Assessment Methods of Nutritional Status - Essay Example

1 ASSESSMENT METHODS OF NUTRITIONAL STATUS. COMPARISON AND CONTRAST OF THE LITERATURE ABOUT NUTRITIONAL ASSESSMENT TOOLS AND CRITICAL EVALUATION OF THE CLINIMETRICS OF EACH. Practically every country in the world today has provided healthcare support for its constituents and has worked out for means to alleviate and even resolve the problem of malnutrition. Each candidate for any public post, whether local or national, almost always include in his political agenda an efficacious healthcare plan. The reason for this is because healthcare and proper nutrition is a primary interest in practically every citizen in the country. In USA alone, the legislature has provided with a huge budget for healthcare outlay to ensure health protection and insurance for each citizen. In 1965, the US Congress passed the Social Security Amendment which established Medicare, which provides for a basic program of hospital insurance together with a medical insurance program. This national health insurance progr4am is intended for citizens aged 65 and over and also for citizens with some form of disabilities under age 65. Today, the Centers for Medicare and Medicaid Services is appointed with the task of administering Medicare (Pulec 2003, p.7-8). The federal government of USA shoulders the funding for this health care program which it generates from social security contributions, general government revenues and monthly premiums paid by enrolled members (Pratt & Hornbeck, 2002). Such is the importance of providing health care programs especially for the elderly that huge expenditures and huge health care costs are expended annually by each nation. Thus, there are programs to resolve undernutrition and malnutrition especially among the elderly because its 2 effects can cause increase in such health care costs and thus a heavy burden not only on the state but the citizens who pay annual contributions to health care programs. In African countries, particularly South Africa, they have expressed a “need for an effective but simple nutrition screening tool that can be used by all levels of health care workers, particularly at community clinics” (Charlton et al 2005). This need is echoed in practically all the four corners of the world: in USA, Europe, Latin America and Asia. Malnutrition is defined as a “condition resulting from a decreased intake of protein and energy, calories, vitamins, and minerals” (Stechmiller 2003, p.170). Malnutrition is also a condition with an imbalance between intake and needs of specific nutrients (Elmstahl et al 1997, p.854). The same author thus considers as malnourished or suffering from undernutrition, those older citizens who do not consume the recommended 30 kcal/kg/day for energy needs. As such, this elderly citizen is considered “in a high risk for nutrient deficiency” (Stechmiller 2003, P. 171). He is then subject to a possible or a likely attack of “cardiac and respiratory problems, infections, deep vein thrombosis and pressure ulcers, perioperative mortality and multi-organ failure” (Omran & Morley 2000, p.50-63). These malnourished citizens would naturally then be pressured to undergo rehabilitation at hospitals, in accordance with the Medicare program and are expected to suffer complications. The sum effect is more healthcare costs to be shouldered by the state as well as the enrolled citizens. Thus, there is a pressing need to find an effective nutritional assessment tools “because Of its profound therapeutic, prognostic, and health maintenance implications” (Stechmiller 2003, p.171). So many literatures tackle nutritional assessment tools and each one varies in the assessment tools utilized but the common denominator for all of them is to find a way to prolong 3 the lives if not save the lives of elderly patients who have suffered from debilitating malnutrition or undernutrition. An ‘assessment tool” is defined as “any device to assess or provide insight into the client’s or patient’s nutritional background or needs. It is also the information gathered or recorded for this purpose” (Simko et al 1995, p.55). The objectives of nutritional assessment tools are to accurately define the nutritional condition of patients, to utilize these assessment tools in order to monitor the effectiveness of nutritional support by noting the changes in the nutritional condition of the patients; and to identify malnutrition and undernutrition as well as identify those individuals requiring this support (Gibney et al 2005, p. 27). The problem facing the hospital staff is the prevalence of hospital malnutrition