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Malnutrition screening of older people by community nurses: An imperative

for population health in Ireland.

Conference Paper · March 2015

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Introduction
With a rise in both the global population of older people and life expectancies in general,
health care systems face a number of challenges in meeting the needs of aged populations
(Han et al 2011). One such challenge is nutritional imbalance, which encompasses two
domains: malnutrition and obesity. Malnutrition and obesity are common clinical and public
health problems, which have adverse effects on many systems of the body and on the
physical and psychological function of the older people adult (Elia & Russell 2009). The
definition of malnutrition in the elderly is a faulty or inadequate nutritional status leading to
undernourishment characterised by insufficient dietary intake, poor appetite, muscle wasting
and weight loss (Chen et al 2010). Obesity, on the other hand, is defined as a BMI ≥30 kg/m2
and presents as ‘abnormal or excessive fat accumulation that may impair health’ (WHO
2014). Representing a growing challenge in older person care, obesity is closely correlated to
functional decline, cardiovascular risk and increased mortality risk (Turcato et al. 2000, Han
et al. 2011, Leitzmann et al. 2011, Samper-Ternent and Al Snih 2012). Screening the older
adult in the community focuses on identifying those at risk of malnutrition, malnourishment
or obesity. In the United Kingdom (UK), approximately 2.8 million people are affected by
malnutrition and about 93 percent of these people are living day to day within the community
(Elia et al 2010). Equally, obesity in older people demonstrates a growing prevalence rate.
For instance, one comparative study between the United States (US) and the UK of the 50-74
age groups (Avendano et al. 2007) identified obesity levels of 28.8 percent in the US, 26.1
percent in the UK and an average of 17.8 percent in Europe. In the 2014 TILDA (Leahy et al
2014) study in Ireland over 35% of older adults are classified as obese. Recognising the
gravity of both malnutrition and obesity in the care of older people, this discussion paper
examines nutritional screening and assessment of community dwelling older people. The
paper commences with a brief examination of demographics, relevant age related changes
and consequences that cause malnutrition and obesity. The discussion also provides a review
of common, validated screening tools in the nutritional assessment of older people. The paper
concludes with an evaluation of the role of the public health nurse/community nurse in the
nutritional assessment of community dwelling older people.

Methods
A systematic search of published works was conducted using three main electronic databases.
These included the CINAHL and MEDLINE (Pubmed) and Cochrane databases. Data were
accessed from the period between January 2008 and December 2013. The databases were
searched using the following keywords: Malnutrition OR Undernutrition OR Weight loss,
Obesity OR Overweight, Nutritional screening OR Nutritional screening tools OR Nutritional
assessment, Community OR Community Nurse OR Community setting. In the CINAHL
search, 49 articles were retrieved and the following inclusion criteria applied, over 65 years
of age, peer reviewed, English language publication, research article and peer reviewed. In
PUBMED 192 articles were retrieved and the following inclusion criteria applied, over 65
years of age, English language publication and human subjects. In the first stage of selection,
the titles and abstracts were assessed for suitability. Full text articles were retrieved for
potentially relevant studies and assessed for suitability for inclusion. Cross-referencing and
searching of government and other relevant publications identified further articles. Relevant
articles were also retrieved from bibliographies in the references of key articles. Relevant

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grey literature and conference proceedings were also sought by a general internet search for
the same time period.

Demographics
People are living longer and older persons represent a growing proportion of global
populations. In 2009, the older world population was an estimated 737 million individuals
aged 60 years and over (United Nations, Department of Economic and Social Affairs,
Population Division, 2009). This number is projected to increase to 2 billion by 2050 (United
Nations, Department of Economic and Social Affairs, Population Division, 2009). Moreover,
the oldest old is one of the fastest growing segments of the population and by 2050, 20% of
the older population worldwide will be aged greater than 80 years (United Nations,
Department of Economic and Social Affairs, Population Division, 2009). In Ireland, the
proportion of the population aged greater than or equal to 65 years has remained steady at
approximately 11 percent for the past 40 years (Kearney et al. 2011). However, it is projected
that this proportion will rise to 14 percent by 2021 and to 19 percent by 2031 (Kearney et al.
2011). In tandem with global trends, the greatest increase will be in the oldest old, (aged >80
years), which is expected to more than treble by 2036 (Kearney et al. 2011). This change in
the demographic profile of the Irish population poses a major public health challenge
(Kearney et al. 2011). As the proportion of older people in the world population is on the
increase, the health system is faced with increasing demands to provide health services for
this group (Watson et al. 2010).

In relation to nutritional needs, in Ireland, it is estimated that 70,000 people aged 65 and over
may be malnourished or at risk of malnourishment (UCD Institute of Food and Health 2010).
The cost of disease related malnutrition exceeds 1.5 billion euro each year, a figure which
represents 10 percent of the healthcare budget (UCD Institute of Food and Health 2010).
Similarly, the SLAN (2007) report (cited in Harrington 2008) report identified that 61 percent
of Irish adults were either overweight or obese. Furthermore, as cited earlier, a recent TILDA
(2014) report, demonstrated that over one third of adults over 50 years in Ireland are obese
with a further 44 percent being overweight.

