Undernutrition in Elderly People

**143**

**Chapter 9**

**Abstract**

malnutrition biomarkers

**1. Introduction**

malnourishment [1].

Undernutrition Risk Assessment

in Elderly People: Available Tools

*Isabel Sospedra, Aurora Norte, José Miguel Martínez-Sanz,* 

Undernutrition is a public health problem all over the world. More than 30 million people are currently affected by undernutrition in Europe, mainly hospitalized or elderly people. Undernutrition has several medical consequences and in the elderly can be associated with adverse clinical symptoms, contributing to frailty, morbidity, hospitalization, and mortality. These medical situations highlight the importance of an early detection and diagnosis, the objective being to prevent or treat undernutrition. This is why the implementation of a complete nutritional assessment in clinical practice is important. Nutritional screenings are essential tools to identify patients that will likely benefit from nutrition therapy. There are currently several screening methods to identify nutritional risk or malnutrition. However, the lack of a standard has aroused controversy about the best tool to use.

Our objective is to describe the screening tools available for the elderly.

Scientific evidence suggests that nutritional status has a great impact on the health and functional status of older people. In addition, during the aging process there are a series of changes that can have a negative impact on nutritional status. These biological, physiological, social, and psychological changes, together with a higher prevalence of morbidities, further increase the susceptibility of the elderly to

The etiology of malnutrition is multifactorial in the elderly. The literature indicates that the elderly are at risk of nutritional deficiencies due to changes in body composition, the digestive system, and the regulation of fluids and electrolytes, sensory alterations, increased likelihood of chronic diseases, poly medication, and hospitalization. But also, social changes—such as retirement, less family responsibility, loneliness, widowhood, or lower purchasing power—increase the risk of inadequate nutrition. Although certain autonomy is maintained, the functional capacity is modified, which makes the daily tasks of life—such as shopping,

**Keywords:** elderly, undernutrition, malnutrition assessment,

*Enrique de Gomar, José Antonio Hurtado Sánchez*

in Clinical Practice

*and María José Cabañero-Martínez*

#### **Chapter 9**

## Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice

*Isabel Sospedra, Aurora Norte, José Miguel Martínez-Sanz, Enrique de Gomar, José Antonio Hurtado Sánchez and María José Cabañero-Martínez*

### **Abstract**

Undernutrition is a public health problem all over the world. More than 30 million people are currently affected by undernutrition in Europe, mainly hospitalized or elderly people. Undernutrition has several medical consequences and in the elderly can be associated with adverse clinical symptoms, contributing to frailty, morbidity, hospitalization, and mortality. These medical situations highlight the importance of an early detection and diagnosis, the objective being to prevent or treat undernutrition. This is why the implementation of a complete nutritional assessment in clinical practice is important. Nutritional screenings are essential tools to identify patients that will likely benefit from nutrition therapy. There are currently several screening methods to identify nutritional risk or malnutrition. However, the lack of a standard has aroused controversy about the best tool to use. Our objective is to describe the screening tools available for the elderly.

**Keywords:** elderly, undernutrition, malnutrition assessment, malnutrition biomarkers

#### **1. Introduction**

Scientific evidence suggests that nutritional status has a great impact on the health and functional status of older people. In addition, during the aging process there are a series of changes that can have a negative impact on nutritional status. These biological, physiological, social, and psychological changes, together with a higher prevalence of morbidities, further increase the susceptibility of the elderly to malnourishment [1].

The etiology of malnutrition is multifactorial in the elderly. The literature indicates that the elderly are at risk of nutritional deficiencies due to changes in body composition, the digestive system, and the regulation of fluids and electrolytes, sensory alterations, increased likelihood of chronic diseases, poly medication, and hospitalization. But also, social changes—such as retirement, less family responsibility, loneliness, widowhood, or lower purchasing power—increase the risk of inadequate nutrition. Although certain autonomy is maintained, the functional capacity is modified, which makes the daily tasks of life—such as shopping, preparing food, or moving from one place to another—difficult. In addition, the coexistence of physical and mental illnesses may increase or decrease nutritional requirements or may limit the individual's ability to obtain adequate nutrition, thereby increasing the risk of malnutrition [2, 3].

This is why the evaluation of the nutritional risk in this type of population is of the utmost importance.

#### **2. Nutritional parameters related to undernutrition**

The assessment of the nutritional status is the step previous to dietarynutritional treatment [4]. It is a global evaluation that includes the nutritional status of the individual as well as the severity of the underlying disease, due to the relationship between them. It establishes a methodology to obtain information about the current and past situation of the elderly person in relation to their diet, body composition, and functional and health status [5, 6]. In addition, it will help in the detection of nutritional risk or malnutrition. Two steps can be established in this assessment process: a first step of screening the nutritional risk or malnutrition, and a second step of complete nutritional assessment to identify the causes and consequences of malnutrition. The second step would be carried out when a nutritional risk or malnutrition has been detected [4, 5, 7].