and the difficulty of so many hospitals to find the ideal assessment tool that would quickly diagnose the nutritional status of elderly patients and with the least cost and the facility of performance even by ordinary caregivers. This is a crucial stage because failure to assess the nutritional status of patients at the earliest stage may result to possible complications, which in turn leads to longer hospital stay, higher expenses and a possible death of the patient. Because of failure to identify the right assessment tool, the patients are not routinely assessed and screened for nutritional status, the same way that blood pressure or heart rate are measured routinely after the patient is admitted to the hospital (Waitzberg & Correa 2003, p.531). Searching for the ideal tool, dubbed as gold standard of nutritional assessment, is a difficult task but author Michael Gibney has drawn out the ideal tool for nutritional status as that which “must be sensitive and specific enough to be unaffected by factors that are not related to 4 nutrition and must respond to nutritional repletion (Gibney 2005, p.27). Other criteria are reliability and validity (Green & Watson 2006, p. 476). Furthermore the chosen tool must provide baseline data about the nutritional status of the patient, which data are then referred to every time follow-up assessments are made. This is important in order to monitor the nutritional progress of the patient and in order to “make decisions about the appropriate nutrition interventions and levels of care” of the patient ( Simko et al 1995, p.58). It should also be noted that these tools make use of a “questionnaire-type format containing more than one risk factor or malnutrition, and give a quantitative or categorical assessment of risk (Green & Watson 2006, p.477). The questions in the questionnaire tackle known risk factors for malnutrition and the resulting scores are used to decide which is the most appropriate course of action to take. It is usually the dietician who carries out the comprehensive assessment and plan of care but when a drug-nutrient interaction must be used, a pharmacist is called in to assess while it is the nurse who should be able to identify elderly patients suffering from or at risk of malnutrition. These elderly patients have been identified as ranging from 65 years of age to over 100 years of age. Whatever assessment tool is chosen, it must have acceptability, that is simplicity of use by hospital staff and it must be tolerable to the patients. Moreover, it must “meet criteria for reliability, validity, sensitivity and specificity before widespread administration can be recommended” (McLaren & Green 1998). The Assessment Methods of Nutritional Status So many literature tackle the different methods of nutritional status available for the use of hospital staff, particularly nurses. Green and Watson (2006) were able to locate 71 of these, of which only 21 are germane to the use for the care of elderly patients. Jones (2002) was able 5 to identify and review 44 of these but had discovered that only 39% of these passed the standards of reliability and validity. Lee and Nieman (2006) asserted that only 4 of these are acceptable, valid and reliable with high sensitivity and specificity i.e. dietary, anthropometric, biometric and clinical. Escott-Stump (2007) considered only 4 of these as important and classified anthropometric as under MNA (mini nutrition assessment). These are NSI (nutrition screening initiative); MNA (mini nutrition assessment); SGA (subjective global assessment); and malnutrition in older people. Simko et al (1995) mentioned only 4 as worthwhile to consider. That is, data collection instruments; objective data (which included anthropometric); subjective data and SGA (subjective global assessment). Kulnik and Elmadfa (2008) were even more discriminating by giving importance to only 2 tools i.e. MNA (mini nutritional assessment) and NuRAS or nutritional risk assessment scale. Charlton et al (2005) mentioned 3 i.e. MNA, biochemical indicators and DETERMINE. Thorsdottir et al (2005) favored FNA (full nutritional assessment) as the ideal tool over MNA and SSM (screening sheet for malnutrition). Jones (2002) was able to identify 44 tools but claimed that only 11 original tools and 3 modifications can be used because the rest contain insufficient and inadequate information for proper usage. Waitzberg and Correa (2003) were able to identify 9 tools that passed the standards of sensitivity and specificity, acceptability, reliability, validity and reproducibility and these are MNA (mini nutritional assessment); anthropometrics (which was uprooted from MNA); biochemical markers; body composition tests; immune response tests; nutritional indices; functional tests; calorimetry; SGA (subjective global assessment). Marin et al (2002) added to the long list immunological indicators. These made use of lymphocyte count. Others that they mentioned were anthropometric and biochemical (serum albumin, transferring and zinc). 