**2. Nutritional screening and assessment**

Up to 30% of all acute hospital admissions are malnourished and this is further deepened during hospitalisation [9]. Hence, all the patients should be screened for risk of malnutrition.

There are various scoring systems available to screen a patient at nutritional risk. Screening is based on history (weight loss, etc.) and physical examination (height, weight, and body mass index (BMI)).'Malnutrition universal screening tool' ('MUST') [Figure 1], rapid nutrition screen for hospitalised patients, nutrition risk index (NRI), Mini Nutritional Assessment-Short Form (MNA-SF), Short Nutritional Assessment Questionnaire (SNAQ©) (Table 1) and Nutri‐ tion Risk Screening (NRS-2002) are some of the commonly available and used composite tools

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

in clinical practice [10–15]. An ideal screening tool should be easy to implement, accurate, reliable, inexpensive, and reproducible. NRS-2002 is the best instrument today because it is robust, simple, quick, validated, and based from an analysis of 128 controlled clinical trials. Patients with the risk criteria had a higher likelihood of a better clinical outcome from nutritional support than patients who did not fulfill the criteria [15]. NRS 2002 has also been used by nurses and dietitians in three hospitals of Denmark. Its reliability was validated by inter-observer variation between a nurse, a dietitian, and a physician with a k = 0.67. Its practicability was shown by the finding that 99% of 750 newly admitted patients could be screened [16]. Supplement 1 shows the 'TTSH Nutrition Screening Tool' (TTSH NST) used by the Nutrition and Dietetics department at Tan Tock Seng Hospital, Singapore. TTSH NST was developed from a cohort of younger hospitalised patients. This was later validated in a cohort of elderly patients using subjective global assessment (SGA) as a comparator. In 281 acute admissions to Tan Tock Seng Hospital with age range of 61–102 years, prevalence of malnu‐ trition was 35% based on SGA. Risk of malnutrition as determined by TTSH NST with a cutoff of 4 had sensitivity, specificity, positive, and negative predictive values of 84%, 79%, 68%, and 90%, respectively, with area under the curve of 0.87. The optimal cut-off remained at 4 even for patients aged >85 years (AUC = 0.85). Risk of malnutrition was predictive of 6-month mortality (adjusted OR: 2.2, *P* = 0.05) and hospital length of stay (*P* < 0.05) [17].


a Patients who scored 0 or 1 points were classified as well-nourished and did not receive intervention. Patients who scored 2 points were classified as moderately malnourished and received nutritional intervention. Patients who scored 3 points were classified as severely malnourished and received nutritional intervention and treatment by a dietician.

Reproduced from: *Am J Clin Nutr* 2005;82:1082-9. © 2005 American Society for Nutrition

**Table 1.** Short Nutritional Assessment Questionnaire a

Nutritional assessment is a more detailed process and is done in patients screened at risk or when metabolic or functional problems prevent a standard plan being carried out. There are few tools for evaluating the nutritional status of hospitalised patients. SGA, short nutritional assessment questionnaire, mini nutritional assessment (MNA), and corrected arm muscle area (CAMA) are tools used for nutritional assessment [18]. The assessment of nutritional status includes a nutritional history and physical examination in conjunction with appropriate laboratory studies [Figure 2]. Regurgitation, hoarse voice, coughing during or after swallow‐ ing, globus sensation, nasal regurgitation, recurrent chest infections, and frequent throat clearing symptoms may indicate dysphagia [19]. In all patients with dysphagia, a complete evaluation of the cause of dysphagia must be performed and for the purpose of this chapter we will only discuss nutrition-related assessment.

The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on 'MUST' see www.bapen.org.uk Copy‐ right © BAPEN 2012

**Figure 1.** 'MUST' flowchart

**Score 2**

in clinical practice [10–15]. An ideal screening tool should be easy to implement, accurate, reliable, inexpensive, and reproducible. NRS-2002 is the best instrument today because it is robust, simple, quick, validated, and based from an analysis of 128 controlled clinical trials. Patients with the risk criteria had a higher likelihood of a better clinical outcome from nutritional support than patients who did not fulfill the criteria [15]. NRS 2002 has also been used by nurses and dietitians in three hospitals of Denmark. Its reliability was validated by inter-observer variation between a nurse, a dietitian, and a physician with a k = 0.67. Its practicability was shown by the finding that 99% of 750 newly admitted patients could be screened [16]. Supplement 1 shows the 'TTSH Nutrition Screening Tool' (TTSH NST) used by the Nutrition and Dietetics department at Tan Tock Seng Hospital, Singapore. TTSH NST was developed from a cohort of younger hospitalised patients. This was later validated in a cohort of elderly patients using subjective global assessment (SGA) as a comparator. In 281 acute admissions to Tan Tock Seng Hospital with age range of 61–102 years, prevalence of malnu‐ trition was 35% based on SGA. Risk of malnutrition as determined by TTSH NST with a cutoff of 4 had sensitivity, specificity, positive, and negative predictive values of 84%, 79%, 68%, and 90%, respectively, with area under the curve of 0.87. The optimal cut-off remained at 4 even for patients aged >85 years (AUC = 0.85). Risk of malnutrition was predictive of 6-month

mortality (adjusted OR: 2.2, *P* = 0.05) and hospital length of stay (*P* < 0.05) [17].

