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MalJNutr13(1): 29-44, 2007 Validation of Nutritional Screening Tools Against Anthropometric and Functional Assessments Among Elderly People in Selangor SuzanaShaharandSitiSaifaHussain Department of Nutrition and Dietetics, Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur Malaysia ABSTRACT This cross sectional study was conducted to determine the validity of three screening tools, Mini Nutritional Assessment Short Form (MNA-SF), Malnu- trition Risk Screening Tool for Community (MRST-C) and Malnutrition Risk Screening Tool for Hospital (MRST-H) among elderly people at health clinics. The screening tools were validated against anthropometric and functional assessments. The anthropometric assessments that were carried out included body weight, height, arm span, body mass index (BMI), calf circumference (CC) and mid upper arm circumference (MUAC). A set of questionnaire on manual dexterity, muscular strength, instrumental activities daily living (IADL) and cognitive status was used to assess functional abilities. A total of 156 subjects were recruited from rural (38 subjects) and urban (118 subjects) health clinics at Sabak Bernam and Cheras respectively. Subjects’ age ranged from 60 to 83 years old, with 44.2% were men and 55.8% women. The preva- lence of muscle wasting among the subjects assessed from MUAC and CC were both 7.0%. MNA-SF had the highest correlation with BMI (r = 0.497, p<0.001), followed by MUAC(r = 0.398, p<0.001), CC (r = 0.473, p<0.001), cog- nitive assessment (r = 0.229, p<0.001) and handgrip strength (r = 0.209, p<0.001). Whilst MRST-C had the highest correlation with IADL score (r = -0.320, p<0.001) and MRST-Hhadthehighestcorrelationwiththelockandkey test (r = -0.325, p<0.01). Sensitivity was the highest for MNA-SF (93.2%), fol- lowed by MRST-H (52.5%) and MRST-C (25.8%). Specificity was the highest for MRST-H (97.3%), followed by MRST-C (90.8%) and MNA-SF (79.4%). Positive predictive value (PPV) for MRST-H, MNA-SF and MRST-C was 55.5%,18.2%and14.1%,respectively.Inconclusion,amongthescreeningtools beingvalidated,MNA-SFisconsideredthemostappropriatetooltobeusedin health clinics for identification of elderly individuals who are at high risk of malnutrition. ____________________ Correspondence author: Assoc Prof Dr Suzana Shahar, Email: suzanas@medic.ukm.my 30 Suzana S & Siji Saifa H INTRODUCTION al screening tools involve estimation of food intake and anthropometric assess- Mortality rates have declined in vir- ment with several biochemical indicators tually all countries due to progress in pre- that are influenced by nutritional status venting infectious diseases and improving (Omran & Morley, 2000). However, some hygiene, sanitation and overall social of the nutritional assessment tools, for development and living standards. As a example anthropometry, dietary intake result, the average life expectancy and biochemical tests may not be appro- throughout the world is projected to reach priate to detect elderly who are at risk of 72 years in 2020 (Fahey et al., 2003). This malnutrition. This is because the methods aging population phenomenon exists are expensive, time consuming and worldwide, both in developing and devel- require a trained personnel to conduct the oped countries (Nourhashemi et al., 2001; assessments (Mohs, 1994). WHO 2002). In Malaysia, based on the There has been a lot of work done to year 2005 statistics, it is estimated that the develop nutritional screening tools that percentage of elderly people age ≥ 65 was are simple, rapid, cheap, effective and 4.6% compared to 3.9% in 2000. It is esti- comprehensive for elderly people. The mated that by the year 2050, the propor- value of a screening tool depends on its tion will be increased by four-fold to 21% sensitivity, specificity, predictive value (7.9 million people) (Department of and also acceptability to both the targeted Statistics, 2005). subjects and healthcare workers (Elia, Afewstudieshaveshownthatelder- 2003). The tools should also consider ly people are at high risk of malnutrition current weight status (e.g. underweight or (Gambert & Kassur, 1994; Jensen et al., obesity), as well as past and likely future 2001). In Malaysia, several studies among changes in weight, both of which are older people in the community have linked to food intake or appetite and shownthatmalnutrition still exists among diseaseseverity(Elia,Zellipour&Stratton, this group of population. The prevalence 2005). varies from more than 2% (Sumaiyah, Amongthedifferent kinds of screen- Muhammad Tauffik & Samiah Yasmin, ing tools that have been used include 2003; Zaitun et al., 2004) to almost 38% Nutrition Screening Index (NSI) (Dwyer, (Suzana, Dixon &Earland,1999;Sherinaet 1994; Grinder & Costello, 1996), Malnutri- al., 2004; Tan, 2006). tion Universal Screening Tool (MUST) Ahealthy diet is an important factor (Elia, 2003), Malnutrition Risk Scale to ensure optimum health and functional (SCALES) (Morley, 1989) and Mini capability and has a major influence Nutritional Assessment Short Form towards physical and functional demands (MNA-SF) (Guigoz, Vellas, & Garry 1994 of the well being of the elderly (Pirlich & &1996;Vellasetal., 2000; Rubenstein et al., Lochs, 2001). Nutritional problems often 2001). They have been used in community go unrecognised and untreated (Reilly et populationtoscreenforelderlywhoareat al., 1995). It is therefore important to have risk of malnutrition. screening methodsthatareabletoidentify The Mini Nutritional Assessment those who are malnourished and those Short Form (MNA-SF) consists of 6 of the who are at risk of developing malnutri- 18itemsofthefullMNA(Rubensteinetal., tion. Nutritional screening tools can rapid- 2001). MNA-SF has been developed in ly identify individuals who are at risk of Switzerland to identify elderly who are at malnutrition for the purpose of further high risk of malnutrition either in the nutritional assessment and intervention hospital or the community. Although the (Green&Watson,2005).Specificnutrition- MNAwasdeveloped specifically for frail Validation of nutritional screening tools among elderly 31 older people, it has been validated in a nutritional status of the elderly. As ade- healthy older population and has been quate nutrition is essential towards the widely used and validated in many well being of the elderly, it is necessary to European countries. It was reported that have an assessment method that could this screening tool has sensitivity, speci- identify elderly individuals who are prone ficity and positive predictive value (PPV) to malnutrition. Screening tools provide of 96%, 98% and 97% respectively in iden- aneconomicalandrapidmethodofidenti- tifying those elderly who are at risk of fying those elderly who are at high risk of malnutrition (Guigoz, Vellas & Garry 1994 malnutrition. However, the screening &1996;Vellasetal., 2000; Rubenstein et al., tools used have to be validated to assess 2001). It has also been evaluated in a group their appropriateness on the intended of Japanese frail elderly and found to have targeted population. This cross-sectional a sensitivity and specificity of 85.9% and study was conducted to determine the 84%inidentifying under-nutrition respec- validity of three screening tools, namely tively (Kuzuya et al., 2005). the Mini Nutritional Assessment Short In Malaysia, a Malnutrition Risk Form (MNA-SF), Malnutrition Risk Screening Tool for Community (MRST-C) Screening Tool for Community (MRST-C) specifically for the community elderly has and Malnutrition Risk Screening Tool for been developed based on local studies Hospital (MRST-H) among elderly people (Suzana, Dixon & Earland, 1999). The who attended the health clinics in an MRST-C has been validated among rural urban and a rural area (Appendix). The elderly Malays and Chinese and also insti- screening tools were validated against tutionalised Chinese elderly at several anthropometric and functional assess- places in Malaysia, including Kedah, ments, as shown in Figure 1. Kelantan and Negeri Sembilan (Suzana et al., 2007). However, its usefulness in detecting malnourished individuals in an METHOD urbansettingorhealthclinicshasnotbeen tested. Another screening tool, Malnutri- This cross