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Real World Application: Meeting Nutrition Screening Challenges in Older Adults
This webinar is supported by Nestlé Nutrition
Moderator:Mary Pyper
Healthy Aging DPG
Speaker:Janet Skates, MS, RD, LDN, FADA
Nutrition Consulting ServicesKingsport, TN
janetskates@yahoo.com
Objectives:
Identify the prevalence of malnutrition in older adults across different practice settings
Describe the advantages of using a validated screening tool
Implement nutrition screening in individual practice settings
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Malnutrition in Older Adults
MG/RSA MRT/ 18.01.10 4Kaiser et al. Clin Nutr 4( suppl 2):113; 2009
Ideal Nutrition Screen
Valid
Reliable
Accurate
Clearly Defined Thresholds
Relevant to Outcomes
Inexpensive
Acceptable to Clients
Easy and Quick to Administer
Thomas DR, Nutr Clin Prac 2008;23:383-387
Validity What is it and why does it matter?
Valid tools actually measure what they claim to measure
Screen for desired outcomes
Components of validity Sensitivity
Specificity
Positive predictive value
Negative predictive value
Inter-rater reliability
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Common Screening Tools
Subjective Global Assessment (SGA)
DETERMINE Checklist
Malnutrition Screening Tool (MST)
Malnutrition Universal Screening Tool (MUST)
Geriatric Nutrition Risk Index
Nutritional Risk Screening Tool (NRS 2002)
Mini Nutrition Assessment (MNA)®
Interactive question “Which screening tool do you currently use?”
MNADeveloped in 1990 Validated for ages 65+Simple, reliable, quick & non-invasiveValidated across care settingsSupported by > 400 publications
Guigoz et al., Nutr. Rev. 1996;54:S59-65Vellas et al., J Am Geriatr Soc 2000;48:1300-1309Rubenstein et al., J Gerontol 2001;56:M366-M372
MNA-SF
Based on the original MNA®
Uses only 6 items
Quicker tool for clinical use
Validated in ambulatory elderly pts
MNADeveloped in 1990 Validated for ages 65+Simple, reliable, quick & non-invasiveValidated across care settingsSupported by > 400 publications
MNA-SF
Based on the original MNA®
Uses only 6 items
Quicker tool for clinical use
Validated in ambulatory elderly pts
Ideal Nutrition Screen
• Valid and reliable scale
• Accurate
• Clearly defined thresholds
• Inexpensive
• Relevant to outcomes
• Acceptable to patient
MNA®
Limited Use in Clinical Practice
Takes too long time
Height and/or weight not available
Nutrition screening of elderly still not embedded in standard clinical practice
Lack of awareness and use in clinical settings
Pros
MNA®
Pros
Ideal Nutrition Screen
• Valid and reliable scale
• Accurate
• Clearly defined thresholds
• Inexpensive
• Relevant to outcomes
• Acceptable to patient
MNA®
Pros Cons
MNA®
Pros
Ideal Nutrition Screen
• Valid and reliable scale
• Accurate
• Clearly defined thresholds
• Inexpensive
• Relevant to outcomes
• Acceptable to patient
Pros
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The 2008 – 2009 MNA® International Initiative
D. Thomas
B. Langkamp‐Henken
K. Charlton
A. Tsai
M. Kuzuya
R. Visvanathan
Aim
Make MNA®-Short Form more user-friendly and facilitate more widespread use in geriatric care
Revalidate the MNA®
Compare with common nutrition assessment criteriaRevalidate MNA® scoring system (cut-off points)
Validate the MNA®-SF as a stand alone toolDetermine best combination of questions for highest sensitivity and specificity Develop valid alternative for BMI Create a scoring system for the MNA®-SF to classify nutritional status identical to full MNA®
23%
46%
31%
n=4502
The elderly were at widespread risk for malnutrition.
