By Anne Wright, Registered Dietitian
It is estimated that over 1.1 million older adults (>65 years) in the UK are malnourished or are at risk of malnutrition1. To coincide with Malnutrition Awareness Week (5-12 October 2020), this blog post will discuss nutrition risk screening tools which could be used remotely with older adults and/or vulnerable people who are shielding at home.
Nutritional screening is a simple process which is used to identify patients at risk of malnutrition. National guidance (NICE) recommends that malnutrition risk screening should be carried out by trained health professionals. All hospital inpatients and people in care homes should be screened on admission, then further when there is clinical concern. For people residing in the community, screening should take place on initial registration at general practice surgeries and when there is clinical concern2.
Malnutrition risk screening tools should be practical, economical, reliable, valid and evidence-based3. They should incorporate a scoring system that is applicable to different clinical conditions and care settings, which can be linked to a care plan4. Most screening tools utilise a variety of variables including recent weight loss (percentage), food intake/appetite and body weight and height (anthropometric) measures.
Screening tools specific to the older adult population include:
Recent COVID-19 shielding restrictions have presented significant challenges for healthcare professionals (HCPs) involved in nutrition risk screening. Some of these tools (such as MUST, MNA-SF, NRS, BAPEN tool) require the HCP to obtain accurate anthropometric measurements. Physically conducting these measurements may not be practical or feasible due to social distancing measures. For example, the Malnutrition Universal Screening Tool (MUST) (a frequently used screening tool) requires objective parameters such as height and weight to determine Body Mass Index (BMI) and percent weight loss over time9.
In some cases, BMI can be estimated using alternative measures such as ulnar length and mid upper arm circumference (MUAC)10. However, these measurements may not be possible due to local infection policies and COVID restrictions11. Plus, obtaining these measurements could be difficult for somebody without previous training or experience.
Remote screening tools have been explored for use with patients when close contact is not feasible or safe. It has been proposed that carers, relatives and/or patients could screen/self-screen for malnutrition risk11. This requires simplified remote screening tools which do not require direct anthropometric measurements.
The following screening tools do not require anthropometric measurements and can be completed by a patient or carer without assistance.
The Patients Association Nutrition Checklist (PANC), developed in partnership with the Malnutrition Pathway (Managing Adult Malnutrition in the Community)12, is a simple tool designed to be used by patients and their carers. It consists of four questions (see Fig 1) and does not require anthropometric measurements. The PANC has shown acceptable sensitivity and specificity when compared to MUST13.
Fig 1: The Patients Association Nutrition Checklist
Pilot studies13 have concluded that the PANC:
Whilst the checklist is not intended to replace the MUST (which should be used wherever possible), it certainly has the potential to be used remotely for shielding patients.
The Simplified Nutritional Appetite Questionnaire (SNAQ) is a simple screening tool; validated to predict weight loss within six months in community-dwelling adults and long-term care residents14, 8. It consists of four questions (relating to appetite, early satiety, food taste and intake) and can be completed by a patient or carer without assistance15. The four questions are:1. My appetite is:
E. Very good
The results are based upon the following numerical scale: a = 1, b = 2, c = 3, d = 4, e = 5. The sum of the scores for the individual items indicated the SNAQ score. A SNAQ score ≤14 indicates significant risk of at least 5% weight loss within six months.
The Malnutrition Screening Tool (MST) consists of two questions regarding recent unintentional weight loss and reduced oral intake.
A numerical score of 0 to 5 is provided to categorise patients as at risk (MST score≥2) or not at risk (MST score <2)6.
The MST has been validated in older patients who are hospitalised or in residential care16, 13. No studies have yet assessed the validity of the MST for community-dwelling older adults13.
Nutrition risk screening is recommended to identify older adults at risk of malnutrition. Recent COVID-19 shielding restrictions have led practitioners to explore screening tools which can be used remotely and completed by a patient or carer without assistance.
There are several alternative screening tools designed to be used by patients and their carers, which could be conducted remotely without the physical presence of an HCP. Whilst these tools are not intended to replace the MUST, they offer a suitable alternative for older or vulnerable patients who are shielding as a result of COVID and may be at risk of malnutrition.