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Nutritional ScreeningNutritional Screening First Step towards better First Step towards better Nutrition care:Nutrition care:

Dr. Nasir H ChoudharyDr. Nasir H ChoudharyRotherham NHS Foundation TrustRotherham NHS Foundation Trust

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OverviewOverview

Importance of malnutrition and Importance of malnutrition and screening for malnutrition.screening for malnutrition.

Outcomes of screening and Outcomes of screening and identification of malnutrition.identification of malnutrition.

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Importance of Importance of malnutritionmalnutrition

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NutritionNutrition--Life line.Life line.

Continued receipt of food and water is Continued receipt of food and water is fundamental to life, and to deny an fundamental to life, and to deny an individual these essential substrates individual these essential substrates

seems morally indefensible.seems morally indefensible.Food is more than nutrition and plays a Food is more than nutrition and plays a

very important role in maintaining very important role in maintaining hope and offering some means of hope and offering some means of

comfort to patientscomfort to patients

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SteppStepp & Pakiz,2001& Pakiz,2001

Nutrition is an important Nutrition is an important issue for Patients on issue for Patients on palliative care and their palliative care and their carerscarers. .

Studies have shown that Studies have shown that appetite and the ability appetite and the ability to eat the most to eat the most important aspect of a important aspect of a patientpatient’’s quality of life. s quality of life.

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Nutrition issues in palliative Nutrition issues in palliative care care (Cline D,2006)(Cline D,2006)

Adequate nutritional intake is often Adequate nutritional intake is often difficult, if not impossible, for the difficult, if not impossible, for the

person with a terminal illness. person with a terminal illness. Patients, families, and caregivers Patients, families, and caregivers

struggle to continue providing food struggle to continue providing food and fluids in the face of declining and fluids in the face of declining

ability and interest.ability and interest.

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Why It is important?Why It is important?

As many as 40 per cent of cancer patients As many as 40 per cent of cancer patients are already malnourishedare already malnourished (Cohen & (Cohen & LeforLefor, 2001)., 2001).

In advanced cancer weight loss vary from In advanced cancer weight loss vary from 39 to 82 percent 39 to 82 percent (Poole & (Poole & FroggattFroggatt, 2002)., 2002).

Malnutrition is associated with increased Malnutrition is associated with increased mortality, higher risk of complications with mortality, higher risk of complications with treatment and a decrease in quality of life. treatment and a decrease in quality of life.

((PerssonPersson & & GlimeliusGlimelius, 2002; Capra et al, 2001)., 2002; Capra et al, 2001).

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““the process of identifying patients/ the process of identifying patients/ clients at risk of malnutrition or those clients at risk of malnutrition or those suspected of becoming at risk due to suspected of becoming at risk due to disease and/or treatmentdisease and/or treatment””

(White, Ham and (White, Ham and LipschitzLipschitz, 1991), 1991)

Nutrition screeningNutrition screening

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Screening Help to IdentifyScreening Help to Identify

No risk.No risk.

No risk now, re evaluate soon.No risk now, re evaluate soon.

At risk, assess further.At risk, assess further.

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Screening & Assessment Screening & Assessment Differ by:Differ by:

Type, depth of information.Type, depth of information.

Skill of those collecting information.Skill of those collecting information.

Time spent in process.Time spent in process.

Expense of process.Expense of process.

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Lifting the Lid on...Lifting the Lid on... Nutrition Screening & Nutrition Screening &

Assessment ToolsAssessment Tools

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ToolsTools Target GroupTarget Group Tool Comprises:Tool Comprises:

MUST Screening ToolMUST Screening ToolTorodovicTorodovic et al, 2003; et al, 2003; EliaElia, 2003, 2003

Adult patients in Adult patients in hospitals, community hospitals, community and all care settings.and all care settings.

3 Sections3 Sections: BMI, unplanned weight : BMI, unplanned weight loss, acute disease effect; score and loss, acute disease effect; score and management plan.management plan.

Nutrition Risk ScreenNutrition Risk Screen--NRSNRSRiley et al, 1995.Riley et al, 1995.

Adult & child hospital Adult & child hospital patients.patients.

5 Sections5 Sections: BMI/ percentile chart, : BMI/ percentile chart, weight loss, appetite, ability to eat, weight loss, appetite, ability to eat, retain food and stress factor.retain food and stress factor.

Subjective Global AssessmentSubjective Global AssessmentEkEk et al, 1996; Baker et al, 1982.et al, 1996; Baker et al, 1982.

Adult hospital Adult hospital patients.patients.