As there is no single marker or nutritional tool that is useful for all types of individuals or physiological or pathological situations and is easily reproducible, predictable, and reliable, correct nutritional assessment involves the use of different nutritional parameters in order to perform an evaluation of the nutritional status that is as complete as possible, according to the subject with which we are dealing; in this case, the geriatric population. In addition, the social and cultural aspects of the patient must also be taken into account, because these data provide information on their resources and ability to prepare food, as well as sociocultural, religious, or personal nutritional habits that may affect the intake and nutritional status. Among the different factors or parameters related to malnutrition that can be assessed in the elderly, we find health status, social and clinical conditions, anthropometry, dietary habits and dietary intake, lifestyle, blood biochemistry, etc. [5, 6]. These factors or parameters and their relationship with malnutrition are described below.

#### **2.1 General health status self-assessment**

Perceived health status is one of the most consolidated indicators and is easy to enquire about in health surveys. It is a feasible tool and has been studied in recent years because it is useful as a global indicator of the level of population health. Some of the factors that lead to a poor self-perception of the state of health in the elderly are age, female sex, comorbidity, not receiving treatments, and little accessibility to other health services [8].

#### **2.2 Social condition**

Many aspects of the individual's life are covered here. Some of the causes that can lead to an inadequate consumption of food and, therefore, to malnutrition, are isolation, the loss of loved ones in charge of organizing meals, difficulties in buying or cooking, poor pensions, or changes in feeding when moving to a geriatric residence. It is important to know where the individual lives and with whom, the main career's situation, characteristics of the home, the level of income, their leisure activities, etc. [9].

**145**

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

This is data from the clinical evaluation performed by a medical professional. It will be necessary to know if the individual suffers or has suffered from any disease, as well as the drugs he or she has taken or is taking for said disease(s). Regarding the intake of drugs, it is important to gather information about the dosage and interac-

Anthropometric measurements provide information about the morphological dimensions of individuals. It is a non-invasive, low cost, and portable method, when compared to techniques requiring more complex devices. The anthropometric parameters include weight, height, skin folds, diameters, lengths, and girth. Some of these have been related to malnutrition: specifically, weight loss in a short period of time (1–6 months) with respect to usual weight, low percentile of the triceps skin

Food intake is a process that varies according to the day of the week, month, or season of the year. Other factors that influence food intake are food preferences and aversions, the person preparing the meals, feeling full (before and during meals), and the ease or difficulty of food intake and/or food preparation, among others. Information concerning these factors is relevant to evaluate food intake [6].

To determine the intake of food and liquids, methods that give similar results if they are repeated in the same situation are required; that is, instruments that offer better reproducibility or precision (agreement of results when the same dietary evaluation method is administered more than once, and on different occasions, to the same individual or group). Currently, there are prospective or retrospective methods, such as the dietary diary, 24-hour recall, and food consumption frequency questionnaire (CFCA), among others. The use of two or more methods can give a better and more accurate estimate of the habitual diet of the individual who has been interviewed, since the disadvantages of one method are offset by the advantages of the other. In addition, it is necessary to use a food composition database to obtain information on energy and nutritional intake (macro and micronutrients), thereby allowing comparison with the recommendations for the intake of energy,

Some of the blood biochemical parameters are biomarkers related to nutritional status. In spite of the fact that most nutritional risk screenings aimed at the elderly population do not contemplate biochemical parameters, they are included in the screening of hospitalized patients. Decreases in the values of some of these biochemical parameters (albumin, lymphocytes, cholesterol, etc.) are important in the detection and assessment

• Albumin: this protein is easily determined due to its long half-life (20 days), but has limitations as a nutritional marker. Changes in blood volume, different pathological situations, or any degree of aggression can produce a decrease in its plasma values, although its decrease is related to an increase in the occur-

*DOI: http://dx.doi.org/10.5772/intechopen.79977*

tions between food and drugs [5].

fold, and decrease in body mass index (BMI) [6, 9].

carbohydrates, proteins, lipids, and micronutrients [5, 6, 10].

of protein malnutrition [6, 9–11]. These parameters are described below:

rence of complications and mortality [6, 10].

**2.5 Dietary intake and eating attitudes**

**2.3 Clinical condition**

**2.4 Anthropometry**

**2.6 Blood biochemistry**

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

#### **2.3 Clinical condition**

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

thereby increasing the risk of malnutrition [2, 3].

**2. Nutritional parameters related to undernutrition**

nutritional risk or malnutrition has been detected [4, 5, 7].

**2.1 General health status self-assessment**

other health services [8].

**2.2 Social condition**

activities, etc. [9].

the utmost importance.

preparing food, or moving from one place to another—difficult. In addition, the coexistence of physical and mental illnesses may increase or decrease nutritional requirements or may limit the individual's ability to obtain adequate nutrition,

The assessment of the nutritional status is the step previous to dietarynutritional treatment [4]. It is a global evaluation that includes the nutritional status of the individual as well as the severity of the underlying disease, due to the relationship between them. It establishes a methodology to obtain information about the current and past situation of the elderly person in relation to their diet, body composition, and functional and health status [5, 6]. In addition, it will help in the detection of nutritional risk or malnutrition. Two steps can be established in this assessment process: a first step of screening the nutritional risk or malnutrition, and a second step of complete nutritional assessment to identify the causes and consequences of malnutrition. The second step would be carried out when a

As there is no single marker or nutritional tool that is useful for all types of individuals or physiological or pathological situations and is easily reproducible, predictable, and reliable, correct nutritional assessment involves the use of different nutritional parameters in order to perform an evaluation of the nutritional status that is as complete as possible, according to the subject with which we are dealing; in this case, the geriatric population. In addition, the social and cultural aspects of the patient must also be taken into account, because these data provide information on their resources and ability to prepare food, as well as sociocultural, religious, or personal nutritional habits that may affect the intake and nutritional status. Among the different factors or parameters related to malnutrition that can be assessed in the elderly, we find health status, social and clinical conditions, anthropometry, dietary habits and dietary intake, lifestyle, blood biochemistry, etc. [5, 6]. These factors or parameters and their relationship with malnutrition are described below.