6 Soderhamn et al (2002) added a new assessment tool for the elderly i.e. NUFFE (nutritional form for the elderly). The other one it tackled is MNA. Mackintosh and Hankey (2001) also displayed a new screening and assessment tool which they named as NST (nutrition screening tool). Yamada et al (2008) added 2 more nutritional assessment tools to the already filled up list. These are GNRI (geriatric nutritional risk index) and MIS (malnutrition inflammation score). These are highly specific for patients undergoing hemodialysis. Another new assessment tool named NST (nutrition screening tool) which in essence is a combination of BMI (body mass index), MUAC (mid upper arm circumference), percentage weight loss and energy intake measurements was presented by Burden et al (2001). Duerksen et al (2000) meanwhile is of the firm belief that SGA (subjective global assessment) is the best nutritional assessment tool for the elderly patients. Wikby et al (2008) however, favors MNA as the best and he then went on to improve its reliability and speed by devising a 2-step MNA (mini nutritional tool). On the other hand Gibney et al (2005) believe that the best assessment tool is one that must be “an aggregate of several individual nutritional indices”. The group mentioned PNI (prognostic nutritional index ), HPI (hospital prognostic indicator) and SGA (subjective global assessment) as the 3 best of this genre or breed. Mini Nutritional Assessment (MNA) MNA holds the distinction of being the favorite of the majority of nutritional assessment practitioners in the whole world. This is but expected because MNA is quick and easy to use (Stechmiller 2003). Guigoz et al (1994) claimed that with MNA, the whole screening process can be completed in less than 15 minutes. The newly modified 2-step MNA is reputed to be even faster or quicker than 15 minutes (Rubinstein et al 1999). It has high reliability and high 7 sensitivity (96%)” (Kulnik et al 2008) and “allows physicians, dietitians, medical students and nurses to quickly evaluate the nutritional status of a subject (Escott-Stump 2007). In experiments to test interrater reliability, it was found that of the patients tested, 18% were malnourished, 29% were at risk for malnutrition and 53% well nourished. The agreement level between the results of tests performed by Wikby’s group and that of the nurses was computed at 62%, making interrater reliability fairly high for MNA (Wikby et al 2008). It also has high specificity of 95% and has a 99.5% very high negative predictive value which is interpreted as the unlikeliness of MNA classifying malnourished patients as nourished or at risk of malnutrition (Charlton et al 2005). The clear conclusion then is that MNA has the incontrovertible capacity to identify elderly patients as either malnourished or at risk of malnutrition. MNA is not only a rapid screening tool but it is cost-effective because it doesn’t require sophisticated laboratory instruments and therefore can be used more often to monitor nutritional status of elderly patients. But it best serves the purpose of immediately in the early stages, testing for the diagnostic risk of nutritional failure before patient suffers weight losses or changes in albumin levels on account of his disease, which results to impaired protein synthesis, his hospitalization and his immobility and drug intake i.e. use of drugs such as warfarin, digroxin and furosemide causes anorexia (Escott-Stump 2007) as well as lowered food intake caused by teeth conditions due to his age. In reality, MNA is comprised of 18 items or questions which are categorized into 4 groups (Guigoz 1994), namely, anthropometric, general assessment, dietary assessment and subjective assessment (Escott-Stump 2007). Many practitioners however, categorize anthropometric tests as in a class of its own. One drawback that MNA suffers from is that it is 8 very useful for elderly patients who require preventive nutritional measures but it lacks potency in cases wherein patients are already bedeviled by severe malnutrition (Waitzberg 2003). Finally, Wikby et al (2008) found that MNAs internal consistency was 0.68 (Cronbach’s alpha) and that the “sensitivity, specificity and diagnostic