Abstract
Objectives
To identify older subjects at risk of malnutrition using the most appropriate tool available for the specific setting and to evaluate the Mini Nutritional Assessment short form (MNA-SF) in a sample of nonagenarians.
Design
Questionnaire based national screening week for the risk and prevalence of malnutrition in older people (NutriAction).
Setting
Older people in the community (CD) and in nursing homes (NH).
Participants
General practices (n=70) and Nursing Homes (n=70).
Measurements
Questionnaire based on items from validated screening instruments: the MNA-SF, the Short Nutritional Assessment Questionnaire (SNAQ) and additional clinically relevant parameters (mobility, independence, social isolation and co-morbidities).
Results
In total 5,334 people were screened of which 16% were aged over 90 years. In this age group, 66% of the screened individuals were at risk of malnutrition (MNA ≤ 11), and women were affected significantly more than men (p<0.001). Actual malnutrition was present in 22% (BMI <20), 20% (SNAQ) and 25% (clinical evaluation). The MNA appeared to be very sensitive but had a low specificity as well in the nonagenarians (98% and 44%) as in the younger old (97% and 52%). The SNAQ was not a sensitive tool for detecting malnutrition in this study population (25%). Although clinical impression had a low sensitivity (60–61%) it has a good specificity (86% in 90+ and 91% below 90yr).
Conclusion
The overall risk of and the prevalence of malnutrition is common in older people. The prevalence is higher in women, in nursing homes and in older age groups. The MNA-SF followed by a clinical subjective evaluation seems to be the preferred strategy for detecting malnutrition in nonagenarians.
Key words: Malnutrition, nonagenarians, screening tool, MNA
Abbreviations
- MNA-SF
Mini-Nutritional Assessment-Short Form
- SNAQ
Short Nutritional Assessment Questionnaire
- CD
community dwelling
- NH
nursing home
Introduction
Malnutrition has important clinical consequences as it results in weight loss, impairs daily life functioning and quality of life, and results in increased complication and mortality rates (1). Malnutrition is also associated with increased hospital admissions and a higher need for community care and as such has an important economic impact. Estimates from the UK suggested that the costs of caring for malnourished patients amount to at least €10.5 million/year, which is substantially higher than that estimated for the treatment of obesity (2).
Nevertheless, malnutrition frequently is under-recognized and therefore also under-treated.
Malnutrition is a problem of all ages, but particularly affects older persons (3). Since disease prevalence increases with age, and disease is frequently associated with malnutrition, it is not surprising that malnutrition or risk of malnutrition is common in the elderly (4). Moreover, ageing per se is associated with metabolic abnormalities that increase the risk of malnutrition (5, 6).
In 2010, 17.6% of the Belgian population was over 65 years of age. The mean lifespan of the population continues to rise and it can be anticipated that the oldest age groups will increase the most both in relative and absolute numbers. In 2000, 58.591 individuals in Belgium were aged over 90 years and 967 were older than 100 years. This will rise to 261.600 (a 4.5-fold increase) and 8.331 (an 8.6-fold increase), respectively, by 2050 (7). Belgian prevalence data on nutritional risk in older subjects, and particular in the >90 years age group, are scarce. If nutritional risk in these older cohorts is not recognized and dealt with at an early stage, healthcare costs are likely to escalate in the years to come. Therefore, early recognition of malnutrition is of key importance. Different screening tools exist to identify individuals ‘at risk’ of malnutrition across the spectrum of nutritional status. They all use different criteria and/or cut off points to detect nutritional risk (8, 9).
The national screening week, NutriAction, was designed to assess the risk and prevalence of malnutrition among community dwelling older adults and nursing home residents in Belgium. A second objective was to increase the awareness of general practitioners, nurses and patients for malnutrition screening. The present paper focuses on the population aged 90 years and older compared to the younger old in the study sample. Moreover, the question was addressed whether the screening instruments have the same value in this older and frailer population.