Perceived health status is one of the most consolidated indicators and is easy to enquire about in health surveys. It is a feasible tool and has been studied in recent years because it is useful as a global indicator of the level of population health. Some of the factors that lead to a poor self-perception of the state of health in the elderly are age, female sex, comorbidity, not receiving treatments, and little accessibility to

Many aspects of the individual's life are covered here. Some of the causes that can lead to an inadequate consumption of food and, therefore, to malnutrition, are isolation, the loss of loved ones in charge of organizing meals, difficulties in buying or cooking, poor pensions, or changes in feeding when moving to a geriatric residence. It is important to know where the individual lives and with whom, the main career's situation, characteristics of the home, the level of income, their leisure

This is why the evaluation of the nutritional risk in this type of population is of

**144**

This is data from the clinical evaluation performed by a medical professional. It will be necessary to know if the individual suffers or has suffered from any disease, as well as the drugs he or she has taken or is taking for said disease(s). Regarding the intake of drugs, it is important to gather information about the dosage and interactions between food and drugs [5].

#### **2.4 Anthropometry**

Anthropometric measurements provide information about the morphological dimensions of individuals. It is a non-invasive, low cost, and portable method, when compared to techniques requiring more complex devices. The anthropometric parameters include weight, height, skin folds, diameters, lengths, and girth. Some of these have been related to malnutrition: specifically, weight loss in a short period of time (1–6 months) with respect to usual weight, low percentile of the triceps skin fold, and decrease in body mass index (BMI) [6, 9].

#### **2.5 Dietary intake and eating attitudes**

Food intake is a process that varies according to the day of the week, month, or season of the year. Other factors that influence food intake are food preferences and aversions, the person preparing the meals, feeling full (before and during meals), and the ease or difficulty of food intake and/or food preparation, among others. Information concerning these factors is relevant to evaluate food intake [6].

To determine the intake of food and liquids, methods that give similar results if they are repeated in the same situation are required; that is, instruments that offer better reproducibility or precision (agreement of results when the same dietary evaluation method is administered more than once, and on different occasions, to the same individual or group). Currently, there are prospective or retrospective methods, such as the dietary diary, 24-hour recall, and food consumption frequency questionnaire (CFCA), among others. The use of two or more methods can give a better and more accurate estimate of the habitual diet of the individual who has been interviewed, since the disadvantages of one method are offset by the advantages of the other. In addition, it is necessary to use a food composition database to obtain information on energy and nutritional intake (macro and micronutrients), thereby allowing comparison with the recommendations for the intake of energy, carbohydrates, proteins, lipids, and micronutrients [5, 6, 10].

#### **2.6 Blood biochemistry**

Some of the blood biochemical parameters are biomarkers related to nutritional status. In spite of the fact that most nutritional risk screenings aimed at the elderly population do not contemplate biochemical parameters, they are included in the screening of hospitalized patients. Decreases in the values of some of these biochemical parameters (albumin, lymphocytes, cholesterol, etc.) are important in the detection and assessment of protein malnutrition [6, 9–11]. These parameters are described below:

• Albumin: this protein is easily determined due to its long half-life (20 days), but has limitations as a nutritional marker. Changes in blood volume, different pathological situations, or any degree of aggression can produce a decrease in its plasma values, although its decrease is related to an increase in the occurrence of complications and mortality [6, 10].


#### **3. Nutritional screening tools available for elderly people**

A wide range of nutritional screening tools have been developed. The screening tools used most commonly, have been developed in several countries specifically for elderly people, are Australian Nutrition Screening Initiative (ANSI) [12], Ayrshire Nutrition Screening Tool (ANST) [13], Canadian Nutrition Screening Tool (CNST) [14], Chinese Nutrition Screen (CNS) [15], Council of Nutrition Appetite Questionnaire (CNAQ ) [16], Simplified Nutritional Appetite Questionnaire (SNAQ ) [16], Short Nutritional Assessment Questionnaire (SNAQ ) [17], Short Nutritional Assessment Questionnaire for the Residential Care (SNAQ RC) [18], Malaysian Tool (MT) [19], Malnutrition Risk Screening Tool-Hospital (MRSTH) [20], Mini Nutritional Assessment (MNA) [21], Mini Nutritional Assessment Short Form (MNA-SF) [22], Minimal Eating Observation and Nutrition Form Version II (MEONF-II) [23], Nursing Nutrition Screening Assessment (NNSA) [24], Nursing Nutritional Assessment (NNA) [25], Nutrition Screening Initiative (NSI "DETERMINE") [26], Nutritional Form for the Elderly (NUFFE) [27], Nutritional Risk Assessment Tool (NRAT) [28], Seniors in the Community Version I (SCREEN I) [29], Seniors in the Community Version II (SCREEN II) [30], South African Screening Tool (SAST) [31], The Burton Score (TBS) [32] and Geriatric Nutrition Risk Index (GNRI-NRI) [33] (**Table 1**). All of them contain several domains, and the parameters included most frequently are those concerning anthropometry, dietary intake, and clinical condition. Among the anthropometric parameters, the most used value is weight change, being the only anthropometric item reported in some of the protocols. Dietary intake comprises information about the quantity and the quality of the food consumed by the patient and, in particular, regarding their appetite and frequency of meals. Some of the instruments also include an item about fluid intake, which is an important aspect to be considered in elderly people. Aspects related to diseases and functional status are the items included most frequently in the clinical condition domain.