Community Nurse and his/her role in nutritional assessment

Public health nurses (PHNs) have traditionally provided core nursing and midwifery care in
the community, with community registered general nurses (CRGNs) in more recent times,
supporting and contributing to community services (INMO 2013). PHNs and CRGNs work
within a geographical caseload and are members of a population based multidisciplinary
team. According to the report by the Irish Longitudinal Study on Ageing, PHN and CRGN
services have a high degree of interaction with older age groups (McNamara et al. 2013).
Considering the majority of older Irish people reside in the community (94% in CSO 2012), it
is an opportunistic site to screen for malnutrition and obesity prompting nutritional health
promotion and management. Therefore, the role of the nurse working in the community is of
huge significance in the early diagnosis of nutritional problems, which can often lead to
increased general practitioner visits and hospitalisation for the older adult (Holdoway 2012a,
TILDA 2014). Community nursing practice focuses on a holistic assessment of the older
person and working in partnership with the client to facilitate a balanced diet, meeting
individual needs. A balanced diet requires a consideration of dietary intake in the context of

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macronutrients (carbohydrates, fat and protein) and micronutrient (vitamins and minerals).
Individual assessment takes into account issues such as the individual’s intake on a daily
basis and how this maps to increased or decreased requirements of the body. Despite this
potential for both primary prevention and secondary care intervention, Irish nurses in the
community are not mandated to engage in routine nutritional screening of older people.
However, a study by Green et al. (2013) on barriers and facilitators of community nurses
(using the Malnutrition Universal Screening Tool (MUST) screening tool), concluded that
screening is more likely where an organisation is perceived to have a clear expectation that it
is under taken and also demonstrates this through audit, training and equipment availability.
Thus, the integration of routine screening for both malnutrition and obesity would be
advantageous in the identification of risk and implementation of early intervention. Such
practices have the potential to limit or even reverse emerging or potential morbidity risks,
reduce negative impacts for the individual and contribute to overall population health. Thus,
early identification, targeted intervention and effective monitoring are central components to
the nutritional assessment of older people within a population health framework.

Malnutrition and the consequences

Nutrition is important for older adults in the community to maintain independence with
activities of daily living and to preserve and promote functional ability. Consequently,
adequate nutrition facilitates general well-being and is an important factor in the ability of
older people to remain in their own home environment (Nykanen et al. 2013). It is well
documented in the research literature that older people are more susceptible to malnutrition as
a result of the biological, psychological, social and economic changes of the ageing process
(Turconi et al. 2012, Nykanen et al. 2013). There are a myriad of age related changes which
impact on nutrition. In the older adult, the body has a reduction in lean mass and reduced
metabolic rate therefore requiring reduced energy (Ahmed & Haboubi 2010). Age related
changes within the gastrointestinal (GI) system affect an older person’s ability to digest,
absorb and eliminate food (Farley et al. 2011). The sense of smell diminishes steadily after
60 years of age, becoming significantly impaired by the age of 80 years (Schmidt Luggan
2010, Best 2013, Ahmed & Haboubi 2010). Due to malnutrition, the older adult is more
susceptible to decline in cognitive and functional ability (Vedantam et al. 2009, Philips et al.
2010). Such changes contribute to the fact that older adults are more susceptible to
underlying disease (Best 2013) and many of these physiological changes of aging place older
adults at risk of malnutrition although it must be noted that symptoms of malnutrition may be
diverse and non-specific. When the older adult is presented with demands on the body for
example acute illness the significance of physical decline becomes apparent because at
advanced age few or no reserves are available therefore increasing the risk of malnutrition in
the older adult. Social isolation is significant because often living alone means the older adult
may also eat alone which has been associated with poor nutritional intake (Callen 2011).
Consequently, malnutrition leads to an increase in morbidity and mortality rates (Huhmann et
al. 2013, Schilip et al. 2012, Andre et al 2012, Cuervo et al. 2009), delayed wound healing
(Timms 2011, Posthauer 2012), contributes to immune dysfunction (Vedantam et al. 2009,
Schilip et al. 2012), causes an increase in hospitalisation episodes and is a factor in longer
total inpatient days (Vedantam et al. 2009, Philips et al. 2010, Cuervo et al. 2009). Moreover,
the consequences of malnutrition have a significant impact on the quality of life of the older
adult (Schilip et al. 2012, Philips et al. 2010). As malnutrition is a health issue which occurs

3
over a period of time, having a mandated policy on routine screening in terms of the optimum
tool and frequency of application would assist community nurses’ holistic assessment of the
older person.

Obesity and the consequences

While malnutrition is a common focus in the literature related to nutritional challenges for
older people, obesity is an issue which has received less attention. The prevalence of obesity
among older adults has increased during the last 20 years and has a growing impact on both
medical and social services (Houston et al. 2009, Samper-Ternent et al. 2012) as well as an
increased financial burden (Institute of Health 1998). Physiologically, in the older adult, there
is a loss of lean tissue and abdominal, intramuscular and visceral fat increase with age age
(Callan and Schmidt 2010) which predisposes the body to risk of obesity. Over eating,
diminished physical activity and resting metabolic rates also increase obesity in older adults
(Callan and Schmidt 2010). While many studies acknowledge obesity in the older adults
when defining malnutrition, they neglect any inclusion of this important area. Overweight
and obesity are major risk factors for institutionalisation, contribute to greater health costs
and increased utilisation of health services and may cause poor health outcomes and
increased mortality rates (Houston 2009). Obesity can also contribute to sleep apnoea and
osteoarthritis (Institutes of Health 1998).
Addressing obesity can be challenging as some arguments focus on the issue that maintaining
weight loss long term is difficult and a pattern of ‘weight cycling’ (repeated loss and regain
of weight) may be more detrimental to health (Institute of Health 1998:xi). Assessment of the
older person must take into account the person’s BMI, waist circumference and overall risk
status. Weight loss diets should be used with caution in the older person as co-morbidities
need to be considered and the fact that dieting can lead to loss of lean muscle as well as fat,
which can have consequences for the older adult (Houston 2009, Soenen and Chapman
2013). Older adults who are obese require referral to a dietician for a comprehensive
assessment and prescription of an individualised weight loss programme specific to their
needs (Soenen et al. 2013, Houston 2009). The ultimate goal of treatment is a change of diet
and an increase in exercise to produce moderate weight loss.