Patients and Methods
Study Population
The study was designed to detect malnutrition or risk of malnutrition in a cohort of persons older than 70 years living either at home (CD) or in a Nursing Home (NH).
An invitation letter was sent to general practitioners working in the community and to the medical and nursing staff practicing in Nursing Homes. They were invited to assess the nutritional status of all their patients during one week (November 24th through November 28th, 2008). Recruitment was stopped when 70 practitioners and 70 nursing homes agreed to the protocol. After acceptance, participant doctors and staff were trained for the protocol.
Screening Tools and Assessment
Subjects were screened for malnutrition using a questionnaire based on items from validated screening instruments: the Mini Nutritional Assessment short form (MNA-SF), the Short Nutritional Assessment Questionnaire (SNAQ) and some additional relevant parameters (mobility, independence, social isolation and co-morbidities). Information on mobility and neuropsychological status was evaluated by a physiotherapist and a psychologist and was available in the patient records. Furthermore a global subjective clinical assessment for malnutrition was performed by the evaluator.
Body weight and height were recorded in order to calculate the Body Mass Index (BMI), which is part of the MNA-SF. Subjects with a BMI<20 were classified as malnourished (10). The MNA-SF consists of 6 items: questioning declined food intake and weight loss during the last 3 months, mobility, psychological stress or acute disease, neuropsychological problems and BMI. A MNA-SF score of ≤ 11 corresponds to a risk of malnutrition, whereas a MNA score of ≥ 12 is indicative for a normal nutritional status. The SNAQ score was calculated based on: unintentional weight loss (>3kg during the last month), decreased appetite over the last month and use of supplemental drinks or tube feeding over the last month (11). Based on the SNAQ, patients can be divided into 3 categories: well nourished, moderately malnourished and severely malnourished.
In addition, following parameters were recorded: age, gender, setting (Community Dwelling, CD, or Nursing Home, NH), presence of chronic disorders (diabetes mellitus, history of cerebral stroke, on-going cancer, swallowing disorder, pressure ulcer, dementia and/or depression). Isolation and/or feeling of isolation were also recorded. Functional ability or mobility was recorded as normal, moderately or severely impaired.
Statistics
Continuous variables were summarized by means of descriptive statistics, categorical variables were tabulated. Percentages were calculated based on the number of subjects with non-missing data for the variable in question.
Differences in neuropsychological problems (none, mild or serious) and mobility (bed or chair bound, able to get out of bed/chair but does not go out, goes out) were tested by means of a Cochran Mantel Haenszel test. Differences in clinical impression (malnourished or not), SNAQ (malnourished or not), BMI (BMI<20 vs. BMI ≥20) and MNA score (MNA<12 vs. MNA ≥12) were assessed by means of logistic regression (both univariate and multivariate). The sensitivity, specificity, positive and negative predictive value of the SNAQ score (malnourished or not), MNA score (MNA<12 vs. MNA ≥12) and subjective clinical assessment were calculated with malnutrition defined as a BMI lower than 20. Separate analyses were performed in the nonagenarian group.
Results
Global sample
The study sample consisted of 5,334 people (3,969 women; I, 335 men) of which 975 lived at home. Mean age was 79.5 ± 7.2 yr (CD) and 84.0 ± 7.8 (NH). The overall risk for malnutrition (MNA ≤ 11) was 57%, and was significantly higher in NH (p<0.001), among women (p<0.001) and in the older age groups (p<0.001). Actual under-nutrition was present in 15.9% (BMI < 20), 17.1% (SNAQ) and 17.6% (clinical evaluation). A new nutritional problem was found in ± 22%, independent from age category. In the older cohorts and in those who were malnourished more mobility problems were seen (p<0.001). Diabetes was present in 19%, a stroke sequel in II. 4%, active malignancies in 7%, swallowing problems in 12% and pressure ulcers in 6%. Social isolation was more prevalent in CD than in NH people (25% vs 15%).
Nonagenarians
In total, 839 subjects older than 90 years were screened (Table 1). The majority (93%, n=784) resided in a nursing home and 87% were women. The mean age was 94.0 ± 3.0 years in CD subjects and 94.3 ± 2.7 years in NH residents. The mean BMI was 23.3 ± 4.5 kg/m2 (range min – max: 14 – 48). Twenty-six percent of the participants experienced weight loss and 6.1% reported to have lost more than 3 kg.
Table 1.
Nutritional status of nonagenarians according to residence
| Community dwelling | Nursing home | p-value | |
|---|---|---|---|
| subjects (n=55) | residents (n=784) | ||
| Weight loss (%) | 0.55 | ||
| No | 61.8 | 67.4 | |
| 1 – 3 kg | 27.3 | 19.3 | |
| > 3 kg | 5.5 | 6.2 | |
|
5.5 | 7.1 | 0.02 |
| Important | 1.8 | 6.4 | |
| Moderate | 38.2 | 23.0 | |
| No | 60.0 | 70.6 | |
| BMI < 20 kg/m2 (%) | 20.0 | 22.1 | 0.72 |
| MNA ≤ 11 (%) | 65.5 | 66.5 | 0.88 |
| SNAQ – malnourished (%) Clinical impression - | 12.7 | 12.9 | 0.90 |
| malnourished (%) | 32.7 | 24.1 | 0.17 |
Diabetes and cancer were present in 12.6% and 6.3% of the participants. Pressure ulcers/chronic wounds and swallowing difficulties were more prevalent in CD individuals (12.7% and 16.4%, respectively) when compared to NH residents (7.9% and 10.3%, respectively) but the difference did not reach statistical significance. On average, 1 in 5 participants was socially isolated. Social isolation was more frequent in CD individuals (29.1% vs. 19.9% in NH residents). Neuropsychological problems (i.e. dementia or depression) were present in 58.9% of women compared to 46.4% of men (p=0.004) and were more prevalent in NH residents than in CD persons (58.6% vs. 41.8%, respectively; p=0.004).
Women suffered more from reduced mobility than their male counterparts (76.8% vs. 57.1%, respectively; p<0.001), however, no differences in reduced mobility were seen between NH residents and CD subjects (74.7% vs 69.0%, respectively; p=0.2).
Nutritional status
Loss of appetite affected more women (31.2%) than men (22.3%) (Table 2) and was significantly more prevalent in CD individuals compared to NH residents (40.0% vs. 29.4%, respectively; p=0.024) (Table 1 and Table 2).
Table 2.
Nutritional status of nonagenarians according to gender
| Women (n=705)* | Men (n=111)%* | p-value | |
|---|---|---|---|
| Weight loss (%) | 0.42 | ||
| No | 66.2 | 73.2 | |
| 1 – 3 kg | 20.3 | 16.1 | |
| > 3 kg | 6.0 | 6.3 | |
| No idea | 7.4 | 4.5 | |
| Loss of appetite (%) | 0.11 | ||
| Important | 6.5 | 2.7 | |
| Moderate | 24.7 | 19.6 | |
| No | 68.8 | 77.7 | |
| BMI < 20 kg/m2 (%) | 22.9 | 15.0 | 0.07 |
| MNA ≤ 11 (%) | 68.9 | 49.5 | <0.001 |
| SNAQ – malnourished (%) | 19.1 | 17.0 | 0.60 |
| Clinical impression – malnourished (%) | 25.8 | 15.9 | 0.03 |
data regarding gender were unavailable for 23 individuals
According to the MNA, 66.4% of the screened individuals were at risk of malnutrition (MNA≤11). Risk of malnutrition was more prevalent in women than in men (68.9% vs. 49.5%; p<0.0001) (Table 2) but was comparable between CD persons and NH residents (65.5% vs. 66.5%, respectively; p=0.88) (Table 1).
