Malnutrition in Geriatric Rehabilitation: Prevalence, Patient Outcomes, and Criterion Validity of the Scored Patient-Generated Subjective Global Assessment and the Mini Nutritional Assessment

      Abstract

      Background

      Accurate identification and management of malnutrition is essential so that patient outcomes can be improved and resources used efficaciously.

      Objectives

      In malnourished older adults admitted to rehabilitation: 1) report the prevalence, health and aged care use, and mortality of malnourished older adults; 2) determine and compare the criterion (concurrent and predictive) validity of the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and the Mini Nutritional Assessment (MNA) in diagnosing malnutrition; and 3) identify the Scored PG-SGA score cut-off value associated with malnutrition.

      Design

      Observational, prospective cohort.

      Participants/setting

      Participants were 57 older adults (65 years and older; mean±standard deviation age=79.1±7.3 years) from two rural rehabilitation units in New South Wales, Australia.

      Measurements/statistical analysis

      Scored PG-SGA; MNA; and the International Statistical Classification of Diseases and Health Related Problems, 10th revision, Australian Modification (ICD-10-AM) classification of malnutrition were compared to establish concurrent validity and report malnutrition prevalence. Length of stay, discharge location, rehospitalization, admission to a residential aged care facility, and mortality were measured to report health-related outcomes and to establish predictive validity.

      Results

      Malnutrition prevalence varied according to assessment tool (ICD-10-AM: 46%; Scored PG-SGA: 53%; MNA: 28%). Using the ICD-10-AM as the reference standard, the Scored PG-SGA ratings (sensitivity 100%, specificity 87%) and score (sensitivity 92%, specificity 84%, ROC AUC [receiver operating characteristics area under the curve]=0.910±0.038) showed strong concurrent validity, and the MNA had moderate concurrent validity (sensitivity 58%, specificity 97%, receiver operating characteristics area under the curve=0.854±0.052). The Scored PG-SGA rating, Scored PG-SGA score, and MNA showed good predictive validity. Malnutrition can increase the risk of longer rehospitalization length of stay, admission to a residential aged care facility, and discharge to hospital or residential aged care facility instead of home.

      Conclusions

      Malnutrition prevalence in the geriatric rural rehabilitation population is high, and is associated with increased health and aged care use. The Scored PG-SGA ratings and score are suitable for nutrition assessment in geriatric rehabilitation. The MNA may be suitable for nutrition assessment in geriatric rehabilitation, but care should be taken to ensure all malnourished patients are identified. Additional examination of the criterion validity of the Scored PG-SGA and MNA will lend confidence to these findings.

      Keywords

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      References

        • Kunert M.P.
        Stress and adaptation.
        in: Porth C.M. Pathophysiology, Concepts of Altered Health States. 7th ed. Lippincott Williams & Wilkins, Philadelphia, PA2005: 187-276
        • Marshall S.
        • Bauer J.
        • Isenring E.
        The consequences of malnutrition following discharge from rehabilitation to the community: A systematic review of current evidence in older adults.
        J Hum Nutr Diet. 2014; 27: 133-141
        • Wellman N.S.
        • Kamp B.J.
        Nutrition in aging.
        in: Mahan L.K. Escott-Stump S. Krouse's Food & Nutrition Therapy. 12th ed. MO Saunders Elsevier, St Louis2008: 286-308
        • Watterson C.
        • Fraser A.
        • Banks M.
        • et al.
        Evidence based practice guidelines for the nutritional management of malnutrition in patients across the continuum of care.
        Nutr Diet. 2009; 66: S1-S34
        • Lacey K.
        • Prichett E.
        Nutrition care process and model: ADA adopts road map to quality care and outcomes management.
        J Am Diet Assoc. 2003; 103: 1061-1072
        • Field L.
        • Hand R.
        differentiating malnutrition screening and assessment: A Nutrition care process perspective.
        J Acad Nutr Diet. 2015; 115: 824-828
        • Vellas B.
        • Guigoz Y.
        • Garry P.J.
        • et al.
        The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients.
        Nutrition. 1999; 15: 116-122
        • Vellas B.
        • Villars H.
        • Abellan G.
        • et al.
        Overview of the MNA—Its history and challenges.
        J Nutr Health Aging. 2006; 10: 456-465
        • Bauer J.
        • Capra S.
        • Ferguson M.
        Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer.
        Eur J Clin Nutr. 2002; 56: 779-785
      1. Marshall S, Young A, Bauer J, Isenring E. Malnourished older adults admitted to rehabilitation in rural New South Wales remain malnourished throughout rehabilitation and once discharged back to the community: A prospective cohort study J Aging Res Clin Practice. In press.