Prevalence of Malnutrition and Obesity

A knowledge of prevalence in the community is important because the health complications
associated with malnutrition require more general practitioner visits, increased
hospitalisation, and prolonged stay in hospital (Rist et al. 2012). An increased demand in
healthcare services translates to an increased burden on health spending (Houston 2009). The
prevalence of malnutrition is generally higher in older adults, but it is strongly dependent on
the population studied (Kaiser et al. 2010). According to European prevalence figures, 5-15
percent of Europeans living in the community are malnourished or at risk of malnutrition
(CARDI 2010). In the UK, approximately 2.8 million people are affected by malnutrition
and around 93 percent of that figure are living day to day within the community (Elia et al
2010). The prevalence of malnutrition in community living older populations ranges between
8-15 percent (Han et al. 2008, Turconi et al. 2012, Johansson et al. 2008, Nykanen et al.

4
2013). However, there can be differences in prevalence depending on environmental setting.
A multinational study by Kaiser et al. (2010) provided data on the prevalence of malnutrition
in twelve countries and four different settings. The study used retrospective data from pooled
analysis of previous published data and examined the nutrition of 4,570 participants with a
mean age of 82 years. The data were collected from different settings including
rehabilitation, hospital, nursing home and community environments. In the combined
database, malnutrition was identified as having as prevalence of 22.8 percent, with
considerable differences between the settings (rehabilitation 50.5%, hospital 38.7%, nursing
home 13.8%, community 5.8%). A study by Schilip et al (2012) had similar findings with the
highest prevalence of malnutrition in the hospital setting (25%) and lowest in older people
receiving community care (17%).
Numerous studies have documented an increase in the prevalence of obesity in the older adult
(Samper-Ternent and Al Snih 2012). The World Health Organisation (WHO) documented
that obesity has doubled since 1980s (WHO 2008). Prevalence studies indicate a wide
variation in the prevalence of obesity but despite variations, all of the studies concur that
obesity has increased over time. An Italian study by Turconi et al. (2012), which reviewed
nutritional status in independent living older adults in the community, states a prevalence of
overweight of 27.6 percent and obesity of 32.9 percent. A separate prevalence study by
Houston (2009) in the US found overweight to be an issue in 68.6 percent of the sample
while obesity was found in 30.5 percent of adults aged 60 years and older. In Canada, the
prevalence of obesity in the 1990s was 12.8 percent (Samper-Ternent and Al Snih 2012)
which was lower than Europe and the USA. However, one comparative study between the
United States (US) and the UK of the 50-74 age groups (Avendano et al. 2009) identified
obesity levels of 28.8 percent in the US, 26.1 percent in the UK and an average of 17.8
percent in Europe. In the USA, data from the National Health and Nutrition Examination
Survey (NHANES) (Fakhouri et al. 2010) demonstrated an obesity level of 35 percent of
older adults over 65 years between the years 2007-2010. In the study sample, rates of obesity
were higher in the 65-74 years group (40.8%) than the 75 and above group (27.8%) (Fakhouri
et al. 2012). It is important to note that older people in settings other than community have a
higher prevalence of adverse health challenges in which nutritional equilibrium is challenged
and older adults dwelling in the community have better health status. This is due to the fact
that health status impacts upon nutritional intake and older people in environments such as
residential care have a poorer functional and/or cognitive health status. While there is global
recognition of malnutrition and obesity in the community, there is no formal initiative or
policy in Ireland to tackle malnutrition or obesity in the community for the older adult.

Political response to malnutrition

Appropriate political responses are essential in addressing malnutrition and obesity in the
community. In order to influence policy and address strategy on national and international
level, it is imperative the issue is brought to the fore of the political agenda. The cost and
scale of malnutrition in older adults was recognised by the European Union (EU) as European
Ministers of Health advocate that Member States lobby to include undernutrition in the WHO
EURO Food and Nutrition Action Plan (European Nutrition for Health Alliance 2013). The
Prague Declaration (European Nutrition for Health Alliance et al. 2007) was committed by
signatory EU member States (including Ireland) to address the problem of malnutrition. This

5
statement acknowledges the significance of malnutrition as an urgent public health issue and
undertakes a commitment to appropriate intervention (UCD Nutrition and Health in an
Ageing Population 2010). Despite the commitment, an Irish national policy has not been
produced. However, in 2013, a European lobby for political impetus took place in the form
of a multi-agency conference in Dublin. The European Nutrition for Health Alliance which
addressed nutrition for all ages was organised to call for malnutrition to be recognised as a
critical health issue. The key actions recommended from the conference were:
1. Public awareness and education.
2. Mandatory nutrition screening.
3. Nutrition training of health professionals
4. Quality standards for nutritional care
5. Equitable access to safe, effective home nutrition.
Rice (2012) argues that Ireland is leading the way in fighting the malnutrition battle as this
was a focus for the Irish Society for Clinical Nutrition & Metabolism (IrSPEN). The initiative
was to build a compelling case for the implementation of a national strategy to fight
malnutrition in an economic crisis and actively contribute to advancing Ireland as a model of
‘best practice’ in nutritional care for all ages (Rice 2012). The motivation behind this was
the government plan to remove nutritional supplements from the medical card scheme, which
would mainly impact on older people. The Irish Society for Clinical Nutrition & Metabolism
(IrSPEN) demonstrated that the cost of not treating malnutrition with oral nutrition
supplements could be 11 percent of the total healthcare budget versus 3 percent to treat
malnutrition with such supplements (Rice 2012). In this study, costs were calculated by (i)
estimating the prevalence of Diet Related Malnutrition (DRM) in health-care settings derived
from age-standardised comparisons between available Irish data and large-scale UK surveys
and (ii) applying relevant costs from official sources to estimates of health-care utilisation by
adults with DRM. No attempt has been made to estimate separately the costs of DRM and
any associated disease, since each can be a cause or consequence of the other. The methods
used are adapted from an evaluation of the cost of malnutrition in the UK by the British
Association for Parenteral and Enteral Nutrition (2009). Thus, the evidence was compelling
and the government agreed to continue to cover the cost of nutritional supplements for
medical card patients. For the older adult in the community, this continued government
support ensured nutritional support was part of medication covered by the medical card.
Similarly, in the UK, the National Institute for Health and Excellence (NICE) UK (2012)
stated in a costing report that “implementation of Nutrition Guidance would deliver third
largest potential savings to the NHS” (NICE 2012:24). Such savings are important in the
context of not only current economic challenges but, as previously discussed, within a social
domain of preventing increased and avoidable related morbidity and mortality consequences.