Concerning the clinical setting used to develop and/or validate the instrument, the three main contexts found are community, hospital, and long-term care

**147**

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

Mild: 85–95% Moderate: 75–84% Severe: <75%

kg/m2

5–10

Mild: 17–18.4 kg/m2 Moderate: 16–16.9

Severe: <16 kg/m2

Mild: percentile 10–15

Moderate: percentile

Severe: percentile <5

% Habitual weight loss = (actual weight (kg)/habitual weight (kg))

BMI = weight (kg)/height (m2

Review percentiles of the population

)

× 100

of origin

**Parameter Definition Range Equation**

facilities (including nursing homes and residential facilities). Among these settings, the self-administration form is used only in the community or in long-term care facilities. However, in hospitals the administration form used most frequently is filled in by qualified health personnel. The number of items comprising the presented tools ranges from 2 (CNST) to 18 (MNA). Taking into account that the respondents are elderly people, the interviews performed by health professionals seem to be the best option, as well as tools with a low number of items, to minimize

In order to have the appropriate arguments for using one or other of the screening methods, the main psychometric parameters that should be considered are the sensitivity and specificity of the test. Among the selected tools the sensitivities ranged from 0.32 for the ANSI [34] to 99% for the MNA [22] and the specificities of the tools ranged from 0.38% for the SCREEN I [29] to 0.96% for the MRSTH [20]. Only for five of these instruments Receiver Operating Characteristic (ROC) curves, as a combined measure of sensitivity and specificity, has been informed [16, 17, 22, 29, 30]. The tool which has shown the best values for both, sensitivity and specificity is MNA and its short form (MNA-SF) and, consequently are the nutritional

**4. Characteristics of nutritional screening: advantages and limitations**

All the screening tools described here were designed specifically for elderly people; however, there is a set of screenings developed for other populations, mainly adults, which could be used also for aged people. This supposes an advantage if different populations need to be compared. Nevertheless, these instruments could

Among the different forms of data collection, face to face interview has been demonstrated to be the most suitable form for this age group. A low number of items are also recommended in order to reduce the burden of the respondent [35]. The domains included in each tool can influence the validity of the evaluations. The use of parameters that examine aspects related to the patient's perception could be less appropriate for elderly patients. The frequent sensorial and cognitive problems of these patients make the collection of accurate data more difficult [36].

lose content validity in comparison with specific aged-population tools.

*DOI: http://dx.doi.org/10.5772/intechopen.79977*

Weight variation with respect to the usual weight

Relationship between weight and

Vertical skinfold in the middle back of

height

the arm

*Anthropometric parameters related to malnutrition.*

% Habitual weight loss

Body mass index (BMI)

Triceps skinfold

**Table 1.**

the burden of the interviewee.

screening tests most commonly used (**Table 2**).


*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

#### **Table 1.**

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

function, it is considered of little clinical use [9].

**3. Nutritional screening tools available for elderly people**

A wide range of nutritional screening tools have been developed.

Nutrition Screening Tool (CNST) [14], Chinese Nutrition Screen (CNS) [15], Council of Nutrition Appetite Questionnaire (CNAQ ) [16], Simplified Nutritional Appetite Questionnaire (SNAQ ) [16], Short Nutritional Assessment Questionnaire (SNAQ ) [17], Short Nutritional Assessment Questionnaire for the Residential Care (SNAQ RC) [18], Malaysian Tool (MT) [19], Malnutrition Risk Screening Tool-Hospital (MRSTH) [20], Mini Nutritional Assessment (MNA) [21], Mini Nutritional Assessment Short Form (MNA-SF) [22], Minimal Eating Observation and Nutrition Form Version II (MEONF-II) [23], Nursing Nutrition Screening Assessment (NNSA) [24], Nursing Nutritional Assessment (NNA) [25], Nutrition Screening Initiative (NSI "DETERMINE") [26], Nutritional Form for the Elderly (NUFFE) [27], Nutritional Risk Assessment Tool (NRAT) [28], Seniors in the Community Version I (SCREEN I) [29], Seniors in the Community Version II (SCREEN II) [30], South African Screening Tool (SAST) [31], The Burton Score (TBS) [32] and Geriatric Nutrition Risk Index (GNRI-NRI) [33] (**Table 1**). All of them contain several domains, and the parameters included most frequently are those concerning anthropometry, dietary intake, and clinical condition. Among the anthropometric parameters, the most used value is weight change, being the only anthropometric item reported in some of the protocols. Dietary intake comprises information about the quantity and the quality of the food consumed by the patient and, in particular, regarding their appetite and frequency of meals. Some of the instruments also include an item about fluid intake, which is an important aspect to be considered in elderly people. Aspects related to diseases and functional status are the items included most frequently in

The screening tools used most commonly, have been developed in several countries specifically for elderly people, are Australian Nutrition Screening Initiative (ANSI) [12], Ayrshire Nutrition Screening Tool (ANST) [13], Canadian

Concerning the clinical setting used to develop and/or validate the instrument, the three main contexts found are community, hospital, and long-term care

result of malnutrition [10, 11].

trition [10, 11].