        • Ottery F.D.
        Patient-Generated Subjective Global Assessment.
        in: McCallum P.D. Polisena C.G. The Clinical Guide to Oncology Nutrition. American Dietetic Association, Chicago, IL2000: 11-23
        • Ottery F.D.
        Rethinking nutritional support of the cancer patient: The new field of nutritional oncology.
        Semin Oncol. 1994; 21: 770-778
        • Sheard J.M.
        • Ash S.
        • Mellick G.D.
        • Silburn P.A.
        • Kerr G.K.
        Nutrition screening and assessment in Parkinson’s disease: A comparison of methods.
        e-SPEN J. 2013; 8: e187-e192
        • Kahokehr A.A.
        • Sammour T.
        • Wang K.
        • Sahakian V.
        • Plank L.D.
        • Hill A.G.
        Prevalence of malnutrition on admission to hospital—Acute and elective general surgical patients.
        e-SPEN J. 2010; 5: e21-e25
        • Bauer J.
        • Egan E.
        • Clavarino A.
        The Scored Patient-Generated Subjective Global Assessment is an effective nutrition assessment tool in subjects with chronic obstructive pulmonary disease.
        e-SPEN J. 2011; 6: e27-e30
        • Desbrow B.
        • Bauer J.
        • Blum C.
        • Kandasamy A.
        • McDonald A.
        • Montgomery K.
        Assessment of nutritional status in hemodialysis patients using Patient-Generated Subjective Global Assessment.
        J Ren Nutr. 2005; 15: 211-216
        • Martineau J.
        • Bauer J.D.
        • Isenring E.A.
        • Cohen S.
        Malnutrition determined by the Patient-Generated Subjective Global Assessment is associated with poor outcomes in acute stroke patients.
        Clin Nutr. 2005; 24: 1073-1077
        • Byles J.
        • Perry L.
        • Parkinson L.
        • et al.
        Encouraging Best Practice Nutrition and Hydration in Residential Aged Care.
        (Final report) Australian Government Department of Health & Ageing, Canberra2009
      2. Australian Institute of Health and Welfare. Rural, regional and remote health: A guide to remoteness classifications. AIHW cat. no. PHE 53. Published 2004. Canberra: AIHW. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459567. Accessed June 21, 2015.

        • National Centre for Classification in Health
        Australian Coding Standards for I.C.D.-10-AM.
        National Centre for Classification in Health, Sydney, Australia2008
        • Agarwal E.
        • Ferguson M.
        • Banks M.
        • Bauer J.
        • Capra S.
        • Isenring E.
        Malnutrition coding shortfalls in Australian and New Zealand hospitals.
        Nutr Diet. 2015; 72: 69-73
        • Bell J.
        • Bauer J.
        • Capra S.
        • Pulle R.
        Concurrent and predictive evaluation of malnutrition diagnostic measures in hip fracture inpatients: A diagnostic accuracy study.
        Eur J Clin Nutr. 2014; 68: 358-362
        • Bell J.J.
        • Bauer J.D.
        • Capra S.
        • Pulle R.C.
        Quick and easy is not without cost: Implications of poorly performing nutrition screening tools in hip fracture.
        J Am Geriatr Soc. 2014; 62: 237-243
      3. Nutrition Screening As Easy As MNA: A Guide To Completing The Mini Nutritional Assessment (MNA). Lausanne, Switzerland: Nestlé Nutrition Institute. http://www.mna-elderly.com/forms/mna_guide_english_sf.pdf. Accessed July 3, 2015.