Political response to obesity

6
An Oireachtas library Report on Obesity-a growing problem (2011) suggests that obesity is
currently estimated to cost the Irish economy over 4 million euros per year in work
absenteeism, premature mortality and increase health service usage. According to the 2011
National Adult Nutrition Survey (NANS 2011), the most dramatic increase in obesity among
Irish adults was observed in 51-64 year old men, increasing from 11 percent to 42 percent
over the past two decades. Irish obesity rates are among the highest in Europe and there is no
indication of decline in prevalence (Sassi et al 2012). In 2005, a key policy document the
Report of the National Taskforce on Obesity made recommendations for the prevention and
treatment of obesity in Ireland. Only partial implementation of the recommendations have
been achieved. In 2011, a new Special Action Group on Obesity was established and set out
priorities to be addressed including tax on sugary drinks and improving nutritional labelling.
Both issues are currently being politically debated. In 2011, both Hungary and Denmark
became the first countries to introduce taxes on fatty and processed foods respectively (Holt
2011). However, in pragmatic terms, policy interventions for obesity can only be realistically
aimed at the environment (making healthy choices easier) rather than the individual
compelling them to take the healthy choices (Swinburn 2011). For this to happen, a concerted
action by governments, food industry and health care professionals needs to be adapted to
tackle obesity. Rutter (2011:746-747) states:
‘Tackling obesity demands an approach that does not merely coordinate
the discrete actions of a huge number of individuals, organisations and
sectors. Those actions need to be integrated, their untended consequences
understood, correction actions undertaken, ineffective interventions
stopped and effective one improved’.
While the political response tackles obesity in all age groups, there is no specific focus on
addressing the obesity epidemic in the older adult in the community. To tackle obesity in the
older adult in the community, health policy needs to state defined objectives and care plans
which incorporate the multidisciplinary team.

Risk factors
It is important to consider risk factors associated with malnutrition and obesity in the older
adult in the community. The list of risk factors related to nutritional imbalance is extensive.
Table 1.1 presents the risk factors as Functional, Medical and Psychological risks and gives
examples of each.

Table 1.1 Risk factors associated with malnutrition.

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Functionality Physical Activities for daily living.
Inability to shop
Unable to prepare food
Medical Cardiac disease Cardiac failure
Respiratory disease Chronic obstructive disease
Gastrointestinal disease Dysphagia, malabsorption
Endocrine Diabetes
Neurological Stroke, Parkinson’s disease, Motor neuron
Infection disease.
Malignancy Pneumonia, urinary tract infection
Physical Disability Cancer
Arthritis

Psychological Dementia Inability to self-care

Depression
Anxiety
Bereavement

A consideration of risk factors is particularly important when a community nurse is assessing

an older adult as the identification of individual and specific risk factors is fundamental to
targeted prevention and amelioration of nutritional imbalance and underpins the impetus for
nutritional screening.

Functional ability
From the literature review, functional ability was a recurring risk factor in many of the
studies and a variety of tools were used to assess functional ability. An assessment of
instrumental activities of daily living (IADLs) (Lawton et al 1969) is a common method to
examine functional ability (Han et al. 2008, Callen 2010, Nykanen et al. 2012). Lawton
describes functional ability as an assessment which measures physical activities more
complex than those needed for personal self-care; they are activities that support the ability to
engage in self-care. Instrumental activities for daily living include cooking, shopping, using
the telephone, housekeeping, doing the laundry, travelling, taking medications and managing
finances. Eight items are scored from independent to dependent with high scores indicating a
higher level of independence. Age related changes of the older adult may increase the risk of
decline so the importance of the information acquired from a functional assessment can
provide information to assist with planning appropriate care. A functional assessment can
give a baseline on the person’s capabilities which facilitates early signs of nutritional
deterioration in the older adult. IADL have been employed in studies focusing on nutrition. A
study by Nykanen et al (2012) used the IADL with the objective of describing the nutritional
status and factors associated with possible malnutrition among community dwelling older
adults. A randomly selected sample of 696 persons aged 75 years and older were included
and findings indicated that impaired functioning in IADLs was associated with possible
malnutrition. This was as a result of difficulty with meal preparation which lead to an
increase in the risk of malnutrition. These findings concurred with studies by Han et al (2008)
and Callen (2011). A study by Söderhamn et al. (2010) found that older people who required
help to manage daily life were medium or high risk for undernutrition. Therefore where
8
functionality is a risk factor, the benefit of using meals on wheels or where meals were
provided to the older adult (by neighbours, family) was an option to address the risk of
malnutrition.