k
69%
Bauer, et al. 2009, IANA
5
39%
14%
47% 53%
14%
33%
6%
32%
62%
50%
41%
9%
n=1384
n=340n=964
n=1586
Hospital
Community
Nursing home
Rehabilitation
MNA® Categories Across Settings
86%
91%
Bauer, et al. 2009, IANA
MNA® categories correlate with nutrition assessment parameters
Bauer, et al. 2009, IANAPhase Angle CRP
TCSAlbumin
Next Challenge
Validate the Short Form as a stand alone tool
Determine best combination of questions for highest sensitivity and specificity
Determine valid alternative for BMI
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The 6 questions used in the original MNA-SF®
correlated with the full MNA®
0.730.890.880.84A-B-D-E-F-N3
0.710.900.820.89A-B-C-D-E-F(Original MNA-
SF)
2
0.710.900.810.90B-C-D-E-F-N1
Youden-Index
Correlation with full
MNA
SpecificitySensitivityQuestions on MNA Form
Rank
Bauer, et al. 2009, IANA
Finding an Alternate for BMI -Why Use Calf Circumference (CC)
In some settings, obtaining weight and height measures may be cumbersome or impossible (bed-bound persons or amputees)
Calf circumference is an easy and quick alternative
Calf circumference correlates with muscle loss in elderly
Using calf circumference measurement was acceptable alternative for BMI.
0.700.860.900.80A-B-D-E-N-R3
0.700.860.840.85A-B-C-D-E-R“CC-MNA-
SF”*
2
0.700.860.840.86B-C-D-E-N-R1
Youden-IndexSpearman’s correlation with long-form MNA
SpecificitySensitivityQuestions on MNA Forms
Rank
*Calf Circumference question used instead of BMIKaiser, et al. 2009, JNHA
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Could the MNA®-SF distinguish
malnourished vs.
at risk for malnutrition vs.
well nourished?
Cut-points were determined to give the highest sensitivity and specificity.
XX
Upper Cut Point –
Optimized for Sensitivity
Lower Cut Point –
Optimized for Specificity
Bauer et al, 2009
Cut-point at 8 points:•Sensitivity 85.2%•Specificity 94.3% •Area under the curve 0.97
Cut-point at 11 points:•Sensitivity 89.3% •Specificity 81.8%
•Area under the curve 0.94
Using either BMI or calf circumference, MNA®-SF correlates with Full MNA®
Long
-form
MN
A sc
ore
0
5
10
15
20
25
30
Original MNA-SF score
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Long
-form
MN
A sc
ore
0
5
10
15
20
25
30
CC-MNA-SF score
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Using BMI Using Calf-Circumference
No complete misclassifications by two categories
79.9%
Correct classifications
72.9%Correct
classifications
Bauer et al, 2009
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BMI available OR Calf Circumference available
A: “Appetite loss“B: “Weight loss“C: “Mobility“D: “Acute disease“E: ”Depression/Dementia“F: “BMI“
Max. 14 points
A: “Appetite loss“B: “Weight loss“C. “Mobility“D: “Acute disease“E: “Depression/Dementia“R: “CC“
Max. 14 points
Malnourished0-7 points
At risk8-11 points
Well nourished12-14 points
Kaiser et al 2009, Rubenstein et al 2001
MNA® International InitiativeOutcomes
Outcomes of new MNA-SF
Drawbacks of old MNA-SF
3 cut-off points identify malnourished and allows direct movement from screening to intervention
Did not identify malnourished without full MNA
Calf-circumference valid alternative when height/weight unavailable
Height and weight not always available
Quick, stand-alone validated tool
Time consuming
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Where should nutrition screening be implemented?
Hospitals
Long term care settings
Assisted living facilities
OAA nutrition programs
Home and community based care
Home health
Medical home and physicians’ offices
Community setting
Using the MNA
Hospitals
Screening is routine
MNA is not applicable to all populations; works well in geriatric units, etc.