• Prealbumin: this is a protein with a half-life of 2 days that decreases in some situations of malnutrition, infection, or liver failure and increases upon renal failure. It should be interpreted with caution if used as a nutritional marker; despite this, it is considered a good indicator for assessing acute nutritional changes [9].

• Protein binding retinol: this is a protein with a half-life of 10 hours, whose levels increase with vitamin A intake or renal failure, and are decreased by liver disease, infection, or severe stress. Due to its sensitivity to stress and renal

• Lymphocytes: these are related to immunity and nutritional status. Total lymphocytes are related to protein depletion and loss of immune defenses as a

• Total cholesterol: in malnourished patients with renal and kidney failure and malabsorption syndrome, low cholesterol levels are associated with an increase in mortality. A decrease in their values to below 150 mg/dl is related to malnu-

**146**

the clinical condition domain.

*Anthropometric parameters related to malnutrition.*

facilities (including nursing homes and residential facilities). Among these settings, the self-administration form is used only in the community or in long-term care facilities. However, in hospitals the administration form used most frequently is filled in by qualified health personnel. The number of items comprising the presented tools ranges from 2 (CNST) to 18 (MNA). Taking into account that the respondents are elderly people, the interviews performed by health professionals seem to be the best option, as well as tools with a low number of items, to minimize the burden of the interviewee.

In order to have the appropriate arguments for using one or other of the screening methods, the main psychometric parameters that should be considered are the sensitivity and specificity of the test. Among the selected tools the sensitivities ranged from 0.32 for the ANSI [34] to 99% for the MNA [22] and the specificities of the tools ranged from 0.38% for the SCREEN I [29] to 0.96% for the MRSTH [20]. Only for five of these instruments Receiver Operating Characteristic (ROC) curves, as a combined measure of sensitivity and specificity, has been informed [16, 17, 22, 29, 30]. The tool which has shown the best values for both, sensitivity and specificity is MNA and its short form (MNA-SF) and, consequently are the nutritional screening tests most commonly used (**Table 2**).

#### **4. Characteristics of nutritional screening: advantages and limitations**

All the screening tools described here were designed specifically for elderly people; however, there is a set of screenings developed for other populations, mainly adults, which could be used also for aged people. This supposes an advantage if different populations need to be compared. Nevertheless, these instruments could lose content validity in comparison with specific aged-population tools.

Among the different forms of data collection, face to face interview has been demonstrated to be the most suitable form for this age group. A low number of items are also recommended in order to reduce the burden of the respondent [35]. The domains included in each tool can influence the validity of the evaluations. The use of parameters that examine aspects related to the patient's perception could be less appropriate for elderly patients. The frequent sensorial and cognitive problems of these patients make the collection of accurate data more difficult [36].


**149**

**Nutrition screening tool**

CNS [15]

**Parameters** Anthropometry

Social condition

Clinical condition

Weight change

Loneliness

Functional status

Disease

Drugs

Skin status

Appetite

Food intake

Frequency of meals

Fluid intake

Emotional status

Self-assessment

Dietary intake Emotional status

Eating attitudes

SNAQ [16]

Dietary intake Eating attitudes

SNAQ [17]

Anthropometry

Dietary intake

Sadness

Food tastes

Feel full, hungry or nauseated

Frequency of meals

4

Longterm care

Self-administered

Range: 4–20

≤14: significant risk of at least

5% weight loss within 6 months

facilities

Community

Appetite

Food tastes

Feeling of fullness

Weight change

Appetite

Supplemental drinks or tube

feeding

3

Hospital

Nursing staff

Range: 0–5

≥2: moderate malnourishment

≥3: severe

malnourishment

Dietitians

Frequency of meals

8

Longterm care

Self-administered

Range: 8–40

≤28: significant risk of at least

5% weight loss within 6 months

facilities

Community

Appetite

CNAQ [16]

Happiness

Health status

Dietary intake

**Specific**

**No. of items**

16

**Setting** Hospital Long-term care facilities

Professional not indicated

**Administration**

**Nutritional score**

Range: 0–32

≤16: malnourished

17–19: risk

>19: normal

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

*DOI: http://dx.doi.org/10.5772/intechopen.79977*


#### *Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

**148**

**Nutrition screening tool**

ANSI [12]

**Parameters** Anthropometry

Social condition

Clinical condition

Functional status

Disease

Oral problems

Drugs

Frequency of meals and food intake

Fluid intake

Alcohol intake

Weight change

6

Hospital

Nursing staff

Range: 0–18

6 or less: moderate risk

7 or more: high risk

Dietary intake

Life style Anthropometry

Clinical condition

Dietary intake

Disease

Frequency of meals

Fluid intake

Appetite

Weight change Food frequency intake

2

Hospital

Dietitians

Range: 0–2

0–1: no risk

2: nutrition risk

CNST [14]

Anthropometry

Dietary intake

ANST [13]