Medical
In table 1.1, the diseases cited are associated with higher rates of malnutrition in the older
adult (Ahmed & Haboubi 2010). Obesity is strongly associated with cardiovascular disease
(TILDA 2014, Houston 2009, McTigue et al. 2012) and diabetes (TILDA 2014, Houston
2009). In a systematic review by McTigue et al (2012), most studies examining incident
cardiovascular-related morbidity found that risk significantly increased with elevated Body
Mass Index (BMI). Moreover,waist circumference may be a more significant indicator of risk
of diabetes (Lee et al. 2008, Howel 2012). Therefore, elevated BMI and waist circumference
(central obesity) are the most significant risk factors associated with both cardiovascular
disease and diabetes in the older adult in the community and to address obesity these need to
be addressed in the first instance. Chronic disorders are known to affect nutritional status in a
negative way (Söderhamn et al. 2012, Ahmed and Haboubi 2010, Han et al. 2011). Many of
the chronic diseases mentioned in table 1.1 may be associated with undernutrition these
include infection and malignancy and arthritis. Disease is accompanied with tissue repair and
an increased activity of body defence mechanisms, which means the older adult has increased
nutrition requirements (Han et al. 2011). Moreover, some disease such as arthritis may
compromise the ability of elderly persons to prepare meals and impact on the quality of food
they eat, therefore exacerbating poor nutritional intake (Han et al. 2011). Other health issues
such as stroke, can impact on the mechanical aspect of ingestion as dysphagia can be a side
effect. Consequently, when considering risk factors in the older adult multiple chronic
medical disorders have a significant impact on nutritional status of the older adult.

Psychological
Older adults with dementia are at high risk for nutritional difficulties and often have
inadequate food and fluid intake (Amella 2007). Attending to adequate nutritional intake
requires accurate assessment, to identify the changes in behaviour, which left untreated, often
lead to malnutrition and dehydration (Aselage 2010). The Edinburgh Feeding Evaluation in
Dementia Scale (EdFED) is an instrument which assesses practical eating problems in people
with late stage dementia (Watson 1994). The Edfed identifies eating difficulties and
determines the level of assistance required and has been found to be of particular use in
nursing practice (Aselage 2010). The benefit of the assessment is that it can be done in
conjunction of family members which allows them to voice concerns regarding independent
or assisted nutritional needs in older adults with dementia. Once the assessment is completed
by the nurse it can be discussed by the multidisciplinary team and further assessment
considered when required. Another common psychological risk factor associated with
malnutrition is depression or depressive symptoms ( Johansson et al. 2008, Callen 2011)
Söderhamn,et al. 2012). Bereavement is another important risk factor. Often when the elderly
lose a spouse, they are prone to suffer consequences of social isolation, loneliness, depression
and malnutrition leading to dietary inadequacies in the older adult in the community (Chen et
al. 2010).

9
The purpose of nutritional screening
The concept of screening comes from epidemiology. Its purpose is the early identification of
risk of a disease or disorder so that early treatment may be initiated resulting in a decrease in
the disease related mortality and morbidity (Phelan and Treacy 2012). The goal of effective
nutrition screening for the older adult in the community is to facilitate the prevention and
early detection of nutrition related complications that could contribute to medical
complications and decrease the ability to live independently. Thus, the purpose of nutritional
screening is to identify older adults who are malnourished or at risk of malnutrition (under or
over) in the community (Huhmann et al. 2012, Institute of Health 1998). There are clear
distinctions between nutritional screening and nutritional assessment. In nutritional screening,
the intervention is aimed at establishing whether an individual is malnourished, or at risk of
becoming malnourished. Nutritional assessment may follow nutritional screening if the
patient is considered at risk or malnourished. Nutritional assessment involves a more
comprehensive assessment including an examination of functional, nutritional and metabolic
variables and is usually performed by a dietician, clinician or a nutritional nurse (Kondrup et
al. 2003). For the purpose of this review, the focus is on nutritional screening to identify a
patient at risk of malnutrition (under and over). Nutritional assessment in the review is an in
depth assessment following screening completed by a dietician or clinician. The Institute of
Health’s (1998) recommendation for the assessment of overweight and obesity is based on
the determination of total body fat. Several methods are available to determine or calculate
body fat such as total body water, total body potassium, bio-electrical impedance and dual-
energy X-ray absorptiometry. However, many these techniques are expensive and not readily
available or indeed practical in the community setting (Institute of Health 1998). In addition,
such methods offer no significant advantage over BMI calculation therefore using BMI is the
most suitable method for assessing overweight and obesity in the community.
Choosing a screening tool requires consideration of a wide range of issues, including the
intended purpose of the tool, its reliability and validity and practical issues associated with its
implementation (Elia and Stratton 2011). In a literature review by Green & Watson (2006),
screening for malnutrition in the older adult in the community is identified as difficult and no
single measure can be used in isolation to assess risk of malnutrition. The older person covers
a heterogeneous group from 65 years of age and the disease process can influence
measurements used to assess for malnutrition, for example, in the case of oedema and
curvature of the spine. Elia and Stratton (2011) reviewed the considerations for screening tool
selection and the role of predictive and concurrent validity. Screening tools are described as
being designed for different aims, applications and processes as delineated below in table 1.2
(Elia and Stratton 2011).

Table 1.2: Aims, applications and processed in nutrition screening tools (Elia and
Stratton 2011)

10
 Aims 1. To identify nutritional status eg Mini
Nutritional Assessment MNA which screens
for malnutrition but not obesity.
2. To identify the need for nutritional
intervention eg Malnutrition Universal
Screening Tool (MUST), this screens to
establish need for nutritional risk and
includes obesity.
3. To predict healthcare use eg Nutritional
Risk index which predicts healthcare
utilisation rather than nutritional status.
Applications The utilisation of screening tools vary
according to the healthcare setting, age,
disease and public health nutrition.
Processes This applies to the user of the screening tool,
doctor, nurse dietician or self.

