Transcript Assessment of nutritional status – basic measurement tools

Assessment of nutritional status
– basic measurement tools
Fergus N Doubal
November 2006
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
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
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
2. Bedside measurements
– Weight
– Height (ulnar length/ mid arm span)
– Mid arm circumference
– Triceps skinfold thickness
3. Laboratory measurements
– Albumin
– Prealbumin
– White blood cells and lymphocytes
– Which reference ranges to use.
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
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
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?
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.
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.
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
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
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
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
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
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
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
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
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
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)
Take home messages
Use MUST
Complex Area
Use tools to assist rather than replace
clinical judgement
Think of malnourishment