1

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

2

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

3

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

4

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

6

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

7

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

8

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

9

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.

10

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

11

- 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

12

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.

13

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