predictivity of MNA-short form versus MNA were 89%, *@% and 92%, respectively. Anthropometric Measurements Anthropometric literally means the measurement of a human being or man and anthropometric measurements refer to the external measurement of body height and weight, which are readily on hand. It is also the monitoring of the weight loss of a patient on a daily, weekly or monthly basis. Both of the above may however suffer from inaccuracy and unreliability if the equipment used is substandard or if the techniques used are not proper or crude. Besides the taking of these from bedridden, non-ambulatory, unsteady patients is difficult. The taking of hip and waist circumference, however, may find acceptability if a trained practitioner does it and in order to attain reproducibility, this should be carried out by that same practitioner. Skinfold measurements however, cannot be relied upon. The reason is measurement involves large parts of the body where skinfolds vary. Thus interpreting it is like solving a difficult enigma and the likelihood is, interpreter will fall into errors (Ulijaszek & Kerr 1998). Also measured here is the body mass index (BMI), biceps and triceps skinfold thicknesses, calf circumference and mid-thigh circumference (Charlton et al 2005). To have a valid and reliable body mass index measurement, it is imperative that the measurement of height is accurate and as we said, an accurate standing height is close to impossible as most of these patients are frail, too sick and too unsteady to stand erectly. 9 Anthropometrics may be the quickest, simplest, handiest and probably the most inexpensive tool that provides objective data but it may also be the most unreliable, unacceptable and non-valid tool because it is highly error-prone. Other than being imprecise and undependable, it is also inaccurate. This is because of the presence of a systematic bias, which is rooted to instrument error (the more sophisticated the instrument , the more the errors will be) and to instrument technique error (Heymsfield 1984). Ulijaszek and Kerr (1999) traced these errors and discovered that the source of the unreliability is the fact that repeated measurements always result to differing values and its inaccuracy is rooted to the fact that measurements always vary from the true values. This is because of observer error. Pederson and Gore (1996) meanwhile, claims, this suffers from validity while Mueller and Martorell (1988) assert, this measurement suffers from reproducibility and bias. But Zerpas (1985) contends that acceptability may still be attained thru a “repeat-measure protocol” consisting of measurements by both trainer and trainee until both results come close to each other. Ulijaszek and Kerr (1999) suggest that when measurements are taken, there should be good lighting, the instruments must be regularly calibrated and practitioner must be devoid of fatigue when he actually takes the measurements. It is of utmost importance that body weight measurement be accurate because loss of body weight is one sure indication of the presence of malnutrition. Once alerted to such malnutrition, personnel should take appropriate action to halt it or even improve it. De Wys et al (1980) proclaimed that “a loss of more than 10% of the usual body weight suggests malnutrition and is associated with higher morbidity and mortality” while Nightingale et al (1996) declared that a “loss of more than one third of the original weight is associated with imminent death”. Of all measurements, body weight may be the most misleading and unreflective of the real body 10 mass because patients are always edematous when they experience resuscitation. It is worthwhile to mention that body density and body fat may also be measured but since the techniques are too complex, they are rarely used. Biochemical Markers or Indicators Probably one of the more expensive tool but reliable and acceptable to assess nutritional status of patients is the test involving biological markers or indicators. Malnutrition results to drastic changes in the body chemistry and to measure the extent of malnutrition which may affect mortality of patient, there must be a test to measure the body chemicals that had undergone drastic altering in composition. Despite cost, it is a good tool to measure “inflammatory response. Thus it is a good predictor of mortality and morbidity’ (Waitzberg & Correa 2003). Among the biochemical indicator tests that are widely used are that for “serum albumin, haemoglobin, ferritin, vitamin B-12, red blood cell folate, cholesterol and vitamin C” (Charlton et al 2005). Other important biochemical