Assessment of nutritional status basic measurement tools

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Assessment of nutritional status basic
measurement tools

• Fergus N Doubal
• November 2006

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Definitions

• Nutrition the process of taking in and
  assimilating nutrients
• Malnutrition lack of proper nutrition
• Dietician an expert on diet and nutrition
• Nutritional state very complex
• Percentage make up/ measurable things/
  deleterious effects

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Who is at risk

• Everybody
• The ill
• The elderly
• The young
• Those with chronic/debilitating disease
• Those who cannot retain/absorb nutrients
• Assessment is a dynamic process

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How do we measure nutritional status

• 1 - Questionnaire - appetite mood what the
  patients normal diet is have they lost weight
  unintentionally do they have physical trouble
  eating past and current medical history

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• 2. Bedside measurements
• Weight
• Height (ulnar length/ mid arm span)
• Mid arm circumference
• Triceps skinfold thickness

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• 3. Laboratory measurements
• Albumin
• Prealbumin
• White blood cells and lymphocytes
• Which reference ranges to use.

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Why do we need a screening tool (and how do they
differ from nutritional assessment tools)

• Screening tool screens for patients who might be
  at risk of malnourishment and determines who
  should be further referred on for specialist
  intervention
• Nutritional assessment tools are used to assess
  current state of nutrition
• The two techniques overlap

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Why do we need a screening tool

• Not all patients will need specialist nutritional
  input.
• Malnourishment is however common and treatable
  with benefits to both the patient and the NHS
• There is a finite number of dieticians

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The Literature

• Confusing
• Each hospital seems to have their own tool
• No gold standard so huge variation in what is
  used as the reference standard
• Many tools have not been validated which in
  itself is a hugely complicated business
• How many tools are there

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Nursing nutritional screening tool nutritional
risk assessment tool seniors in the community
risk evaluation for eating and nutrition simple
screening tools 1 and 2 Ayreshire nutrition
screening tool nursing nutritional
assessment nutritional assessment
checklist nutritional risk assessment
scale scales nutritional screening
tool nursing nutritional screening
tool nutrition assessment chart nutrition risk
of older adults risk score nutritional form for
the elderly five question nutritional screening
tool nutritional risk index nutritional
screening tool australian nutrition screening
initiative mini nutritional assessment determine
Level 1 screen.
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• All of the above are for the elderly
• There are over 50 published tools
• Most take between 2-30 minutes to complete
• Mini nutritional assessment seemed to be coming
  out top (needed a which report) although it is
  backed by Nestle.

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Considerations

• Who is the tool for
• And in which country
• Is it easy do the nurses like it
• Do the patients like it
• Has it been validated by somebody who did not
  invent it
• Why is a new tool being made
• Muddle

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I asked the dieticians and nurses

• What we use now is the Falkirk score
• Taken from Falkirk
• Based upon scores re BMI weight history ability
  to eat appetite/intake mental state disease
  state clinical condition skin age
• Guidelines at bottom monitor/frequency/refer
  and food chart
• Easy nurses liked it
• On Stroke Unit WGH all patients had form and all
  weighed
• Features in the NHS Scotland best practice
  guidelines
• No evidence published and then wham

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Malnutrition Universal Screening Tool This is
the new NHS Lothian tool to be used by all
Healthcare teams (Apart from Theatres Children
Maternity and Renal services) Launch week
beginning 30th October CD Rom will be on the
intranet Clinical areas will have a resource pack
cards Road shows from 12m.d 2p.m. Come along
and see the resource packs get your pocket guide
and chat to Dietitians CPPD staff Monday 30th
REH Dining room Tuesday 31st AAH Dining
room Wednesday 1st St Johns Dining room Thursday
2nd RIE Foyer Friday 3rd WGH Dining room
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MUST

• Developed by the MAG which is a standing
  committee of BAPEN which was set up to promote
  good nutrition in 1992
• Published in 1994
• BAPEN says that it has good internal and external
  and all sorts of other validity and is a good
  predictor of outcome and is fantastic in every
  way no references obvious

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Evidence

• I looked but could not find much
• Two studies published by members of the MAG
  linking MUST with LOS and medical outcom
• Another study compared MUST with SGA and NRI and
  NRS 2002 and concluded that all can be used
  although NRS 2002 had higher sens and spec than
  the others but they used SGA as a reference

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So the MUST score

• Five step screening tool for adults
• Includes management guidelines
• Will be gradually implemented in Lothian over the
  next wee while
• Nice and glossy
• Good charity backing

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Steps

• Measure BMI
• Note percentage unplanned weight loss
• Establish acute disease score
• Add scores together to calculate overall risk
• Use management guidelines to develop care plan

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Good points

• Co-ordinated approach
• Just one tool
• Charity backed
• Easy to use
• Quick
• Appears to relate to clinical outcomes
  destination LOS but only adjusted for age

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Bad points

• Not a huge amount of easily found independently
  published validity testing
• May not apply to subgroups of patients ie those
  with cancer and may result in too many patients
  being referred to the dieticians ie all acutely
  unwell patients score 2 points

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Future

• Useful of oral mucosal epithelial cell apoptosis
  rate in nutritional assessment.
• Nutrition 22 (2006) in press
• Malnourished patients had lower rates of
  apoptosis (conserving energy)

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Take home messages

• Use MUST
• Complex Area
• Use tools to assist rather than replace clinical
  judgement
• Think of malnourishment