sectional study was con- tion Risk Screening Tool for Hospital ducted among elderly people who visited (MRST-H) recently has been developed the outpatient health clinics of Klinik locally and validated to identify elderly Kesihatan Cheras Baru (an urban area), hospitalised patients who are at risk of Klinik Kesihatan Bagan Terap at Sabak malnutrition. It is a screening tool that Bernam (a rural area) and at the Rumah includes physical, clinical and anthropo- Sejahtera Day Care Centre, Cheras (an metric examinations (Sakinah, 2006). As urban area), which is a day care centre for this tool has been developed andvalidated non-institutionalised elderly people. Sub- basedonhospitalisedelderly,italsoneeds jects recruited in this study included those to be validated in a community setting. who were aged 60 years and above, were In Malaysia, government health clin- free from physical deformation that could ics provide inexpensive access to medical have affected the anthropometric assess- services for most of the elderly. Currently, ments, were able to communicate and had functional assessments have been includ- given consent. The subjects were recruited ed as part of the medical assessment for from July to September 2006. elderlypatientswhoattendselectedhealth Subjects were asked to provide infor- clinics which conduct the “Elderly Health mationonsocio-demographicandperson- Program”. Besides measurements of body al profile such as marital status, source of weightandheight,therearenonutritional income, level of education and job status, risk assessments carried out to assess the through an interview. All subjects were 32 Suzana S & Siji Saifa H “NewTests”fornutritional screening “Established Tests” of nutritional andfunctional status MNA-SF Anthropometry: BMI CC MUAC Armspan MRST-C Functional status: IADL Quadriceps muscle Lock and key MRSC-H Cognitive assessment Handgrip strength Figure 1. Tests used in the study screened for malnutrition risk using three especially in the lower limb (Sakinah, screeningtools,namelyMNA-SF,MRST-C 2006). and MRST-H(Appendix). Then they were Functional assessment involved a assessed for anthropometric and function- self reported functional disability using al status, as reference standards or estab- Instrumental Activity Daily Living (IADL) lished tests for nutritional status assess- (Fillenbaum et al., 1988) and cognitive ments. The anthropometric assessments assessmentbasedontheElderlyCognitive that were carried out included body Assessment Questionnaire (ECAQ) (Kua weight and height (Fidanza & Keller, & Ko, 1992). Manual dexterity was also 1991), arm span (Kwok&Whitelaw,1991), assessed using Lock and Key test (Manan- calf circumference (CC) (Chumlea, Guo & dhar, 1995). Climbing stairs to assess Vellas, 1994) and mid upper arm circum- quadriceps muscle strength (Bennet, 1999) ference (MUAC) (Ferro-Luzzi & James, and handgrip strength using Hand Dyna- 1996). Body mass index (BMI) was calcu- nometer (Hillman et al., 2005) were also lated from measured height and estimated conducted as functional assessment. The height from arm span for those with whole process of data collection took kyphosis(Suzana&Ng,2003).MUACand about 40 minutes to complete. CCare parameters used for measurement Data analysis was analysed using of muscle mass and subcutaneous adipose “Statistical Package for the Social Sciences tissue (Woods & Moshang, 2005) and a 12.0” (SPSS version 12.0). Unpaired t test low MUAC among the elderly has been wasusedtodifferentiate between sex, age showntoincreaseriskofmortality(Tajima group and locations (urban and rural) for et al., 2004). A MUAC value of less than numerical data. Chi squared test was used 23.0 cm for men and 22.0 cm for women to assess the differences between sex, for indicates loss of peripheral muscle mass factors on demography and psychosocial (Ferro-Luzzi & James, 1996). As for CC, a factors, and functional status that are cate- valueoflessthan30.1cmformenand27.3 gorical data. Correlation test was used to cm for women will indicate muscle loss, assess the nutritional screening tools
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