EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To evaluate the nutritional status of all individuals in assisted accommodation (such as service flats, old people's homes, group living for the demented and nursing homes) in three Swedish municipalities.

Inclusion Criteria:

The study population comprised all 994 individuals in assisted accommodation, in 12 service flats and in types with 24-hour care: nine old people's homes, seven group living for the demented and five nursing homes.

Exclusion Criteria:

53 did not want to participate
12 were seriously ill
seven could not be measured
50 had other reasons, such as severe contractures.

Description of Study Protocol:

Recruitment

The study population comprised all 994 individuals in assisted accommodation, in 12 service flats and in types with 24-hour care: nine old people's homes, seven group-living for the demented and five nursing homes. Three locations were included in the study: two country municipalities (one in northern and one in southwestern Sweden) and a district administration in urban Stockholm.

Design

Cross-sectional study.

Statistical Analysis

For comparisons between groups, analysis of variance and Bonferroni's test for multiple comparisons were used
Pearson's correlation coefficients were determined in correlation analyses
For nominal variables, group comparisons were made using the chi-square analysis.

Data Collection Summary:

Timing of Measurements

Subjects received an examination and Mini Nutritional Assessment (MNA).

Dependent Variables

Nutritional status measured using MNA scale (0 to 30 points), consisting of 18 point-weighted questions in 4 categories (anthropometry, global and dietary issues, and self-assessment)
Anthropometry included BMI, mid-upper arm and calf circumferences, and weight loss during the previous three months
Fewer than 17 points indicates malnutrition, 17 to 23.5 points indicates a risk for malnutrition and more than 24 points indicates that the person is well-nourished
Neuropsychological problems measured with the Berger scale
Pressure sores assessed according to a visual staging method
Two dietitians and two district nurses were responsible for data collection in the three locations.

Independent Variables

Institutionalization in service flats, old people's homes, group living for the demented or nursing homes.

Description of Actual Data Sample:

Initial N: 994 eligible subjects. 122 (15%) were not examined. 53 did not want to participate, 12 were seriously ill, seven could not be measured and 50 had other reasons, such as severe contractures.

Attrition (final N): 872 examined (69% female). 349 lived in service flats, 261 in old people's homes, 96 in group living for the demented and 166 in nursing homes.

Age: Mean age, 85 years±8 years

Ethnicity: Not mentioned

Location: Sweden.

Summary of Results:

Variables	All	Service Flats	Old People's Homes	Group Living for the Demented	Nursing Homes
Mean MNA points	18.6±4.9	20.8±4.6	18.5±4.2	18.3±4	14.2±3.9
MNA<17	36%	21%	33%	39%	71%
MNA 17-23.5	48%	49%	57%	51%	29%
MNA>23.5	16%	30%	10%	10%	---
Mean BMI	23.6±4.5	24.2±4.5	23.6±4.6	23.9±4.1	22.3±4.2
BMI<20	23%	18%	25%	19%	33%
BMI 21-23	32%	30%	30%	35%	37%
BMI 24-26	24%	28%	24%	22%	18%
BMI>27	21%	24%	21%	24%	12%

Other Findings

Malnutrition, defined as MNA less than 17, was noted in 36% of the study population. 418 (48%) were in the risk zone for malnutrition (17 to 23.5 points) and 140 (16%) were well-nourished (>24 points).

The average MNA score in the whole population was 18.6 points±5 points.

Divided according to accommodation type, the MNA scores were less than 17 in 21% of individuals in service flats, 33% of those in old people's homes, 39% of those in group living for the demented and 71% of those in nursing homes. The corresponding values for MNA scores 17 to 23.5 (risk for malnutrition) were 49%, 57%, 51% and 29%, respectively.

Mean BMI values were 24.2±4.5 (service flats), 23.6±4.6 (old people's homes), 23.9±4.1 (group living for the demented) and 22.3±4.2 (nursing homes).

BMI values less than 20 were found in 18% of those in service flats, in 25% of those in old people's homes, in 19% off those in group living for the demented and in 33% of those in nursing homes.

Both MNA and BMI correlated with upper arm and calf circumference, with r values ranging from 0.4 to 0.7 (P<0.001).

MNA and BMI correlated significantly (r=0.52, P<0.001).

Age correlated with MNA and BMI with r values of 0.1 (P<0.01) and 0.14 (P<0.001), respectively.

Subjects with significant help requirements during meals ate fewer whole meals per day than those who could feed themselves.

In the group of individuals with MNA less than 17, the mean number of pharmaceuticals prescribed was 5 (range, 0 to 14).

56% of the individuals with MNA less than 17 also had BMI less than 20, 50% had recent acute illness/psychological stress, 79% had reduced mobility, 90% were assessed as having neuropsychological problems, 20% had pressure sores or skin ulcers, 50% had reduced food intake during the previous three months due to poor appetite or chewing/swallowing difficulties, 47% drank less than one liter of fluid per day and 75% ate fewer than two meals per day.

Author Conclusion:

Based on the MNA, one third of the study subjects living in assisted accommodation, and more than half of those living in nursing homes seemed to be malnourished. Further studies are necessary to assess to what extent these nutritional disturbances are reversible.

Funding Source:

Government:

Swedish National Board of Health and Welfare

Reviewer Comments:

Representative of those living in assisted accommodation.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	N/A
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes