Twenty years ago, ESPEN published its “Guidelines for nutritional screening 2002”, with the note that these guidelines were based on the evidence available until 2002, and that they needed to be updated and adapted to current state of knowledge in the future. Twenty years have passed, and tremendous progress has been made in the field of malnutrition risk screening. Many screening tools have been developed and validated for different patient groups and different health care settings. Some countries even have introduced mandatory screening for malnutrition at admission to hospital. Yet, changes in society and healthcare require a reflection on current practice and policies regarding malnutrition risk screening. In this opinion paper, we share our perspectives on malnutrition risk screening in the twenty-twenties, addressing the changing and varying profile of the malnourished individual, the goals of screening and screening tools (i.e., preventive or reactive), the construct of malnutrition risk (i.e., screening for risk factors or screening for existing malnutrition), and screening alongside a patient's journey.
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PURPOSE OF REVIEW: With the shifts in society, healthcare and the profile of the malnourished individual, a re-consideration of the goal of nutritional risk screening is needed: screening for malnutrition, or screening for risk of malnutrition? In this review article, we reflect on the role of nutritional risk screening in relation to prevention and treatment of malnutrition.RECENT FINDINGS: Within the Global Leadership Initiative on Malnutrition (GLIM) Initiative, modified Delphi studies are currently being conducted to reach global consensus on the conceptual definition and operationalization of 'risk of malnutrition'. This is necessary because various studies have demonstrated that different nutritional screening tools identify different individuals, due to variability in screening tool criteria, which influences GLIM outcomes. Upon screening, three different situations can be distinguished: having risk factors for malnutrition without clear signs of presence of malnutrition, having mild signs of malnutrition (malnutrition in progress), or having obvious signs of malnutrition.SUMMARY: The outcomes of the studies on 'risk of malnutrition' will guide the screening step within the GLIM process, and will help professionals to make informed choices regarding screening policy and screening tool(s).
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Objectives: The aim of this study was to determine how diagnosing and coding of malnutrition in an internal medicine ward setting influences potential hospital reimbursement. Methods: Patients admitted to the internal medicine ward of Centro Hospitalar do Médio Ave between April 24 and May 22, 2018 were screened by Nutritional Risk Screening 2002, and patients classified as at “risk for malnutrition” were assessed by the Patient-Generated Subjective Global Assessment (PG-SGA). For each patient, medical coders simulated coding, taking into account the malnutrition diagnosis by PG-SGA, and compared it with the real coding as retrieved from the medical records. For the coding, the Diagnosis-Related Group and Severity of Illness were determined, allowing the calculation of hospitalization cost (HC) according to Portuguese Ministerial Directive number 207/2017. The increase of HC in this subsample was extrapolated to the number of patients admitted during 2018, to obtain the estimated unreported annual HC. Results: Of the 71% (92/129) participants having malnutrition risk according to Nutritional Risk Screening 2002, 86% were malnourished. Including malnutrition diagnosis in the coding of malnourished patients increased the level of Severity of Illness in 39% of cases and increased HC for this subsample, resulting in €52 000. Extrapolating for the annual HC, total HC reached €1.3 million. Conclusions: Identifying malnourished patients and including this highly prevalent diagnosis in medical records allows malnutrition coding and consequent increase of HC. This can improve the potential hospital reimbursement, which could contribute to the quality of patient care and economic sustainability of hospitals.
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This study evaluates the concurrent validity of five malnutrition screening tools to identify older hospitalized patients against the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria as limited evidence is available. The screening tools Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), Mini Nutritional Assessment—Short Form (MNA-SF), and the Patient-Generated Subjective Global Assessment—Short Form (PG-SGA-SF) with cut-offs for both malnutrition (conservative) and moderate malnutrition or risk of malnutrition (liberal) were used. The concurrent validity was determined by the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the level of agreement by Cohen’s kappa. In total, 356 patients were included in the analyses (median age 70 y (IQR 63–77); 54% male). The prevalence of malnutrition according to the GLIM criteria without prior screening was 42%. The conservative cut-offs showed a low-to-moderate sensitivity (32–68%) and moderate-to-high specificity (61–98%). The PPV and NPV ranged from 59 to 94% and 67–86%, respectively. The Cohen’s kappa showed poor agreement (k = 0.21–0.59). The liberal cut-offs displayed a moderate-to-high sensitivity (66–89%) and a low-to-high specificity (46–95%). The agreement was fair to good (k = 0.33–0.75). The currently used screening tools vary in their capacity to identify hospitalized older patients with malnutrition. The screening process in the GLIM framework requires further consideration.