        • Šimundić A.-M.
        Measures of diagnostic accuracy: Basic definitions.
        Med Biol Sci. 2008; 22: 61-65
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Marshall S.
        • Young A.
        • Bauer J.
        • Isenring E.
        Nutrition screening in geriatric rehabilitation: Criterion (concurrent and predictive) validity of the Malnutrition Screening Tool and the Mini Nutritional Assessment-Short Form.
        J Acad Nutr Diet. 2016; 116: 795-801
        • Pagano M.
        • Gauvreau K.
        • Pagano M.
        Principles of Biostatistics. Vol. 2. Duxbury Press, Pacific Grove, CA2000
        • Deeks J.J.
        • Higgins J.P.
        Statistical algorithms in Review Manager 5.
        Statistical Methods Group of The Cochrane Collaboration, Oxford, UK2010: 1-11
        • Glas A.S.
        • Lijmer J.G.
        • Prins M.H.
        • Bonsel G.J.
        • Bossuyt P.M.
        The diagnostic odds ratio: A single indicator of test performance.
        J Clin Epidemiol. 2003; 56: 1129-1135
        • Neumann S.A.
        • Miller M.D.
        • Daniels L.
        • Crotty M.
        Nutritional status and clinical outcomes of older patients in rehabilitation.
        J Hum Nutr Diet. 2005; 18: 129-136
        • Visvanathan R.
        • Penhall R.
        • Chapman I.
        Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes.
        Age Ageing. 2004; 33: 260-265
        • Charlton K.
        • Nichols C.
        • Bowden S.
        • et al.
        Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up.
        Eur J Clin Nutr. 2012; 66: 1224-1228
        • Beck E.
        • Patch C.
        • Milosavljevic M.
        • et al.
        Implementation of malnutrition screening and assessment by dietitians: Malnutrition exists in acute and rehabilitation settings.
        Nutr Dietet. 2001; 58: 92-97
        • Shum N.
        • Hui W.
        • Chu F.
        • Chai J.
        • Chow T.
        Prevalence of malnutrition and risk factors in geriatric patients of a convalescent and rehabilitation hospital.
        Hong Kong Med J. 2005; 11: 234-242
        • Tsai A.C.
        • Shih C.L.
        A population-specific Mini-Nutritional Assessment can effectively grade the nutritional status of stroke rehabilitation patients in Taiwan.
        J Clin Nurs. 2009; 18: 82-88
        • Compan B.
        • Di Castri A.
        • Plaze J.
        • Arnaud-Battandier F.
        Epidemiological study of malnutrition in elderly patients in acute, sub-acute and long-term care using the MNA.
        Age Nutr. 2000; 11: 33-39
        • Kaiser M.J.
        • Bauer J.M.
        • Ramsch C.
        • et al.
        Frequency of malnutrition in older adults: A multinational perspective using the Mini Nutritional Assessment.
        J Am Geriatr Soc. 2010; 58: 1734-1738
        • Westergren A.
        • Karlsson S.
        • Andersson P.
        • Ohlsson O.
        • Hallberg I.R.
        Eating difficulties, need for assisted eating, nutritional status and pressure ulcers in patients admitted for stroke rehabilitation.
        J Clin Nurs. 2001; 10: 257-269
        • Westergren A.
        • Unosson M.
        • Ohlsson O.
        • Lorefalt B.
        • Hallberg I.R.
        Eating difficulties, assisted eating and nutritional status in elderly (> or = 65 years) patients in hospital rehabilitation.
        Int J Nurs Stud. 2002; 39: 341-351
        • Neumann S.A.
        • Miller M.D.
        • Daniels L.A.
        • Ahern M.
        • Crotty M.
        Mini Nutritional Assessment in geriatric rehabilitation: Inter-rater reliability and relationship to body composition and nutritional biochemistry.
        Nutr Diet. 2007; 64: 179-185
        • Chumlea W.C.
        • Hall G.
        • Lilly F.
        • Siervogel R.
        • Guo S.S.
        The Mini Nutritional Assessment and body composition in healthy adults.
        Nestle Nutr Workshop Ser Clin Perform Programme. 1999; 1 (discussion 21-2): 13-21
        • Miller D.K.
        • Perry H.
        • Morley J.E.
        Associations among the Mini Nutritional Assessment instrument, dehydration, and functional status among older African Americans in St. Louis, Mo., USA.
        Nestle Nutr Workshop Ser Clin Perform Programme. 1999; 1: 79-86
        • Young A.M.
        • Kidston S.
        • Banks M.D.
        • Mudge A.M.
        • Isenring E.A.
        Malnutrition screening tools: Comparison against two validated nutrition assessment methods in older medical inpatients.
        Nutrition. 2013; 29: 101-106
        • Persson M.D.
        • Brismar K.E.
        • Katzarski K.S.
        • Nordenström J.
        • Cederholm T.E.
        Nutritional status using Mini Nutritional Assessment and Subjective Global Assessment predict mortality in geriatric patients.
        J Am Geriatr Soc. 2002; 50: 1996-2002
        • Christensson L.
        • Unosson M.
        • Ek A.
        Evaluation of nutritional assessment technique in elderly people newly admitted to municipal care.
        Eur J Clin Nutr. 2002; 56: 810-818
      4. Australian Government. Caring for Older Australians. Vol. 1. Productivity Commission, Canberra, Australia2011
      5. Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes. National Health and Medical Resarch Council, Canberra, Australia2005
        • Perissinotto E.
        • Pisent C.
        • Sergi G.
        • Grigoletto F.
        • Enzi G.
        Anthropometric measurements in the elderly: Age and gender differences.
        Br J Nutr. 2002; 87: 177-186

      Biography

      S. Marshall is a PhD candidate, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia.

      Biography

      A. Young is an accredited practising dietitian, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.

      Biography

      J. Bauer is an associate professor, Nutrition and Dietetics, School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Queensland, Australia.

      Biography

      E. Isenring is a professor, Nutrition and Dietetics, Faculty of Health Sciences and Medicine, Bond University, Bond Institute of Health and Sport, Robina, Queensland, Australia.