruit and the first course at dinner. The sensitivity and specificity of the questionnaire in detecting consumers of <50% or 75% of the offered foods were always >80%, except for bread and first course, as well as fruit at dinner.

CONCLUSIONS

The present study shows that this semi-quantitative questionnaire on food consumption reproduces with sufficient precision the measures obtained by weighing. The questionnaire appears also to be a valid and suitable instrument for the identification of patients with poor food intake in a neurorehabilitation hospital.

Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients

OBJECTIVE

Although several validated nutritional screening tools have been developed to "triage" inpatients for malnutrition diagnosis and intervention, there continues to be debate in the literature as to which tool/tools clinicians should use in practice. This study compared the accuracy of seven validated screening tools in older medical inpatients against two validated nutritional assessment methods.

METHODS

This was a prospective cohort study of medical inpatients at least 65 y old. Malnutrition screening was conducted using seven tools recommended in evidence-based guidelines. Nutritional status was assessed by an accredited practicing dietitian using the Subjective Global Assessment (SGA) and the Mini-Nutritional Assessment (MNA). Energy intake was observed on a single day during first week of hospitalization.

RESULTS

In this sample of 134 participants (80 ± 8 y old, 50% women), there was fair agreement between the SGA and MNA (κ = 0.53), with MNA identifying more "at-risk" patients and the SGA better identifying existing malnutrition. Most tools were accurate in identifying patients with malnutrition as determined by the SGA, in particular the Malnutrition Screening Tool and the Nutritional Risk Screening 2002. The MNA Short Form was most accurate at identifying nutritional risk according to the MNA. No tool accurately predicted patients with inadequate energy intake in the hospital.

CONCLUSION

Because all tools generally performed well, clinicians should consider choosing a screening tool that best aligns with their chosen nutritional assessment and is easiest to implement in practice. This study confirmed the importance of rescreening and monitoring food intake to allow the early identification and prevention of nutritional decline in patients with a poor intake during hospitalization.

Malnutrition in systemic sclerosis

SSc is a chronic multi-system disease with wide-reaching consequences. Gastrointestinal features are present in over 90% of cases and these, together with other disease manifestations, may lead to nutritional decline. This produces substantial morbidity, including reliance on enteral support and even parenteral nutrition-dependent intestinal failure. These complications carry an associated mortality. Up to 18% of patients with SSc are reported to be at high risk of malnutrition [as assessed by Malnutrition Universal Screening Tool (MUST) criteria], with risk increasing with disease severity. Little is known about this decline, its rate of progression and how it affects the individual. Few case series report on nutritional interventions. Most current interventions are based on experience in other diseases. The development of specialist knowledge of SSc-related gastrointestinal disease management and nutritional screening and interventions is required. This paper reviews current knowledge relating to malnutrition and its management in SSc.

Mini Nutritional Assessment and functional capacity in community-dwelling elderly in rural Luozi, Democratic Republic of Congo

AIM

Good nutrition is beneficial both for the health and the functional capacity of the elderly. However, malnutrition is a serious health problem among the elderly, particularly the elderly living in rural areas in many developing countries. The aim of the present study was to carry out a cross-sectional study of the elderly in the city of Luozi, Democratic Republic of Congo, through the use of the long and the short forms of the Mini Nutritional Assessment (MNA) scale.

METHODS

We carried out a cross-sectional study in the city of Luozi, a city facing serious socioeconomic problems as a result of wartime conditions in the country. The study included 370 volunteer community-dwelling elderly people aged 65-88 years, both male and female. Investigations took into account the MNA, the activities of daily living, and the instrumental activities of daily living, falls, current diseases and lifestyle.

RESULTS

Approximately 57.8% of the participants were at risk of malnutrition, whereas 28.4% were malnourished according to the MNA scale. MNA scores were significantly lower (Student's t-test, P=0.03) in those with a fall history (MNA score 18.3±4.0) compared with those who did not (MNA score, 21.0±2.7). All the participants with malnutrition suffered from at least one chronic disease. The percentage of participants with dependency was significantly higher in the malnourished participants (87.6%) than in well-nourished participants (50.9%).

CONCLUSION

These findings provide information that malnutrition is a serious health concern among elderly people in the city of Luozi, and shows the need for adequate nutrition and social programs for the elderly.

Mini nutritional assessment

PURPOSE OF REVIEW

To summarize recent evidences and advances on the implementation and the use of the Mini Nutritional Assessment (MNA).

RECENT FINDINGS

Despite being introduced and validated for clinical use about 20 years ago, the MNA has recently received new attention in order to more widely disseminate among healthcare professionals the practice of a systematic nutritional screening and assessment of the old patient. Particularly, the structure has been implemented to face the difficulties in having the patients contributing to the assessment and to reduce further the time required to complete the evaluation. Recent data also confirm that in older populations prevalence of malnutrition by this tool is associated with the level of dependence. The rationale of nutritional assessment is to identify patients candidate to nutritional support. However, the sensitivity of the MNA is still debated because it has been associated with a high-risk 'overdiagnosis' and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.

SUMMARY

The MNA is a simple and highly sensitive tool for nutritional screening and assessment. The large mass of data collected and the diffusion among healthcare professionals clearly support its use. However, the cost-effectiveness of interventions based on its scoring deserves investigation.

Considerations for screening tool selection and role of predictive and concurrent validity

PURPOSE OF REVIEW

Nutrition screening tool selection can be difficult. This review critically examines the relevance of validity, specifically concurrent (agreement between tools) and predictive validity (prediction of outcomes), which have been the focus of several recent studies. An operational framework for screening tool selection is provided to contextualise the findings.

RECENT FINDINGS

Studies of predictive and concurrent validity involving screening tools comprising a variable number of nutritional and non-nutritional items (some nonmodifiable) have yielded inconsistent results. The use of one tool as a gold standard to judge the relative merits of other tools can be misleading because there is no agreed gold standard and different tools were designed for diagnostic, prognostic or other purposes. The use of observed outcomes (without nutritional intervention) as the gold standard may not adequately reflect the value of tools designed to assess nutritional status and need for nutritional intervention.

SUMMARY

Over-reliance on concurrent and predictive validity can be confusing and even counter-productive if used inappropriately. A proposed framework for screening tool selection indicates many factors should be considered so that there is purpose and harmony between the screening tool and the screening programme.

Nutritional evaluation of alcoholic inpatients admitted for alcohol detoxification

AIMS

To assess nutritional risk of alcoholic patients admitted for alcohol detoxification.

METHODS

Screening of nutritional risk of alcoholic patients using the Malnutrition Universal Screening Tool.

RESULTS

Fifty-three percentage patients at presentation were rated as being at medium or high risk of malnutrition.

CONCLUSION

Malnutrition should be actively considered and screened for in alcoholic patients admitted for alcohol detoxification due to its high prevalence and benefits obtained from treatment.