Based on clinical impression, 24.7% of the screened individuals were classified as malnourished (Table 2). Of these individuals, 95.4% had an MNA score of ≤ 11 and 52.8% had a BMI <20 kg/m2. Actual malnutrition, based on a BMI <20 kg/m2, was observed in 21.9% of the participants and tended to be higher in women than in men (22.9% vs. 15.0%; p=0.07) (Table 2). The SNAQ identified 19.0 % of the participants as malnourished. The prevalence of malnutrition according to this screening tool did not differ significantly between men and women (17.0% vs. 19.1%, p=0.60) (Table 2) or CD persons and NH residents (27.8% vs. 18.4%, p=0.09) (Table 1).
Table 3.
General health status and mobility in nonagenarians with or without malnutrition as defined by a cut-off value of 20 for BMI
| BMI < 20 | BMI ≥ 20 | p-value | |
|---|---|---|---|
| Diabetes (%) | |||
| Yes | 6.4 | 13.7 | 0.01 |
| No | 93.6 | 86.3 | |
| Functional consequences of CVA (%) | |||
| Yes | 13.4 | 6.1 | 0.002 |
| No | 86.6 | 93.9 | |
| Social isolation (%) | |||
| Yes | 30.8 | 17.3 | <0.001 |
| No | 69.2 | 82.7 | |
| Cancer (%) | |||
| Yes | 5.3 | 6.1 | 0.69 |
| No | 94.7 | 93.9 | |
| Swallowing difficulties (%) | |||
| Yes | 19.1 | 8.3 | <0.001 |
| No | 80.9 | 91.7 | |
| wounds/pressure ulcers (%) | |||
| Yes | 9.3 | 7.7 | 0.50 |
| No | 90.7 | 92.3 | |
| Neuropsychological problems (%) | |||
| No | 30.6 | 46.7 | <0.001a |
| Mild dementia or depression | 42.8 | 32.5 | 0.91b |
| Severe dementia or depression | 26.7 | 20.8 | 0.003c |
| Oral nutritional supplement/tube feeding (%) | |||
| Yes | 32.6 | 10.7 | <0.001 |
| No | 67.4 | 89.3 | |
| Mobility (%) | |||
| Bed or chair bound | 55.6 | 38.7 | 0.002d |
| Able to get out of bed/chair but does not go out | 25.6 | 33.1 | 0.56e |
| Goes out | 18.9 | 28.2 | <0.001f |
a. no neuropsychological problems vs. mild dementia or depression; b. mild dementia or depression vs. severe dementia or depression; c. no neuropsychological problems vs. severe dementia or depression; d. bed or chair bound vs. able to get out of bed/chair but does not go out; e. able to get out of bed/chair but does not go out vs. goes out; f. bed or chair bound vs. goes out
Table 4.
General health status of nonagenarians according to risk of malnutrition as defined by a cut-off value of 11 or lower for MNA-SF score
| MNA ≤ 11 | MNA ≥ 12 | p-value | |
|---|---|---|---|
| Diabetes (%) Yes | 11.6 | 14.3 | |
| No | 88.4 | 85.7 | 0.26 |
| Functional consequences of CVA (%) | |||
| Yes | 10.1 | 3.0 | |
| No | 89.9 | 97.0 | 0.0008 |
| Social isolation (%) | |||
| Yes | 25.5 | 9.3 | |
| No | 74.5 | 90.7 | <0.001 |
| Cancer (%) | |||
| Yes | 5.6 | 6.4 | |
| No | 94.4 | 93.6 | 0.64 |
| Swallowing difficulties (%) | |||
| Yes | 14.9 | 1.1 | |
| No | 85.1 | 98.9 | <0.001 |
| Wounds/pressure ulcers (%) | |||
| Yes | 10.8 | 2.6 | |
| No | 89.2 | 97.4 | <0.001 |
| Neuropsychological problems (%) | |||
| No | 25.8 | 76.8 | <0.001a |
| Mild dementia or depression | 42.9 | 19.6 | <0.001b |
| Severe dementia or depression | 31.3 | 3.6 | <0.001c |
| Oral nutritional supplement/tube feeding (%) | |||
| Yes | 22.3 | 1.5 | |
| No | 77.7 | 98.5 | <0.001 |
| Mobility (%) | |||
| Bed or chair bound | 58.1 | 11.2 | <0.001d |
| Able to get out of bed/chair but does | 31.5 | 31.9 | <0.001e |
| not go out | |||
| Goes out | 10.4 | 56.9 | <0.001f |
a. no neuropshychological problems vs. mild dementia or depression; b. mild dementia or depression vs. severe dementia or depression; c. no neuropsychological problems vs. severe dementia or depression; d. bed or chair bound vs. able to get out of bed/chair but does not go out; e. able to get out of bed/chair but does not go out vs. goes out; f. bed or chair bound vs. goes out
Nearly 15.4% of the screened subjects used oral nutritional supplements or tube feeding (20.4% CD vs. 15.1% NH). The majority (>96%) of the subjects consumed 3 meals per day, regardless gender or residence.