When considering screening tools, it is imperative that a screening tool meets the following
criteria: a) validity, b) reliability, c) ease of use, d) sensitivity and e) specificity (Perry 2009,
Elia and Stratton 2011, Philips 2010). Validity means the tool must have the ability to give a
true measure of a patient’s degree of risk. It has many dimensions, face, content, construct,
criterion, concurrent and predictive. In case of nutritional screening tools, concurrent and
predictive validity is considered particularly important due to suitability and merit for clinical
use (Philip 2010, Elia and Stratton 2011). In terms of reliability, the tool must be able to give
consistent results when used by different people. Again, this is important for nutritional
screening as if two different healthcare professionals used the same tool, with the same
person in the same setting and at the same time, they should get a similar inter-rater result
(where the findings remain the same) (Philips 2010, Elia and Stratton 2011). Ease of use is
important in the community setting as measurement is conducted in the person’s own home
or community health centre setting (Elia and Stratton 2011). Sensitivity is the ability to detect
the ‘risk’ when risk it truly present, reflecting the accuracy of the tool (Perry 2009).
Specificity refers to the tool’s ability to produce a negative result when the patient being
screened is not ‘at risk’, thus correctly identifying patients who are not at risk. However, it
should be noted that “the accuracy (sensitivity & specificity) of screening depends on the
accuracy of the specific screening tool used. It cannot be determined precisely for any
malnutrition screening tool because there is no recognised gold standard for the measurement
of malnutrition.” (NICE 2006:367). Another important issue is to consider the training and
education of nurses in screening for malnutrition in the community. For example, who will
provide the training? Or what is the cost effectiveness of the screening tool? (Philips et al.
2010). When reviewing the literature for nutritional screening in the community, screening
tools that met all of the aforementioned criteria and considerations were only included in the
review. These were the Malnutrition Universal Screening Tool (MUST) and the Mini
Nutritional Assessment (MNA) tool.

The NICE (2006) guidelines for nutrition support in adults

11
The National Institute for Clinical Excellence (2006) has identified screening guidelines
across healthcare settings. These guidelines do not mention excess nutrient provision
(obesity) however screening for obesity is included by assessing Body Mass index (BMI).
Screening for malnutrition or the risk of malnutrition should only be carried out by healthcare
professionals with appropriate skills and training (NICE 2006). The NICE guidelines
recommend screening for malnutrition in all hospital patients on admission and all outpatients
at their first outpatient clinic appointment. Screening for care homes residents has been
recommended when there is a concern related to nutrition. However, in Ireland, in residential
care, the Health Information and Quality Authority (HIQA 2008), the Irish health regulatory
body, introduced mandatory screening for malnutrition under the National Quality Standards
for Residential Care Settings for Older People (HIQA 2008) and this resulted in a focused
care imperative related to the nutritional status of older people in residential care. Despite this
guidance for malnutrition, HIQA recommendations do not include explicit screening for
obesity.
Following tool recommendations from the HSE (2008), the screening tool of choice in
residential care settings is the MUST. In the hospital setting, the guidelines for preventing
under-nutrition in Acute Hospitals (DOHC 2009) recommends every patient must be assessed
for nutritional risk by nursing staff within 24 hours of admission to hospital. The nutritional
risk screening method must be evidence based and the recommended for screening is also the
MUST. In Ireland, there is no mandatory screening of the older adult in the community
therefore malnutrition risk or malnutrition (both under and over) is not screened for routinely
in the community by nurses or in general practice. In view of the health and economic impact
of nutritional problems for older people, this lack of standardisation demonstrates a gap in
primary and secondary public health potential.

Screening Tools
Several studies have examined the use of screening tools in the community setting by
healthcare staff. In a qualitative study by Green et al. (2013), the barriers and facilitators to
screening for malnutrition in the community by community nurses was examined using the
MUST screening tool. The thematic findings that emerged from the research were that
professional judgement as good as screening, time and resources were needed to screen and
intervene, nurses could be immersed in an supportive or unsupportive organisational culture
(which impacted nutritional screening), there was a need for training and sharing of good
practice with staff needing to experience ease and acceptability of the screening tool and,
finally better communication between care settings was essential. One of the limitations of
this study was the interviewed number of community nurses was low, with only 20
participants. In addition, the research was carried out in one health trust and may not be
reflective of the community as a whole.
A systematic literature review by Philips et al. (2010) examined nutritional screening tools in
community dwelling older adults. The study revealed that although many nutritional
screening tools have been developed, few have been evaluated for use in the care of older
adult in the community setting. Ten screening tools were identified for use in community-
dwelling older adults and subjected to validity and/or reliability testing: Mini Nutritional
Assessment-Short Form (MNA-SF), Malnutrition Universal Screening Tool (MUST),

12
Nutrition Screening Initiative (NSI), which includes the DETERMINE checklist and Level 1
and 11 Screen, Australian Nutritional Screening Initiative (ANSI), Seniors in the
Community: Risk Evaluation for Eating and Nutrition (SCREEN I and SCREEN II), Short
Nutritional Assessment Questionnaire (SNAQ), Simplified Nutritional Appetite
Questionnaire (SNAQ) and two unnamed tools. In a literature review by Philips et al. (2010)
the ‘MUST’ screening tool’s overall rating for validity, reliability and acceptability was
similar to the MNA-SF and Screen II. In the review by Philips et al. 2010, it reported
discussion on ease of use of screening tools and the results were mixed with participants
rating tools (MUST, MNA-SF, Screen II) as ‘very easy’ to ‘difficult’ to use in practice.
Philips concluded that of the tools assessed with older adults in the community setting, the
MNA-SF appears to be the most appropriate tool although further reliability testing and
continued validation through sound methodological studies needed to be conducted For the
purposes of this literature review, the MNA tool in all its forms and the MUST screening tool
will be discussed as applicable in the community setting. A limitation of this review is that
only two screening tools are considered, However, a pragmatic choice was made by the
authors due to the MUST and MNA tool being the most widely used tools in Ireland.

