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Aims and objectives. To compare screening results using different nutritional screening instruments with respect to nutritional risk and associations with perceived health and health-related issues in a group of older hospital patients.
Background. The association between lower perceived health and nutritional risk in older people is widely known. It is advised to use a screening instrument to identify nutritional at-risk patients.
Design. A cross-sectional study design was used.
Methods. One hundred and fifty-eight older patients, in three medical hospital wards in two hospitals in southern Norway, were interviewed using a questionnaire containing questions about background variables, perceived health and health-related issues and the nutritional screening instruments Nutritional Form for the Elderly and Mini Nutritional Assessment (including Mini Nutritional Assessment-Short Form). Data were also collected regarding the screening instrument Nutrition Risk Screening 2002. All data were analysed using statistical methods.
Results. Many patients were at nutritional risk independent of instrument used. Nutrition Risk Screening 2002 identified fewer nutritional at-risk patients than the other instruments did. Perceived ill health was significantly associated with nutritional risk using instruments specifically designed for older people. Feeling satisfied with life and lower risk of undernutrition were two important predictors for perceived good health.
Conclusions. Nutritional Form for the Elderly, Mini Nutritional Assessment and Mini Nutritional Assessment-Short Form could identify approximately the same number of nutritional at-risk patients. Being at nutritional risk had a negative impact on older patients’ perceived health.
Relevance for practice. Corresponding nutritional screening results can be obtained using either Nutritional Form for the Elderly or Mini Nutritional Assessment, as well as Mini Nutritional Assessment-Short Form. Instruments designed for older people should be used to screen older patients. Factors associated with nutritional risk can aid nurses in becoming aware of nutritional at-risk patients. Preventing undernutrition is important for overall health enhancement.
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An association between lower perceived health and being at nutritional risk is widely known in older people (Chen et al. 2001, Margetts et al. 2003). In several recent studies, this association regarding older people has been found when a nutritional instrument, the Mini Nutritional Assessment (MNA®), was used to identify those at nutritional risk (Johansson et al. 2007, 2009). In addition to impaired perceived health (Johansson et al. 2009), lower functional status (Chen et al. 2007) was found to predict poor nutritional status in older people. Other factors associated with undernutrition, when using MNA® in a small group of hospitalised older patients with chronic obstructive pulmonary disease, were found to be lower body mass index (BMI) and being dependent on daily community services (Odencrants et al. 2008). Furthermore, when using MNA®, lower level of life satisfaction was found in older people at nutritional risk (Johnson 2005).
Many hospital patients are undernourished on admission and become even more so during their hospital stay. To detect undernutrition or risk of undernutrition, the European Society for Clinical Nutrition and Metabolism (ESPEN) recommends using a nutritional screening instrument at admission (Kondrup et al. 2003a). The ESPEN guidelines regarding the choice of screening tools in different clinical settings have been followed in Scandinavia, for example, as national guidelines in Norway (Norwegian Directorate of Health 2009). Recommended nutritional screening instruments, according to ESPEN guidelines, are MNA® for screening older people and Nutrition Risk Screening 2002 (NRS-2002) for hospital screening (Kondrup et al. 2003a). NRS-2002 was developed to be used in hospitals in an acute care setting but was not specifically developed for older patients, while MNA® was designed for older people. MNA®, however, can be used in the community in both long-term care and acute care settings (Sieber 2006).
When choosing an instrument, it is important to use the most appropriate tool regarding the actual health care setting (Anthony 2008). This choice should also be considered carefully, and the criteria for reliability, validity, sensitivity and specificity should be met (Green & Watson 2006). Studies have been performed to compare different nutritional instruments in hospital settings. In a study by Raslan et al. (2010), NRS-2002 and Mini Nutritional Assessment-Short Form (MNA-SF), which is an abbreviated form of the complete MNA®, were compared regarding their identifying abilities as tools for predicting unfavourable outcomes in hospital patients. NRS-2002 was found to be the best, even in older patients. MNA® and NRS-2002 were compared among geriatric hospital patients by Bauer et al. (2005). MNA® could identify more patients who were at nutritional risk or undernourished than NRS-2002 could. NRS-2002 was found to be completed in more patients than MNA®.
As perceived ill health is concomitant with nutritional risk in older people (Chen et al. 2001, Margetts et al. 2003), it should be of interest to investigate this association by using and comparing a new nutritional screening instrument, the Nutritional Form For the Elderly (NUFFE) (Söderhamn & Söderhamn 2001, 2002), with established, recommended nutritional screening instruments as MNA®, MNA-SF and NRS-2002 among a group of older Norwegian patients in an acute care setting. To have knowledge about different nutritional screening instruments, nutritional screening results and factors associated with nutritional risk in older patients should aid nurses in becoming aware of and highlight these patients as a risk group for undernutrition.