Although people with diabetes are more obese (p<0.025) they tend to score more for malnutrition. Women with diabetes are at higher risk of malnutrition (MNA ≤ 11) than men (64.4% vs. 36.4%). NH residents with diabetes are at higher risk of malnutrition (MNA ≤ 11) than their CD counterparts (62.4% vs. 43.0%).
Ninety-six percent of the screened subjects with swallowing difficulties are at risk of malnutrition (p<0.001).
Multivariate regression analysis showed that decreased mobility, neuropsychological problems (including dementia or depression), social isolation and swallowing difficulties were associated with a significantly higher risk of malnutrition.
The sensitivity, specificity and positive and negative predictive value of the different screening methods (MNA, SNAQ and clinical impression) were determined in the sample of nonagenarians and compared with the values in the group under 90 (Table 5) . Based on this approach, the MNA appeared to be a very sensitive test for detecting malnutrition (97-98%) as well in nonagenarians as in younger old. However, its specificity is low in both groups (44-52%). The SNAQ, on the other hand, has a very low sensitivity (24-25%) but a high specificity (91-92%). Clinical impression had a sensitivity of 60-61% and a high specificity (86-91%).
Table 5.
Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MNA-SF, SNAQ and clinical impression in nonagenarians compared to the younger old
| N | Sensitivity | Specificity | PPv | NPv | |
|---|---|---|---|---|---|
| 90 Plus | |||||
| MNA-SF | 949 | 0,98 | 0,44 | 0,32 | 0,99 |
| Clinical Impression | 928 | 0,60 | 0,86 | 0,53 | 0,89 |
| SNAQ | 933 | 0,24 | 0,91 | 0,42 | 0,82 |
| Under 90 | |||||
| MNA-SF | 4350 | 0,97 | 0,52 | 0,26 | 0,99 |
| Clinical Impression | 4293 | 0,61 | 0,91 | 0,55 | 0,93 |
| SNAQ | 4300 | 0,25 | 0,92 | 0,35 | 0,88 |
Discussion
The data from this national screening week, NutriAction, show that 66% of the screened nonagenarians were at risk of malnutrition. Risk of malnutrition particularly affected women. One of the objectives was to evaluate whether the different available screening tools have the same value in this older and frailer population. In nonagenarians and younger old, the MNA appeared to have a high sensitivity but a low specificity, whereas the SNAQ was not a sensitive tool for detecting malnutrition in nonagenarians. Although the sensitivity of the clinical impression was low, the specificity was good.