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BACKGROUND/OBJECTIVES: Traditional malnutrition screening instruments, including the Malnutrition Universal Screening Tool (MUST), strongly rely on low body mass index (BMI) and weight loss. In overweight/obese patients, this may result in underdetection of malnutrition risk. Alternative instruments, like the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), include characteristics and risk factors irrespective of BMI. Therefore, we aimed to compare performance of MUST and PG-SGA SF in malnutrition risk evaluation in overweight/obese hospitalized patients.SUBJECTS/METHODS: We assessed malnutrition risk using MUST (≥1 = increased risk) and PG-SGA SF (≥4 = increased risk) in adult patients at hospital admission in a university hospital. We compared results for patients with BMI < 25 kg/m 2 vs. BMI ≥ 25 kg/m 2. RESULTS: Of 430 patients analyzed (58 ± 16 years, 53% male, BMI 26.9 ± 5.5 kg/m 2), 35% were overweight and 25% obese. Malnutrition risk was present in 16% according to MUST and 42% according to PG-SGA SF. In patients with BMI < 25 kg/m 2, MUST identified 31% as at risk vs. 52% by PG-SGA SF. In patients with BMI ≥ 25 kg/m 2, MUST identified 5% as at risk vs. 36% by PG-SGA SF. Agreement between MUST and PG-SGA SF was low (к = 0.143). Of the overweight/obese patients at risk according to PG-SGA SF, 83/92 (90%) were categorized as low risk by MUST. CONCLUSIONS: More than one-third of overweight/obese patients is at risk for malnutrition at hospital admission according to PG-SGA SF. Most of them are not identified by MUST. Awareness of BMI-dependency of malnutrition screening instruments and potential underestimation of malnutrition risk in overweight/obese patients by using these instruments is warranted.
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Background and aims: Malnutrition screening is a first step in the nutrition care process for hospitalized patients, to identify those at risk of malnutrition and associated worse outcome, preceding further assessment and intervention. Frequently used malnutrition screening tools including the Malnutrition Universal Screening Tool (MUST) mainly screen for characteristics of malnutrition, while the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) additionally includes risk factors for development of malnutrition, yielding a higher percentage of patients at risk. To investigate whether this translates into higher risk of worse outcome, we aimed to determine the predictive validity of MUST and PG-SGA SF for prolonged hospitalization >8 days, readmission, and mortality <6 months after hospital discharge.Methods: In this observational study, MUST was performed according to university hospital protocol. Additional screening using PG-SGA SF was performed within 24 h of hospital admission (high risk: MUST ≥ 2, PG_SGA SF ≥ 9). Associations of MUST and PG-SGA SF with outcomes were analyzed by logistic- and Cox PH-regression.Results: Of 430 patients analyzed (age 58 ± 16 years, 53% male, BMI 26.9 ± 5.5 kg/m2), MUST and PG-SGA SF identified 32 and 80 at high risk, respectively. One-hundred-eight patients had prolonged hospitalization, 109 were readmitted and 20 died. High risk by MUST was associated with mortality (HR = 3.9; 95% CI 1.3–12.2, P = 0.02), but not with other endpoints. High risk by PG-SGA SF was associated with prolonged hospitalization (OR = 2.5; 95% CI 1.3–5.0, P = 0.009), readmission (HR = 1.9; 95% CI 1.1–3.2, P = 0.03), and mortality (HR = 34.8; 95% CI 4.2–289.3, P = 0.001), independent of age, sex, hospital ward and previous hospitalization <6 months. In the 363/430 patients classified as low risk by MUST, high risk by PG-SGA SF was independently associated with higher risk of readmission (HR = 1.9; 95% CI 1.0–3.5, P = 0.04) and mortality (HR = 19.5; 95% CI 2.0–189.4, P = 0.01).Conclusions: Whereas high malnutrition risk by MUST was only associated with mortality, PG-SGA SF was associated with higher risk of prolonged hospitalization, readmission, and mortality. In patients considered as low risk by MUST, high malnutrition risk by PG-SGA SF was also predictive of worse outcome. Our findings support the use of PG-SGA SF in routine care to identify patients at risk of malnutrition and worse outcome, and enable proactive interventions.
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Aims and objectives: To examine the predictive properties of the brief Dutch National Safety Management Program for the screening of frail hospitalised older patients (VMS) and to compare these with the more extensive Maastricht Frailty Screening Tool for Hospitalised Patients (MFST-HP). Background: Screening of older patients during admission may help to detect frailty and underlying geriatric conditions. The VMS screening assesses patients on four domains (i.e. functional decline, delirium risk, fall risk and nutrition). The 15-item MFST-HP assesses patients on three domains of frailty (physical, social and psychological). Design: Retrospective cohort study. Methods: Data of 2,573 hospitalised patients (70+) admitted in 2013 were included, and relative risks, sensitivity and specificity and area under the receiver operating characteristic (AUC) curve of the two tools were calculated for discharge destination, readmissions and mortality. The data were derived from the patients nursing files. A STARD checklist was completed. Results: Different proportions of frail patients were identified by means of both tools: 1,369 (53.2%) based on the VMS and 414 (16.1%) based on the MFST-HP. The specificity was low for the VMS, and the sensitivity was low for the MFST-HP. The overall AUC for the VMS varied from 0.50 to 0.76 and from 0.49 to 0.69 for the MFST-HP. Conclusion: The predictive properties of the VMS and the more extended MFST-HP on the screening of frailty among older hospitalised patients are poor to moderate and not very promising. Relevance to clinical practice: The VMS labels a high proportion of older patients as potentially frail, while the MFST-HP labels over 80% as nonfrail. An extended tool did not increase the predictive ability of the VMS. However, information derived from the individual items of the screening tools may help nurses in daily practice to intervene on potential geriatric risks such as delirium risk or fall risk.