Malnutrition Universal Screening Tools (MUST)

The MUST was developed by the Malnutrition Advisory Group, a standing committee of
BAPEN (British Association for Parental and Enteral Nutrition) and it has been reviewed
regularly since its launch since 2003. It is supported by many governmental and non-
governmental organisations including the British Dietetic Association (BDA), the Royal
College of Nursing (RCN) and the Registered Nursing Home Association (RNHA) and is the
most commonly used screening tool in the UK (Russell and Elia 2010). The purpose of the
MUST screening tool is to help identify adults who are underweight and at risk of
malnutrition as well as those who are obese. The MUST has been evaluated in hospitals,
outpatient clinics, general practice, community and care homes. Using the MUST screening
tool to categorise patients for their risk of malnutrition was found to be rapid, easy,
reproducible and consistent (BAPEN 2003).
The MUST tool involves assessment of weight status (BMI), change in weight, and the
presence of an acute disease resulting in no dietary intake for more than 5 days (or likely to
result in no dietary intake for more than 5 days). It can also be viewed as tracing the clinical
journey of the patient, from the past (history of unintentional weight change) to the present
(current weight status or BMI) and into the future (likely effect of underlying condition). All
three components can independently influence clinical outcome. In situations where weight
and height cannot be measured, self-reported measurements, other surrogate measurements,
and clinical judgment can be used to reliably estimate underweight, obesity and overall
malnutrition risk. The tool categorises patients into low, medium, or high risk of malnutrition
and identifies the obese. It provides guidance on the interpretation of measurements, and
suggests appropriate care plans, which can be modified to take into account local policy and
resources.

There are 5 steps in the MUST process as described in table 1.3

Table 1.3 How to screen using the ‘MUST’

13
Step BMI: Body mass index gives an interpretation of chronic protein-energy status
1 based on an individual’s height or weight.
Subjective criteria: In circumstances where height or weight or BMI cannot be
obtained, the following criteria can help form a clinical risk impression of an
individual’s overall nutritional risk category. BMI can be reviewed subjectively
on clinical impressionby examining if the individual is thin, has an acceptable
weight or is overweight. Obvious wasting (very thin) and obesity (very
overweight) can be noted.
Step Weight loss: Unplanned weight loss over 3-6 months is a more acute risk factor
2 for malnutrition than BMI. To establish weight loss score, ask if there has been
weight loss in the last 3-6 months, and if so how much, or it may be in the medical
records.
Deduct the current weight from the previous weight to calculate amount of weight
lost. If the patient has lost no weight, then score 0 –(no risk). If they have lost
between 5-10% total body weight, score 1 –(at risk) and if they have lost greater
than 10% body weight, score 2- (malnourished). Subjective criteria includes
where there is no weight height or BMI available, and/or where clothes and
jewellery have become loose fitting. It may also be noted there is a history of
decreased food intake, reduced appetite or dysphagia over a 3-6 month period.

Step Acute disease can affect risk of malnutrition. If the patient is currently affected by
3 any acute patho-physiological conditions and there has been no nutritional intake
for 5 days, they are likely to be at nutritional risk. A score of 2 is added to the
score.

Step Overall risk of malnutrition. This is achieved by adding the scores from step 1,2
4 and 3 to calculate overall risk of malnutrition.
Score 0= low risk, 1=medium risk, 2 or more =high risk.

Step Management guidelines which puts in place a plan of care and reassessing as per
5 risk and local and national guidelines.

The MUST screening tool is the tool for screening in the community recommended by NICE,
2006 and is the most popular nutritional assessment tool in the UK and Ireland. Scott (2008)
outlined how an adjusted version of the MUST used in the acute setting can be adapted for
use in the community. Where the option of weighing a patient with a calibrated scales is
unavailable, for example in a person’s home, the Mid Upper Arm Circumference (MUAC)
will determine an estimated BMI. Changes in MUAC reflect a change in BMI. This ensures
older adults can be assessed for malnutrition in their own home. One of the strengths of the
MUST tool is that, unlike the MNA, it screens for both malnutrition and obesity in the older
adult (Elia and Russell 2009). One of the benefits of the MUST screening tool is that it may
be used across the spectrum of healthcare settings, so screening conducted initially in one
setting (eg community) can be easily transferred and utilised to another setting (ie hospital).
In this way, deterioration or improvement can be analysed seamlessly.

14
Mini Nutritional Assessment (MNA)

The MNA (Guigoz et al. 1994) is a validated nutrition screening and assessment tool that can
identify older people aged 65 and above who are malnourished or at risk of malnutrition. The
MNA assesses issues specific to ageing such as functionality, depression, dementia as well as
anthropometric measures, social situation and food patterns. The original MNA was
developed in 1994 and was a two part assessment with an 18-item questionnaire developed
by practicing geriatricians in the United States and Europe and scientists with the Nestle
Research Centre to assess Nutritional status of adults over 65 (Guigoz et al. 1994). It takes
approximately 15 minutes to complete. Using a 30-point scoring system, the MNA identifies
patients as well nourished, at risk of malnutrition, or malnourished. It is part of the
comprehensive geriatric assessment. Although the MNA was developed for malnutrition, as it
measures BMI the MNA can also identify obesity.
Mini nutritional assessment Screen
The first 6 questions focus on Screening
A Has food intake declined over the past 3 months, (score 0-2)
due to loss of appetite, digestive, digestive
problems, chewing or swallowing difficulties
B Involuntary weight loss during the last 3 months (score 0-3)
C Mobility (Score 0-2)
D Has the patient suffered psychological stress or (score 0-2)
acute disease in the past 3 months
E Neuropsychological problems (score 0-2)
F Body mass index (score 0-3)

The screening score maximum for this section is 14. The scores translate to:
12-14 Normal nutritional status
8-11 At risk of malnutrition