Implementing routine screening to detect malnutrition has been hindered by the lack of universally agreed criteria to identify it. Consequently, there are a variety of nutritional tools in use that incorporate different anthropometric, biochemical, and clinical criteria which have often been developed for use in a particular setting or for a specific patient group (8, 9). Most instruments screen for nutritional risk and not for existing malnutrition. An ‘at risk’ status may result from the effects of disease or treatment, or may arise in a well-nourished individual due to an acute event that may result in a limited or no nutritional intake for a period of time. Individuals identified as high risk are likely to be but are not necessarily frankly malnourished. Therefore, a more detailed nutritional assessment should be undertaken for “at-risk” individuals to establish the degree of malnutrition present, its causes and best course of action. Actually, this indicates that the first screening level is based on simple measurements that identify people who may be at risk for malnutrition. Only after that, a complete nutritional assessment should describe their actual nutritional status with biochemical, anthropometric, functional parameters of muscle strength (handgrip), bio-impedance, and dual energy X-ray absorptiometry measurements.
Results from a world-wide international pooled database on malnutrition in older people according to the MNA (n=6257, 27 datasets, mean age 82.3 years) found that about two thirds of older people are either at risk or already malnourished (overall 22.8% malnourished and 46.2% at risk). The prevalence in community-dwelling older people was 5.8% and 50.5% in patients in recuperative care (12). Data from the Belgian Health Interview surveys show a progressive loss of weight with aging. Moreover, this weight loss is significantly correlated with frailty and loss of mobility in community dwelling elderly (13).
According to a recent literature review, the MNA-SF appeared to be the most appropriate nutrition screening tool for use in community-dwelling older adults with a reported sensitivity of 98% (14) and a specificity of 94% (8). The SNAQ had a high specificity (98%) (15), whereas the nutritional screening Initiative (NsI) had a low specificity (11%) (16) and a low sensitivity (14%) (17) in this setting.
When people grow older, they lose the capacity of adapting well to changes in their environment. This loss of homeostasis in the broad sense leads to an increased vulnerability, called frailty. In our study sample the degree of institutionalisation was indeed significantly higher with older age. The nonagenarians also differed from the younger old in that they were more often malnourished, suffered more from diabetes, stroke sequels and chronic wounds, and were more socially isolated and less mobile. Also the percentage of women continues to rise. The question remains then whether the same screening instruments keep their validity in the detection of malnutrition in the oldest old. The sensitivity, specificity and negative and positive predictive values from the different tools in the nonagenarians (94 ± 3 yr) was compared with the results of the younger old (81 ± 7 yr). There was no real change in the values with increasing age. Therefore, it can be concluded that MNA-SF remains a very sensitive instrument to detect malnutrition and is superior to the SNAQ, also at higher age. However its specificity is low. On the other hand a subjective clinical impression, although it has a low sensitivity, scores very well regarding its specificity. A combination of simple screening instruments with different degrees of sensitivity and specificity can improve the power of the screening. So, a first screening with the MNA-SF together with a subsequent subjective clinical assessment may be the screening strategy of choice in detecting the nonagenarian at risk for malnutrition.
Study limitations
There is no universal definition of malnutrition, especially in elderly. In the present study, malnutrition was defined as a BMI < 20. This definition and cut-off value were arbitrarily chosen, but are in accordance with suggestions of cut-off points in the MUST tool (Malnutrition universal screening Tool) and the guidelines from ESPEN.
The sample size of the CD cohort is much smaller (n=55) than the NH cohort (n=784). Therefore, absence of statistical significance between the parameters analysed should be taken with caution. Likewise, there is no representative distribution between the male (n=111) and female (n=705) population. Statistics regarding gender differences should therefore be interpreted cautiously.
Conclusion
Older people have a higher risk of malnutrition and are also more likely to be actually malnourished. The prevalence is higher in women, in nursing homes and in older age groups. Based on the data of this screening week, the preferred strategy for detecting malnutrition in nonagenarians appears to be the MNA-sF, followed by a clinical subjective evaluation.
Acknowledgements
The authors wish to thank P. Papeleu, Phd, for her assistance in the preparation of the manuscript.
Conflicts of interest
This study has been supported by an unrestricted Grant from Nutricia Advanced Medical Nutrition, Belgium.
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