Weight change

Loneliness

Food access

**Specific**

**No. of items**

12

**Setting** Community

Self-administered

Range: 0–29

0–3: good

4–5: moderate nutritional risk

6 or more: high nutritional risk

Administered by family

members or caregivers

**Administration**

**Nutritional score**


**151**

**Nutrition screening tool**

MNA [21]

**Parameters** Anthropometry

Weight change

BMI Arm circumference

Calf circumference

Clinical condition

Dietary intake

Functional status

Disease

Frequency of meals and food intake

Fluid intake

Appetite

Self-assessment

MNA-SF [22]

Anthropometry

Clinical condition

Dietary intake Anthropometry

Clinical condition

Weight change

6

Hospital

Nursing staff

Range: 0–8

0–2: low risk of undernutrition

3–4: moderate risk of

undernutrition

≥5: high risk of undernutrition

BMI (or calf circumference)

Functional status

Oral problems

Clinical signs

Dietary intake Anthropometry

Clinical condition

Dietary intake

Weight change Functional status

Disease

Frequency of meals and food intake

5

Hospital

Nursing staff

Range: 0–100

<65: high risk

65–79: moderate risk

80–100: minimal risk

Dietitians

NNSA [24]

Appetite

MEONF-II [23]

Appetite

Functional status

Disease

Weight change

6

Longterm care

Health care

Range: 0–14

≥12: normal-no need for further

assessment

≤11: possible malnutritioncontinue assessment

professionals

facilities

Community

Hospital

BMI

Nutritional problems

Health status

Hospital

**Specific**

**No. of items**

18

**Setting** Long- term care facilities Community

Health care professionals

**Administration**

**Nutritional score**

Range: 0–30

≥24: well nourished

17–23: at risk of malnutrition

<17: malnourished

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

*DOI: http://dx.doi.org/10.5772/intechopen.79977*


#### *Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

**150**

**Nutrition screening tool**

SNAQRC [18]

**Parameters** Anthropometry

Clinical condition

Dietary intake

> MT [19]

Anthropometry

Social condition

Clinical condition

Weight change

Food access

Functional status

Disease

Oral problems

Frequency of meals and food intake

Appetite

Smoking

Weight change

5

Hospital

Health care

Range: 0–8

≥5: high risk of malnutrition

professionals

Arm circumference

Calf circumference

Social condition

Clinical condition

Functional status

Food access

Dietary intake

Life style Anthropometry

MRSTH [20]

11

Rural

Interviewer

Two sections:

A (range: 0–7): undernutrition:

≥4 high risk of undernutrition

B (range: 0–5): dietary

inadequacy: ≥2 high risk of

consuming an inadequate diet

community

(professional not

indicated)

Appetite

Functional status

Weight change

BMI

**Specific**

**No. of items**

3 + 1 (BMI)

Longterm care

facilities

members or

care workers

Trained care works

for anthropometric

measures

**Setting**

**Administration**

Self-administered

Administered by family

**Nutritional score**

Traffic light system

Red score: high risk of

undernourishment

Orange score: moderate risk of

undernourishment

Green score: no risk


**153**

**Nutrition screening tool**

NRAT [28]

**Parameters** Anthropometry

Clinical condition

Dietary intake Eating attitudes

Self-assessment

SCREEN I [29]

Anthropometry

Social condition

Clinical condition

Dietary intake

Weight change

Food access

Loneliness

Functional status

Oral problems

Frequency of meals and food intake

Fluid intake

Appetite

Supplemental drinks

Dietary intake changes

Weight change

Food access

Loneliness

Functional status

Oral problems

Frequency of meals and food intake

Fluid intake

Appetite

Supplemental drinks

Dietary intake changes

Quality of meals

17

Community

Self-administered

Range: 0–64

Cut-offs not specified

Dietitians

SCREEN II [30]

Anthropometry

Social condition

Clinical condition

Dietary intake

15

Community

Self-administered

Not specified

Interviewer

(professional not

indicated)

Weight change Functional status

Oral problems

Frequency of meals

Appetite

Feeling of fullness

Health status

Thinness

**Specific**

**No. of items**

9

**Setting** Community

Nursing staff

Range: 0–26 0–6: little or no risk

7–16: probable risk

≥17: malnourished

Dietitians

**Administration**

**Nutritional score**

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

*DOI: http://dx.doi.org/10.5772/intechopen.79977*


*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

**152**

**Nutrition screening tool**

NNA [25]

**Parameters** Anthropometry

Clinical condition

Dietary intake

NSI "DETERMINE" [26]

Anthropometry

Social condition

Clinical condition

Appetite

Frequency of meals

Weight change

Loneliness

Food access

Functional status

Disease

Oral problems

Drugs

Frequency of meals and food intake

Alcohol intake

Weight change

Loneliness

Food access

Functional status

Disease

Oral problems

Drugs

Frequency of meals and food intake

Appetite

Dietary intake changes

Portion size

Health status

Self-assessment

Dietary intake

15

Long-term

Nursing staff

Range: 0–30

Norwegian version cut-offs:

<6: low risk

6–10: medium risk

≥11: high risk

care facilities

Dietary intake

Life style Anthropometry

Social condition

Clinical condition

NUFFE [27]

10

Community

Self-administered

Range: 0–21

0–2: good

3–5: moderate nutritional risk

6 or more: high nutritional risk

Administered by

family members or

caregivers

**Specific** Weight change Functional status

Disease

**No. of items**

> 9

**Setting**

Hospital

Nursing staff

Dietitians

**Administration**

**Nutritional score**

Range: 9–36

<18: low risk

19–27: moderate risk

28–36: high risk


*Summary of nutritional screening tools.*

**155**

Spain

**Author details**

provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. 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,

Isabel Sospedra, Aurora Norte, José Miguel Martínez-Sanz\*, Enrique de Gomar,

Nursing Department, Faculty of Health Sciences, University of Alicante, Alicante,

José Antonio Hurtado Sánchez and María José Cabañero-Martínez

\*Address all correspondence to: josemiguel.ms@ua.es

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice*

has been compared to standard criteria used to evaluate nutritional status.