tests are that for the determination of lymphocyte count and transferin level, platelet count and zinc level” (Atkinson et al 1992). However some authors classify the latter into immunological assessment. Major surgery, such as joint prosthesis and other kinds ofalways induce the body to suffer malnutrition because of loss of body nutrients. These consequently result to “loss of immunocompetence” (Gherini et al 1993). Likewise surgical procedures such as fracture treatment cause hypermetabolism to the body (Pratt et al 1981). In all kinds of surgery, in cases of body trauma and acute infection as well as body stress. The tendency of the body is to lower the chemical content of important body chemicals such as albumin, cholesterol, transferring etc., with a resulting severe malnutrition problem that may lead to possible mortality. There is therefore an urgent need to supplement the lost nutrients by the use of hepatic proteins as 11 as nutritional markers. These are “albumin, transferring, retinol binding proteins and transthyretin (pre-albumin)” (Waitzberg & Correa 2003). It is imperative that this kind of malnutrition be immediately remedied because it causes delay in wound or stress healing, longer rehabilitation and hospitalization and thus enormous expenses. The analysis of serum albumin in the body is one of the most common and important assessment tool to identify body malnutrition because albumin has high sensitivity and specificity to body changes due to trauma and stress caused by surgery, “hepatic disorders, extra protein losses and in cases of acute infection or inflammation” (Jeejeebhoy 1998). Others are “hepatic and renal failure, hormone infusion and infection” (Lopez-Hellin et al 2002). In all of the above cases, albumin level nosedives sometimes to a precarious level due to its increased degradation and decreased synthesis, transcapillary losses to the extravascular space and its replacement by body fluids (Brugler et al 2002). When such albumin loss reaches 3 times, the patient suffers septic shock (Jeejeebhoy 1998). The incidence of low body cholesterol is also used to predict possible disease complications and even mortality. In case of major surgery which demands faster wound healing and lesser complications lymphocyte count is utilized to assure post-operative success. The normal lymphocyte count is 1500-3300 cell per cubic meter. But when such count dips below 1500 cells per cubic meter, the body is at risk of suffering healing complications (Marin et al 2002). In summary this mode of assessment of nutritional status is not only essential to patients’ rehabilitation after surgery, stress or severe disease but it is a reliable, valid and most acceptable tool for the aforesaid cases. However, its availability is under question not to mention its high cost which may be repulsive to the common masses. 12 Assessments of Nutrient Intake There are 5 assessment tools to monitor nutrient intake of patients and these are: FNA (full nutritional assessment); NuRAS (nutritional risk assessment scale); SDA (short dietary assessment); NUFFE (nutritional form for the elderly) and NST (nutrition screening tool). SDA or short dietary assessment is the assessment of nutrient intake and consists of recording the number of meals taken by the patient, his food and fluid intake and the measurement of the patient’s energy nutrient intake. His food is weighed prior to intake and this continues 7 consecutive weekdays. His body weight is monitored from time to time. This is the simplest and crudest and thus suffers from lack of sensitivity and specificity not to mention reliability and acceptability. This is due to the fact that measurement of body wweight of unsteady, ill and probably immobile patient is prone to error (Kulnik 2008). NuRAS or nutritional risk assessment scale confirms a diagnosis of undernutrition in frail, hospitalized elderly patients and equates their nutritional status to the number of nutritional risks they are subjected to. A study shows that using this method, 37.8% had been identified as malnourished, 48.3% as at risk of malnutrition and 13.9% as nourished (Kulnik 2008). FNA or full nutritional assessment is a quick and simple screening tool that combines assessment methods from MNA and SSM (shorter screening method) and contains only 4 questions. It has as its baseline parameters-“malnutrition and clinical outcome, duration of hospital stay and mortality” (Thorsdottir et al 2005)./ Thus it finds high acceptability as indicator of nutritional status. It has high precision in its identity of patients suffering from malnutrition and