Did you lose weight intentionally?

122 Seminars in Dysphagia

a

**Question Score**

 Patients who scored 0 or 1 points were classified as well-nourished and did not receive intervention. Patients who scored 2 points were classified as moderately malnourished and received nutritional intervention. Patients who scored 3 points

Nutritional assessment is a more detailed process and is done in patients screened at risk or when metabolic or functional problems prevent a standard plan being carried out. There are few tools for evaluating the nutritional status of hospitalised patients. SGA, short nutritional assessment questionnaire, mini nutritional assessment (MNA), and corrected arm muscle area (CAMA) are tools used for nutritional assessment [18]. The assessment of nutritional status includes a nutritional history and physical examination in conjunction with appropriate laboratory studies [Figure 2]. Regurgitation, hoarse voice, coughing during or after swallow‐ ing, globus sensation, nasal regurgitation, recurrent chest infections, and frequent throat clearing symptoms may indicate dysphagia [19]. In all patients with dysphagia, a complete

∙ 6 Kg in past 6 months 3 ∙ 3 Kg in the past month 2 Did you experience a decreased appetite over the past month? 1 Did you use supplemental drinks or tube feeding over the past month? 1

were classified as severely malnourished and received nutritional intervention and treatment by a dietician.

Reproduced from: *Am J Clin Nutr* 2005;82:1082-9. © 2005 American Society for Nutrition

**Table 1.** Short Nutritional Assessment Questionnaire a

**Figure 2.** Nutritional assessment

The nutritional history should evaluate the following:

**1.** *Food intake*

A change in the dietary pattern due to dysphagia should be ascertained.

**2.** *Body weight*

The presence of unintentional weight loss over past six months should be ascertained. 10% or greater unintentional weight loss over the past six months is categorised as severe weight loss and is associated with a poor clinical outcome. In a study involving 3,047 patients enrolled in 12 chemotherapy protocols of Eastern Cooperative Oncology Group, Dewys WD, et al. has shown that chemotherapy response rates and median survival rates were lower in patients with weight loss [20]. The *functional status* of the patients (e.g., bedridden) and *metabolic stress* due to accompanied illness or injury also need to be ascertained.

**3.** *Physical examination*

*Body mass index (BMI)*: Patients are classified by BMI as underweight (<18.5 kg/m2 ), normal weight (18.5–24.9 kg/m2 ), overweight (25.0–29.9 kg/m2 ), class I obesity (30.0–34.9 kg/m2 ), class II obesity (35.0–39.9 kg/m2 ), or class III obesity (≥40.0 kg/m<sup>2</sup> ) [21].

*Hand grip strength, gait speed, triceps skin fold thickness, mid-arm circumference, mucosal xerosis,* and *edema* are some of the physical signs which could help establish malnutrition in patients with dysphagia. Handgrip strength reflects, in part, the association of muscle strength and lean body mass with malnutrition [22]. In a study conducted by the International Academy on Nutrition and Aging (IANA) Task Force, gait speed at usual pace is found to be a consistent risk factor for disability, cognitive impairment, falls, institutionalisation, and/or mortality and at least as sensitive as composite tools [23].

#### **4.** *Laboratory studies*

Measurements of serum albumin, prealbumin, retinol-binding protein, transferrin, createnine height index, createnine extretion in urine and total lymphocyte count have been shown to correlate with clinical outcome. In a study involving 17 critically ill patients, Apelgren KN et al. have shown that a serum albumin <2.5 g/dL concentration is associated with an increased incidence of medical complications and death and it correctly separated 93% of patients in terms of survival prognosis [24]. Serum albumin levels are often used as a surrogate for preoperative nutritional assessment, but it is confounded by coexisting inflammation [25, 26]. Injury and inflammation decreases synthesis, increases degradation and transmembrane losses from the plasma compartment. In addition, albumin is also lost from open wounds (burns, etc.), peritonitis and through the gastrointestinal tract and/or kidneys in certain diseases. The association between hypoalbuminemia and poor clinical outcome is independent of both nutritional and inflammatory status [27]. Serum albumin is a good predictor of clinical outcomes but is a poor marker for nutritional assessment.