The inclusion of objective parameters, such as anthropometric measurements or clinical data, helps to avoid this disadvantage. However, the collection of such data, especially for parameters derived from biochemical analyses, involves a high cost

The absence of a Gold Standard criterion to validate this kind of instrument supposes a disadvantage. This is a reason for the ongoing development of new, appropriate parameters. Although most of these tools are widely used, none of them

There is no single nutritional marker that can predict or diagnose malnutrition; rather, the state of health, social and clinical conditions, anthropometry, eating habits, and blood chemistry of the elderly person under consideration—in relation to their specific situation (health, illness, hospitalization, or institutionalization) must be taken into account. Therefore, the tools described here that include various

*DOI: http://dx.doi.org/10.5772/intechopen.79977*

and cannot be achieved in all settings.

dimensions are currently the most recommended.

**5. Conclusions**

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

*Undernutrition Risk Assessment in Elderly People: Available Tools in Clinical Practice DOI: http://dx.doi.org/10.5772/intechopen.79977*

The inclusion of objective parameters, such as anthropometric measurements or clinical data, helps to avoid this disadvantage. However, the collection of such data, especially for parameters derived from biochemical analyses, involves a high cost and cannot be achieved in all settings.

The absence of a Gold Standard criterion to validate this kind of instrument supposes a disadvantage. This is a reason for the ongoing development of new, appropriate parameters. Although most of these tools are widely used, none of them has been compared to standard criteria used to evaluate nutritional status.

#### **5. Conclusions**

*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

**154**

**Nutrition screening tool**

SAST [31]

**Parameters** Anthropometry

Social condition

Clinical condition

Dietary intake Self-assessment

TBS [32]

Anthropometry

Social condition

Clinical condition

Functional status

Symptoms

Skin risk areas

Dietary intake Anthropometry

Social condition

Biochemistry

**Table 2.**

*Summary of nutritional screening tools.*

Age

Albumin

Knee height

No items

Hospital

Professional not

Grades of nutrition-related risk:

<82: major risk

82 to <92: moderate risk

92 to ≤98: low risk

>98: no risk

indicated

Usual weight

GNRI-NRI [33]

Appetite

Age

Sex

Weight change

7

Hospital

Nursing staff

Range: 6–28

0–5: well nourished

6–10: moderately nourished

11–15: poorly nourished

≥16: very poorly nourished

Dietitians

BMI

Health status

Frequency of meals and food intake

Disease

**Specific** Arm circumference

Functional status

**No. of items**

10

**Setting** Community

Longterm care

facilities

**Administration**

Trained fieldworkers

Range: 0–23

**Men**

<9.5: malnourished

9.5–14.5: risk of malnutrition

>14.5: well nourished

**Women**

<9.5: malnourished

9.5–16: risk of malnutrition

>16: well nourished

**Nutritional score**

There is no single nutritional marker that can predict or diagnose malnutrition; rather, the state of health, social and clinical conditions, anthropometry, eating habits, and blood chemistry of the elderly person under consideration—in relation to their specific situation (health, illness, hospitalization, or institutionalization) must be taken into account. Therefore, the tools described here that include various dimensions are currently the most recommended.

#### **Author details**

Isabel Sospedra, Aurora Norte, José Miguel Martínez-Sanz\*, Enrique de Gomar, José Antonio Hurtado Sánchez and María José Cabañero-Martínez Nursing Department, Faculty of Health Sciences, University of Alicante, Alicante, Spain

\*Address all correspondence to: josemiguel.ms@ua.es

© 2018 The Author(s). Licensee IntechOpen. 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.

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screening tool for malnutrition: The short nutritional assessment questionnaire (SNAQ ). Clinical Nutrition (Edinburgh, Scotland). 2005;**24**(1):75-82

[18] Kruizenga HM, de Vet HCW, Van Marissing CME, Stassen EEPM, Strijk JE, van Bokhorst-de Van der Schueren MAE, et al. The SNAQ(RC), an easy traffic light system as a first step in the recognition of undernutrition in residential care. The Journal of Nutrition, Health & Aging. 2010;**14**(2):83-89

[19] Shahar S, Dixon RA, Earland J. Development of a screening tool for detecting undernutrition and dietary inadequacy among rural elderly in Malaysia: Simple indices to identify individuals at high risk. International Journal of Food Sciences and Nutrition. 1999;**50**(6):435-444

[20] Sakinah H, Suzana S, Noor Aini MY, Philip Poi JH, Shahrul Bahyah K. Development of a local malnutrition risk screening tool-hospital (MRST-H) for hospitalised elderly patients. Malaysian Journal of Nutrition. 2012;**18**(2):137-147