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The study group (n = 158) ranged in age between 65–94, with a mean age of 78·0 (SD 8·0). Background variables of the participating patients are shown in Table 1. The women (mean age 79·3, SD 7·6) were older than the men (mean age 76·0, SD 7·4, p = 0·007). The mean value of BMI (n = 154) was 24·1 kg/m2 (SD 4·9). The women had a lower BMI (mean 22·9 kg/m2, SD 4·6) than the men (mean 25·3 kg/m2, SD 5·0, p = 0·002).
Table 1. Background variables in the study group (n = 158)
|Background variables|| ||n (%)|
|Civil status||Single or widow/-er||75 (47·5)|
|Type of dwelling||Own home||127 (80·4)|
|Residential living||31 (19·6)|
|Former profession||House wife||1 (0·6)|
|Blue-collar workers||115 (72·8)|
|White-collar workers||36 (22·8)|
|Main medical diagnosis||Infections||69 (43·7)|
|Lung diseases||34 (21·5)|
|Cancer diseases||31 (19·6)|
|Heart/kidney diseases||13 (8·2)|
|Other diagnoses||11 (7·0)|
Perceived health and nutritional screening results
Of the patients in the total study group (n = 158), more patients perceived ill health than those who perceived good health. In Table 2, the results are displayed considering perceived health and health-related issues. There was no difference between women and men (p = 0·5) regarding perceived health, but more women than men perceived themselves as being helpless (p = 0·005).
Table 2. Perceived health and health-related issues in the study group (n = 158)
|Perceived health and health-related issues||Yes % (n)||No % (n)|
|Perceived good health||46·8 (74)||53·2 (84)|
|Regularly help to manage the daily life||46·8 (74)||53·2 (84)|
|Perceived helplessness||36·7 (58)||63·3 (100)|
|Being active||64·6 (102)||35·4 (56)|
|Feeling satisfied with life||72·0 (113)||28·0 (44) 1 missing|
The nutritional screening results revealed that NUFFE-NO median score was 7 (interquartile range 5–12) (n = 158). NUFFE-NO identified 38% (n = 60) of the patients being at low risk of undernutrition, 29·1% (n = 46) at medium risk and 32·9% (n = 52) at high risk of undernutrition. MNA® median score was 22·5 (interquartile range 19–25) (n = 153), and the screening results, using MNA®, showed that 39·2% (n = 60) were at no risk of undernutrition, 43·8% (n = 67) at risk of undernutrition and 17% (n = 26) undernourished. MNA-SF median score was 10 (interquartile range 8–12) (n = 154), and MNA-SF identified 35·1% (n = 54) at no risk of undernutrition and 64·9% (n = 100) at risk of undernutrition. NRS-2002 median score was 2 (interquartile range 0–3) (n = 153), and NRS-2002 screened 55·6% (n = 85) to be at low risk of undernutrition and 44·4% (n = 68) at risk of undernutrition.
The dichotomised screening results, being at no risk or at risk of undernutrition, using the different screening instruments are displayed in Table 3. In Table 4, differences are shown between being at no risk and at risk of undernutrition, using different nutritional screening instruments, regarding perceived health and health-related issues.