Part two of the MNA focuses on Assessment

Assessment
G Lives independently (Score 0-1)
H Takes more than 3 prescription drugs per day (score 0-1)
I Pressure score or skin ulcer. (score 0-1)
J How many full meals does the patient eat daily (score 0-3)
K Selected consumption markers for protein (score 0-3)
consumption
L Consumes two or more servings of fruit or (Score 0-1)
vegetables per day.
M How much fluid is consumed is consumed per day (score 0-1)
N Mode of feeding (score 0-2)

15
O Self-view of nutritional status (score 0-2)
P In comparison with people of the same age, how (score 0-2)
does the patient consider his/her health status
Q Mid arm circumference in cm (score 0-1)
R Calf circumference in cm (score 0-1)

The assessment score maximum points is 16

Screening and assessment scores are cumulated to give an overall score
The malnutrition indicator score can be determined as follows:
24-30 points Normal nutrition status
17-23.5 points At risk of Malnutrition
Less than 17 points malnourished.
Although the original MNA is an excellent tool for the research setting (as it provides
additional information about the causes of malnutrition), its use was considered time
consuming. The requirement to complete the full 18 questions of two step MNA (version 2)
limited its use in clinical practice (Skates and Anthony 2012). In 2001, Rubenstein et al
devised MNA short form (MNA-SF). The MNA-SF takes approximately 5 minutes to
complete. It comprises of the first 6 questions of the full MNA and retains the accuracy and
validity of the full MNA. The MNA-SF is the preferred form of the MNA for clinical practice
in the community, hospital or long term care settings, due to its ease of use and practicality.
In 2009, Kaiser et al achieved validation for the MNA-SF as a stand-alone tool for nutritional
assessment which also included an option to substitute calf circumference when BMI is not
available allowing individuals who cannot be weighed or measured to be nutritionally
screened. Once screening is completed the nurses’ role is to identify malnutrition and refer to
specialist for comprehensive assessment ensuring appropriate treatment is initiated.

Discussion
The community nurse’s role in health education of the older adult is pivotal to assess for
nutritional health challenges. A comprehensive assessment of the older person, should
include a screening tool, and the community nurse should also assess predisposing and
contextual factors for weight loss and obesity such as depression, bereavement, or isolation.
Education regarding an appropriate diet for the older adult is essential and care planning
goals should focus on a partnership approach with the older person and, if present, his/her
caregiver, to develop reasonable and acceptable methods of journeying to a healthy weight
status. Meeting the nutritional requirements of the older adult can be a challenge because of
the age related changes that interfere with optimal food intake. One of the issues can be a
reduction in appetite and there are many simple advice guidelines available (for example,
Food first Advice Leaflet (DHSSP)) which outline how to eat well with a small appetite. The
community nurse can use such leaflets to discuss how to eat well and consider options
suitable to the individual needs of the older person. Such care planning should include a
discussion on why eating is essential to health and well-being and the importance of three
balanced meals a day. It is also important to discuss the different food groups, their

16
recommended daily allowances and give pragmatic examples of each. The community nurse
can discuss food fortification for older adult who has lost weight and give examples how to
make their food more nutrient dense. In terms of obesity, the community nurse can discuss
low fat diets and low calorie diets and look at how daily intakes can be substituted with
appropriate foods. Where an older adult is at high risk, the involvement of the
multidisciplinary team is necessary for full assessment when required. The importance of this
is to identify an underlying cause for malnutrition or obesity and treat appropriately. As there
may be a complex presenting case, the multidisciplinary team needs to be involved for
optimum success. The community nurse, the general practitioner, the geriatrician and
dietician need to collaboratively work with the older adult in conjunction with the family for
optimal success. Areas that may need to be considered include the older adult’s ability to
shop, dexterity and understanding, food choices, exercises and referral, if needed to other
agencies. In the community, family support and involvement are essential, where possible. In
addition, at a community level, there may be opportunities to have education sessions for
older people with regard to nutritional health or exercise specific to this population group.
The community nurse’s role is to inform and educate the older adult of the services available
in the community.

Conclusion
Malnutrition and obesity are significant public health challenges for older people in
contemporary society. It is desirable to discover malnutrition in the older adult at the earliest
possible stage in the community before severe consequences have set in so that early and
prompt intervention can be initiated. Similarly, older adults are likely to benefit from
diagnosis of obesity and initiation of intensive lifestyle interventions (McTigue et al 2012).
Community nurses are ideally situated to identify nutrition issues among older adults as they
are at the forefront of client care in the home (Rist et al. 2012). They have an important role
to play in assessment and the subsequent provision and monitoring of basic nutrition
interventions as part of an interdisciplinary team with direction and guidance from a dietician
led program (Rist et al. 2012). With appropriate training, nutritional assessment can be
completed by the community nurse and where necessary referral should be enabled to
specialist care, otherwise the value of screening is undermined (Green 2013). Currently,
Ireland has no standard in assessing the nutritional status of older people in the community.
In healthcare settings such as hospital and residential care settings, where it is compulsory to
screen on admission an integral part of policy guidelines, nutritional assessment compliance
is better. Assessment should be based on valid and reliable tools which allow ease of use,
such as the MNA and the MUST. Thus, in the community, nutritional screening needs to be
mandatory to ensure primary and secondary intervention is mobilised as soon as possible and
to prevent a deterioration in health status. Consequently, screening needs to be initiated at an
organisational level where there is clear policy and guidelines to screen with the appropriate
training and equipment. The community nurse is the key link to assess, identify and treat
malnutrition in the community as optimising public health and health promotion are central
aspects in their professional role. This is particularly important in the context of optimising
health in a rising population of older people both in Ireland and globally. Moreover, in fiscal
termsThe evidence has shown that the cost of treating malnutrition is less than the total
healthcare costs of treating the consequences of malnutrition.

17
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