[21] Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The mini nutritional assessment as part of the geriatric evaluation. Nutrition Reviews. 1996;**54**(1 Pt 2): S59-S65

[22] Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: Developing the short-form mininutritional assessment (MNA-SF). The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2001;**56**(6):M366-M372

[23] Westergren A, Norberg E, Vallén C, Hagell P. Cut-off scores for the minimal eating observation and nutrition form— Version II (MEONF-II) among hospital

inpatients. Food & Nutrition Research. 2011;**55**:7289

[24] Pattison R, Corr J, Ogilvie M, Farquhar D, Sutherland D, Davidson HIM, et al. Reliability of a qualitative screening tool versus physical measurements in identifying undernutrition in an elderly population. Journal of Human Nutrition and Dietetics. 1999;**12**(2):133-140

[25] McCall R, Cotton E. The validation of a nursing nutritional assessment tool for use on acute elderly wards. Journal of Human Nutrition and Dietetics. 2001;**14**(2):137-148

[26] Posner BM, Jette AM, Smith KW, Miller DR. Nutrition and health risks in the elderly: The nutrition screening initiative. American Journal of Public Health. 1993;**83**(7):972-978

[27] Söderhamn U, Söderhamn O. Developing and testing the nutritional form for the elderly. International Journal of Nursing Practice. 2001;**7**(5):336-341

[28] Ward C, Little B, Perkins C, et al. Development of a screening tool for assessing risk of undernutrition in patients in the community. Journal of Human Nutrition and Dietetics. 1998;**11**(4):323-330

[29] Keller HH. The SCREEN I (seniors in the community: Risk evaluation for eating and nutrition) index adequately represents nutritional risk. Journal of Clinical Epidemiology. 2006;**59**(8):836-841

[30] Keller HH, Goy R, Kane S-L. Validity and reliability of SCREEN II (seniors in the community: Risk evaluation for eating and nutrition, Version II). European Journal of Clinical Nutrition. 2005;**59**(10):1149-1157

[31] Charlton KE, Kolbe-Alexander TL, Nel JH. Development of a novel

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*Nutrition in Health and Disease - Our Challenges Now and Forthcoming Time*

[10] Ravasco P, Anderson H, Mardones F. Métodos de valoración del estado nutricional. Nutrición Hospitalaria.

[11] Ignacio de Ulíbarri J, González-Madroño A, de Villar N, González P, González B, Mancha A, et al. CONUT: Una herramienta para controlar el estado nutritivo. Primera validación en una población hospitalaria. Nutrición Hospitalaria. 2005;**20**(1):38-45

[12] Lipski PS. Australian nutrition screening initiative. Australasian Journal on Ageing. 1996;**15**(1):14-17

[13] Mackintosh MA, Hankey CR. Reliability of a nutrition screening tool for use in elderly day hospitals. Journal of Human Nutrition and Dietetics.

[14] Laporte M, Keller HH, Payette H, Allard JP, Duerksen DR, Bernier P, et al. Validity and reliability of the new Canadian Nutrition Screening Tool in the "real-world" hospital setting. European Journal of Clinical Nutrition.

[15] Woo J, Chumlea WC, Sun SS, Kwok T, Lui HH, Hui E, et al. Development of the Chinese nutrition screen (CNS) for use in institutional settings. The Journal of Nutrition, Health & Aging.

[16] Wilson M-MG, Thomas DR, Rubenstein LZ, Chibnall JT, Anderson S, Baxi A, et al. Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. The American Journal of Clinical Nutrition.

[17] Kruizenga HM, Seidell JC, de Vet HCW, Wierdsma NJ, van Bokhorst-de Van der Schueren MAE. Development

2001;**14**(2):129-136

2015;**69**(5):558-564

2005;**9**(4):203-210

2005;**82**(5):1074-1081

and validation of a hospital

2010;**25**:57-66

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[3] Rathnayake KM, Wimalathunga M, Weech M, Jackson KG, Lovegrove JA. High prevalence of undernutrition and low dietary diversity in institutionalised elderly living in Sri Lanka. Public Health Nutrition.

[2] Brownie S. Why are elderly individuals at risk of nutritional deficiency? International Journal of Nursing Practice.

2010;**5**:207-216

**References**

2006;**12**(2):110-118

2015;**18**(15):2874-2880

[4] García de Lorenzo A, Álvarez Hernández J, Planas M, Burgos R, Araujo K. Consenso multidisciplinar sobre el abordaje de la desnutrición hospitalaria en España. Nutrición Hospitalaria. 2011;**26**(4):701-710

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[6] Salas-Salvadó J. Nutrición y dietética clínica. España: Elsevier; 2008. 702 p

[7] Álvarez J, Río JD, Planas M, García Peris P, García de Lorenzo A, Calvo V, et al. Documento SENPE-SEDOM sobre la codificación de la desnutrición hospitalaria. Nutrición Hospitalaria.

2008;**23**(6):536-540

2015;**17**(2):171-183

[8] Vergara DMC, Arango DC. Percepción del estado de salud y factores asociados en adultos mayores. Revista de Salud Pública.

Editores Médicos; 2004. 364 p

[9] Gómez Candela C, Reuss Fernández JM. Manual de recomendaciones nutricionales en pacientes geriátricos.

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**159**

Section 5

Modification of Different

Foods

### Section 5