Table 3. Screening results, using different screening instruments, dichotomised regarding the number of patients at no risk and at risk of undernutrition, respectively
| ||No risk of undernutrition % (n) and scores||Risk of undernutrition % (n) and scores|
|NUFFE-NO (n = 158)||38% (n = 60) <6 scores||62% (n = 98) ≥6 scores|
|MNA® (n = 153)||39·2% (n = 60) ≥24 scores||60·8% (n = 93) ≤23·5 scores|
|MNA-SF (n = 154)||35·1% (n = 54) ≥12 scores||64·9% (n = 100) ≤11 scores|
|NRS-2002 (n = 153)||55·6% (n = 85) <3 scores||44·4% (n = 68) ≥3 scores|
Table 4. Comparison of nutritional screening results related to perceived health and health-related issues
|Variables||NUFFE-NO No risk/risk||MNA® No risk/risk||MNA-SF No risk/risk||NRS-2002 No risk/risk|
|Perceived ill health % (n)||26·2% (22)/73·8% (62)**||26·5% (22)/73·5%(61)**||24·1% (20)/75·9% (63)*||50·0% (41)/50·0% (41)|
|Perceived good health % (n)||51·4% (38)/48·6% (36)||54·3% (38)/45·7% (32)||47·9% (34)/52·1% (37)||62·0% (44)/38·0% (27)|
|No regularly help % (n)||45·2% (38)/54·8% (46)||53·8% (49)/46·2% (42)*||44·6% (37)/55·4% (46)*||62·7% (52)/37·3% (31)|
|Regularly help % (n)||29·7% (22)/70·3% (52)||28·2% (20)/71·8% (51)||23·9% (17)/76·1% (54)||47·1% (33)/52·9% (37)|
|No helplessness % (n)||50·0% (50)/50·0% (50)**||46·9% (45)/53·1% (51)||46·4% (45)/53·6% (52)**||64·6% (62)/35·4% (34)*|
|Helplessness % (n)||17·2% (10)/82·8% (48)||26·3% (15)/73·7% (42)||15·8% (9)/84·2% (48)||40·4% (23)/59·6% (34)|
|Not being active % (n)||17·9% (10)/82·1% (46)**||20·4% (11)/79·6% (43)**||20·4% (11)/79·6% (43)*||41·5% (22)/58·5% (31)|
|Being active % (n)||49·0% (50)/51·0% (52)||49·5% (49)/50·5% (50)||43·0% (43)/57·0% (57)||63·0% (63)/37·0% (37)|
|Not satisfied with life % (n)||20·5% (9)/79·5% (35)*||23·3% (10)/76·7% (33)||20·9% (9)/79·1% (34)||37·2% (16)/62·8% (27)*|
|Satisfied with life % (n)||45·1% (51)/54·9% (62)||45·9% (50)/54·1% (59)||40·9% (45)/59·1% (65)||63·3% (69)/36·7% (40)|
Predictors for perceived good health
The results from the logistic regression analyses are presented in Table 5. It was found that lower risk of undernutrition using NUFFE-NO, MNA® and MNA-SF scores could predict perceived good health in the analyses 1–3, respectively. But such results from NRS-2002 scores were not obtained in the fourth analysis. When scores from all instruments were included in the fifth regression analysis, higher MNA® scores, i.e. lower risk of undernutrition, emerged as a predictor for perceived good health. When BMI was excluded in the sixth analysis, the screening scores from NUFFE-NO, i.e. lower risk of undernutrition, emerged as a predictor. Feeling satisfied with life was a positive predictor in all regression analyses. More advanced age was found to be a predictor in the first, fifth and sixth analyses. A lower BMI value was a predictor in analyses where it was included, with the exception of the fourth analysis with the NRS-2002 scores.
Table 5. Predictors for perceived good health that emerged in several logistic regression analyses
|Dependent variable||Predictors||R2 Nagelkerke||B||SE||df||p-value||OR (95% CI)|
|Perceived good health or ill health|
| Nr 1||Age||0·37||0·057||0·027||1||0·032||1·059 (1·005–1·115)|
|Satisfied with life||1·839||0·518||1||<0·001||6·290 (2·279–17·365)|
|NUFFE-NO scores||−0·199||0·052||1||<0·001||0·819 (0·741–0·907)|
| Nr 2||BMI||0·39||−0·182||0·054||1||0·001||0·834 (0·750–0·927)|
|Satisfied with life||1·754||0·508||1||0·001||5·779 (2·135–15·644)|
|MNA® scores||0·264||0·064||1||<0·001||1·302 (1·149–1·475)|
| Nr 3||BMI||0·33||−0·131||0·048||1||0·006||0·877 (0·799–0·964)|
|Satisfied with life||1·985||0·498||1||<0·001||7·276 (2·740–19·322)|
|MNA-SF scores||0·291||0·086||1||0·001||1·338 (1·129–1·584)|
| Nr 4||Being active||0·26||0·965||0·410||1||0·019||2·625 (1·176–5·861)|
|Satisfied with life||1·907||0·495||1||<0·001||6·736 (2·555–17·761)|
| Nr 5||Age||0·42||0·054||0·027||1||0·045||1·056 (1·001–1·113)|
|Satisfied with life||1·880||0·524||1||<0·001||6·555 (2·349–18·292)|
|MNA® scores||0·275||0·066||1||<0·001||1·316 (1·157–1·498)|
| Nr 6||Age||0·35||0·069||0·026||1||0·009||1·071 (1·017–1·128)|
|Satisfied with life||1·856||0·516||1||<0·001||6·398 (2·325–17·606)|
|NUFFE-NO scores||−0·174||0·049||1||<0·001||0·841 (0·764–0·925)|
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