LTC / Subacute Care
Ideal population
May be seen as duplicating MDS/RAP process
Assessment is routine
Thomas DR, Nutr Clin Prac2008;23:383-387
Using the MNA
Assisted Living
Potential to identify those most likely to benefit from intervention and prevent transfer to more expensive care
Lack of regulations
Screening not embedded into process
Home Care
Screening not required
Equipment to measure height and weight may not be available – calf circumference easily measured
Easy for other clinicians to include in assessment process
Langkamp-Henken B. J Nutr Health Aging.
2006;10(6): 502-506.
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Using the MNA
Medical Home / Physician Office
Great potential to become part of medical home concept – fits wells with modelObtaining heights and weights and interviewing are routine; nutrition screening may not be
OAA Nutrition Programs / CMS
Home & Community Based Services
Screening “mandatory" in some, but not all programsFits well with programsNetwork and identify champion for resourcesTie screening to improved outcomes
ADA Medical Home Workgroup’s “Patient-Centered Medical Home Strategic Plan”, 2009
What are the challenges in implementing screening?
Cost
Lack of personnel
Lack of time
Lack of knowledge
Other?
Interactive question
“What challenges do you face in implementing nutrition screening in your practice?
Who can complete the MNA? Practice Setting
Nutrition staff; other staff; volunteersHome and Community Based Settings / other Community Settings
MD, Nursing and other MD Office staffMedical Home
Nursing staff; Admitting staff; Preadmission staff; RD; other professional staff
Home Health
Nursing staff; admitting staff; preadmission staff; nutrition staff; volunteers
Assisted Living
Meal site supervisor; assessment manager; admitting staff; RD; volunteers
OAA Nutrition Sites; other congregate meal sites
Nursing staff; nutrition staff; admitting staff; preadmission staff; volunteers
LTC
Nursing staff; nutrition staffHospitals
Challenges -Lack of Personnel
Completing the MNA does not require special skills
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- Challenges -Lack of Time
MNA takes ~ 5 minutes
Relevant information
Information may already be collected
Embed screening into routine practice
- Challenges -Lack of Knowledge
Educate MDs, discharge planners, and other health/social service professionals on importance of nutrition for healthful aging
New MNA® ResourcesMNA® Video**
Updated MNA® User Guides**
Proceedings from IAGG meeting*
Posters from IANA and ESPEN
JNHA article*** Posted on NNI website (www.nestlenutrition-institute.com
** Posted on MNA website (www.mna-elderly.com)
MNA Video and Other Resourceswww.mna-elderly.com
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Measuring Calf Circumference (CC)
Client should sit with the left leg hanging loosely or stand.
Wrap the tape around the calf at the widest part and note the measurement.
Check measurements above and below the point to ensure that the first measurement was the largest.
CC in centimeters0 = CC < 31 centimeters3 = CC ≥ 31 centimeters
Your critical
role
Advocate for . . . (validated) screening and referral systems for older adults.
Participate in programs that provide . . . nutrition screening and nutrition therapy . . . for older adults.
Provide routine nutrition assessments that include weight status . . . and advocate for assessment of functional status, cognitive status, depression . . .
J Am Diet Assoc. 2010;110:463-472)
How Do We Change Practice?
Start small at one site or one unit
Develop simple protocol/automate process
Identify and develop champion
Assess and address barriers
Educational reminders (manuals and user guides, pocket cards, mailings, computer screens, automated reminders)
Audit, provide feedback, share information
Stress importance of impact on client
Cahill NE, Heyland DK, JPEN 2009: In press.
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Next Steps
What is one step you can take to implement nutrition screening in your practice?
What do you need to be successful?
Conclusion
Malnutrition in older adults is a common problem.
The cornerstone of managing malnutrition is screening and early detection to facilitate prompt treatment.
The revised MNA is a valid tool that can now classify individuals as malnourished using the same scale as the full MNA.
When BMI cannot be obtained, calf circumference is an acceptable alternative.
The MNA® remains the most well validated and primary screening tool for older adults.
The RD is critical to implementing malnutrition screening.
Questions?
janetskates@yahoo.com
www.mna-elderly.com
This webinar is supported by Nestlé Nutrition
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