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Aim: The prevalence of age‐related malnutrition is increasing in almost all Western countries. Because of their expertise, dietitians should have a central role in the management of malnutrition. This review aimed to synthesise the literature on the role of the dietitian in the management of malnutrition in the elderly in comparison with other health professionals. Methods: In November 2018, a search of Embase, Medline Ovid, Cinahl Ebscohost, Cochrane Central, Web of Science and Google Scholar was undertaken using ‘dietitian’, ‘elderly’ and ‘malnutrition’ as the main search terms. Qualitative and quantitative empirical research studies that focussed on the role of dietitians as the (main) subject of the study were included. Data extraction and data synthesis were performed by the three authors using a thematic synthesis approach. Results: Three themes emerged from the coding and synthesis of the 21 included studies. The first theme demonstrates that other health professionals' time for, and knowledge of, screening policies negatively affects the role of the dietitian. The second theme demonstrates that the importance of nutritional care is acknowledged. However, this does not always imply familiarity with dietetics nor does it always mean that other health professionals think involving dietitians is worth the effort. The third theme demonstrates that issues of workload appeared to be especially important in crossing or guarding role boundaries. Conclusions: The role of dietitians in managing age‐related malnutrition is not always clear and coherent. Therefore, how dietitians shape their role to provide optimal management of malnutrition in the elderly is open to debate. https://doi.org/10.1111/1747-0080.12546 LinkedIn: https://www.linkedin.com/in/matthijs-fleurke-66279110/ https://www.linkedin.com/in/dorien-voskuil-9b27b115/
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The aim of this systematic review was to examine the association between malnutrition and oral health in older people (≥ 60 years of age). A comprehensive systematic literature search was performed in four databases (PubMed, CINAHL, Dentistry and Oral Sciences Source, and Embase) for literature from January 2000 to May 2020. Both observational and intervention studies were screened for eligibility. Two reviewers independently screened the search results to identify potential eligible studies, and assessed the methodological quality of the full-text studies. A total of 3240 potential studies were identified. After judgement for relevance, 10 studies (cross-sectional (n = 9), prospective cohort (n = 1)) met the inclusion criteria. Three studies described malnourished participants as having fewer teeth, or functional (tooth) units (FTUs), compared to well-nourished participants. Four studies reported soft tissue problems in malnourished participants, including red tongue with blisters, and dry or cracked lips. Subjective oral health was the topic in six studies, with poorer oral health and negative self-perception of oral health in malnourished elderly participants. There are associations between (at risk of) malnutrition and oral health in older people, categorized in hard and soft tissue conditions of the mouth, and subjective oral health. Future research should be focused on longitudinal cohort studies with proper determination of malnutrition and oral health assessments, in order to evaluate the actual association between malnutrition and oral health in older people.
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Background: Undernutrition is a common complication of disease and a major determinant of hospital stay outcome. Dutch hospitals are required to screen for undernutrition on the first day of admission.Objective: We sought to determine the prevalence of the screening score “undernourished” with the use of the Short Nutritional Assessment Questionnaire (SNAQ) or Malnutrition Universal Screening Tool (MUST) and its relation to length of hospital stay (LOS) in the general hospital population and per medical specialty.Design: We conducted an observational cross-sectional study at 2 university, 3 teaching, and 8 general hospitals. All adult inpatients aged ≥18 y with an LOS of at least 1 d were included. Between 2007 and 2014, the SNAQ/MUST score, admitting medical specialty, LOS, age, and sex of each patient were extracted from the digital hospital chart system. Linear regression analysis with ln(LOS) as an outcome measure and SNAQ ≥3 points/MUST ≥2 points, sex, and age as determinant variables was used to test the relation between SNAQ/MUST score and LOS.Results: In total, 564,063 patients were included (48% males and 52% females aged 62 ± 18 y). Of those, 74% (419,086) were screened with SNAQ and 26% (144,977) with MUST, and 13.7% (SNAQ) and 14.9% (MUST) of the patients were defined as being undernourished. Medical specialties with the highest percentage of the screening score of undernourished were geriatrics (38%), oncology (33%), gastroenterology (27%), and internal medicine (27%).Patients who had an undernourished screening score had a higher LOS than did patients who did not (median 6.8 compared with 4.0 d; P < 0.001). Regression analysis showed that a positive SNAQ/MUST score was significantly associated with LOS [SNAQ: +1.43 d (95% CI: 1.42, 1.44 d), P < 0.001; MUST: +1.47 d (95% CI: 1.45, 1.49 d), P < 0.001].Conclusions: This study provides benchmark data on the prevalence of undernutrition, including more than half a million patients. One out of 7 patients was scored as undernourished. For geriatrics, oncology, gastroenterology, and internal medicine, this ratio was even greater (1 out of 3–4). Hospital stay was 1.4 d longer among undernourished patients than among those who were well nourished.
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