2 Sections:2 Sections: History of weight loss, History of weight loss, dietary intake change, GI symptoms,dietary intake change, GI symptoms,Functional capacity, disease, Functional capacity, disease, Phy.SigsPhy.Sigs

Malnutrition Screening Tool.Malnutrition Screening Tool.Ferguson et al, 1999.Ferguson et al, 1999.

Adult Hospital Adult Hospital patientspatients

3 Questions3 Questions: Unintentional weight : Unintentional weight loss, amount of loss, dietary intake/ loss, amount of loss, dietary intake/ appetite.appetite.

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ToolsTools Target GroupTarget Group Tool Comprises:Tool Comprises:

Derby Nutritional Score Derby Nutritional Score --DNSDNSGoudgeGoudge et al, 1998.et al, 1998.

Adult hospital Adult hospital patientspatients

7 Sections:7 Sections: Body weight for height, Body weight for height, mobility, GI symptoms, skin mobility, GI symptoms, skin condition, appetite and dietary intake, condition, appetite and dietary intake, psychological state and age.psychological state and age.

Mini Nutritional Assessment.Mini Nutritional Assessment.Rubenstein et al, 2001.Rubenstein et al, 2001.

Older adultsOlder adults 66-- Items initial screen: Items initial screen: BMI, BMI, recent weight loss, mobility, recent weight loss, mobility, cognitive/ mood state, appetite and cognitive/ mood state, appetite and eating. If at risk proceed with full 18eating. If at risk proceed with full 18-- item versionitem version

Nutritional Risk IndexNutritional Risk Index-- NRINRIWolinskyWolinsky et al, 1990.et al, 1990.

Older adultsOlder adults 1616--items questionnaire:items questionnaire: medical medical history, medications, eating abilities, history, medications, eating abilities, dietary habits and intake, smoking dietary habits and intake, smoking and weight change.and weight change.

Nutritional Risk Assessment ScaleNutritional Risk Assessment ScaleWolinskyWolinsky et al, 1990.et al, 1990.

Older adultsOlder adults 1212--items questionnaire: medical items questionnaire: medical history, eating abilities, medications, history, eating abilities, medications, cognitive/ mood state, social habits cognitive/ mood state, social habits and weight loss.and weight loss.

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Nutrition screening helps Nutrition screening helps assure:assure:

nutrition care is delivered consistentlynutrition care is delivered consistently

resources are directed to the appropriate resources are directed to the appropriate clientsclients

initiates process of recognising and initiates process of recognising and responding to nutrition related problemsresponding to nutrition related problems

increases the likelihood that increases the likelihood that interventions will follow.interventions will follow.

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Nutrition screening toolsNutrition screening tools

nonnon--invasiveinvasive

quick and simplequick and simple

able to be implemented in any settingable to be implemented in any setting

able to be completed by no technical able to be completed by no technical staff, family or clientstaff, family or client

(Elmore et al., 1994)(Elmore et al., 1994)

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An effective nutrition An effective nutrition screening tool should be:screening tool should be:

inexpensiveinexpensive

easily administered with minimal easily administered with minimal nutritional expertisenutritional expertise

site and population specificsite and population specific

designed to incorporate only routine designed to incorporate only routine tests and data done on admissiontests and data done on admission

(Handbook of Clinical Dietetics, ADA, 1992)(Handbook of Clinical Dietetics, ADA, 1992)

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Screening Tools we have!Screening Tools we have!

Malnutrition Universal Screening Tool Malnutrition Universal Screening Tool (MUST).(MUST).

Modified MUST Screening Tool.Modified MUST Screening Tool.

Modified Patient Generated SGA.Modified Patient Generated SGA.

Any tool available.Any tool available.

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What is good?What is good?

Easy to use.Easy to use.

Includes guidelines / Includes guidelines / recommendations.recommendations.

Can use in different clinical settings.Can use in different clinical settings.

Validated.Validated.

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What is wrong?What is wrong?

Quite lengthy.Quite lengthy.

Another piece of paper to fill in.Another piece of paper to fill in.

Not possible to use in certain clinical Not possible to use in certain clinical conditions.conditions.

Not specific in certain clinical Not specific in certain clinical conditions.conditions.

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Birmingham PCT.Birmingham PCT.

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Palliative Dietetic care Model.Palliative Dietetic care Model.

Nutritional screening at all key points Nutritional screening at all key points e.g GP, Cancer specialty clinic, Hospital, e.g GP, Cancer specialty clinic, Hospital, Nursing home and Hospice.Nursing home and Hospice.

Referral to dietitian.Referral to dietitian.

Regular follow ups/ review throughout Regular follow ups/ review throughout treatment.treatment.

Regular information sharing with health Regular information sharing with health and social care professionals involved in and social care professionals involved in patientpatient’’s care, e.g MDT meetings etc.s care, e.g MDT meetings etc.

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