has pinpointed 58.3% of the patients as being malnourished. Its precision is higher than MNA and its specificity and sensitivity were found to be 88% and 89% respectively. Thus, its misclassification rate is only 11.7%. It however has questionable validity because it cannot be claimed that it is valid for all patients and all age groups. Furthermore, it requires 13 blood analysis and thus might not be acceptable to some patients (Thorsdottir et al 2005). NUFFE or nutritional form for the elderly is a simple, reliable and valid tool that nurses may use to identify and assess undernourishment or risk of undernourishment among elderly patients 65 years old and above. It is very simple and only involves determination of patients’ dietary history, recording of his food and fluid intake. It makes use of a scoring system in which the maximum score is 30. The higher the score, the higher the degree of undernutrition or risk of undernutrition. It had been proven that NUFFE is a fairly reliable and valid assessment tool with a Cronbach coefficient of 0.72 (Soderhamn 2002). NST or nutrition screening tool monitors “changes in body weight, appetite and dietary intake” of patients over 65 years of age for the purpose of identifying patients who are either malnourished or at risk of being malnourished (BAPEN 1996). For each level of NST, a nurse and dietitian are both required to make assessments and the level of agreement between the two is computed as either “good agreement or very good agreement as defined by Cohen’s kappa” (Mackintosh 2001). The parameter consists of assessments on admission and at regular intervals and its 6 classifications are “weight; appetite; dietary intake; fluid intake; aqbility to eat; clinical condition” (Mackintosh 2008). The maximum score is 18 and those scoring from 7-18 is referred for further assessment. The studies of Burden et al (2001) revealed that NST has a sensitivity of 82%, a specificity of 52%. Mackintosh & Hankey (2001) using Spearman Rank’s Correlation concluded that NST is a reliable and valid tool to identify “patients at high risk of po0or nutritional status”. It also has fair reproducibility as the determined “Cohen’s kappa level is 0.42% which denotes significant agreement between nurse and dietitian in their assessment of the same patient. Assessment of Skeletal Muscle Mass Functional Tests assess the nutritional status of patients by measuring skeletal muscle 14 function. The principle is based on the fact that undernutrition causes degeneration of skeletal muscle function. The procedure consists of giving electrical stimulus to the adductor pollicis muscle or electrical stimulus to the ulnar nerve at the wrist. In both cases, contraction of the adductor pollicis muscle is measured. Other tests involve ‘handgrip dynamometry, the ability to perform work in an ergometer, changes in heart rate during maximal exercise and respiratory muscle strength” (Hunt et al 1985). It’s only drawback is that there is a dearth of good equipment available for that purpose and that “standardized expertise has limited its usage”. SGA or subjective global assessment assesses nutritional status based on patient’s medical history and his physical examination. It may involve assessment of skeletal muscle mass but the physical examination part refers mainly to “weight loss, altered food consumption, gastrointestinal derangements, decreased functional capacity, subcutaneous tissue loss, muscle wasting and presence of edema” (Detsky et al 1987). Since its application is too broad, it should not be considered as a mode for assessment of skeletal muscle mass. We all should thank for all these nutritional assessment tools because it gives hope to patients suffering from malnutrition or are at risk of malnutrition. There are now high chances their lives may be lengthened or they may get a reprieve from impending mortality. 15 REFERENCES BAPEN 1996, ‘Standards and guidelines for nutritional support of patients in hospitals,’ British Association for Parenteral and Enteral Nutrition. Brugler, L., Stankovic,A., Bernstein,L., ‘The role of visceral protein markers in protein calorie Malnutrition, Clin. Chan. Lab. Med. Vol. 40, pp.1360-1369. Burden, ST., Bodey, S., Bradburn, YJ., Murdoch, S., Thompson, AL., & Sim, JM., 2001, ‘Validation of a nutrition screening tool: testing the reliability and validity. Journal of Human Nutrition Dietetics vol. 14, pp. 269-275. De Wys, WD., Begg, C., Lavin, PT., 1980, Prognostic Effect of weight loss prior to chemotherapy in cancer patients, Am Jur Med vol. 69, pp.491-497. 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