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Recommendations Summary

MiOA: Malnutrition Assessment in Long-Term Care (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    MiOA: Long-Term Care Mini-Nutritional Assessment

    We suggest that registered dietitian nutritionists use the Mini-Nutritional Assessment (MNA) for malnutrition assessment in older adults living in long-term care. The MNA is a valid tool that can identify older adults that are malnourished and may predict mortality.

    Rating: Level 1(C)
    Imperative

    MiOA: Long-Term Care Subjective Global Assessment and Patient-Generated Subjective Global Assessment

    We suggest that registered dietitian nutritionists consider using the Subjective Global Assessment (SGA) or Patient Generated Global Assessment (PGA-SGA) if use of the Mini-Nutritional Assessment (MNA) is not feasible for malnutrition assessment in older adults living in long-term care. The SGA and PG-SGA may be valid tools that can identify older adults with malnutrition, although more evidence is needed.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      No obvious harms or risks associated with the use of MNA or SGA for nutrition assessment in long-term care or the community were identified by the expert panel. Time and cost may be necessary to train dietitians to use the MNA or SGA. Both MNA, SGA, and Patient Generated Subjective Global Assessment (PG-SGA) have readily available online training materials and dietitians are typically familiar with these resources, or they are readily discoverable. Additional costs may be required for incorporating MNA or SGA into electronic health records or implementation into existing practices or procedures.  

    • Conditions of Application

      Effective identification and treatment for malnutrition first requires nutrition screening. Nutrition screening is a rapid and simple method to determine the risk of malnutrition and can efficiently identify older adults who need nutritional assessment and malnutrition diagnosis and subsequent nutrition care. The Academy recommends the use of the Malnutrition Screening Tool (MST) for all older adults, regardless of age, medical history, or setting. Additional information on nutrition screening can be found in the Evidence Analysis Library or in the systematic review and position papers published by Skipper et al 2020.1, 2

      Practitioners may consider using the Mini-Nutrition Assessment (MNA), or if it is not feasible to implement MNA, the Subjective Global Assessment (SGA) or Patient Generated Subjective Global Assessment (PG-SGA) to assess nutrition status, and potentially diagnose malnutrition. Feasibility to implement the MNA may be impacted by barriers such as current organizational policies and procedures. Unfortunately, there are no strong and valid agreed upon criteria to diagnose malnutrition in older adults among healthcare professionals. The Academy of Nutrition and Dietetics and the American Society for Enteral and Parenteral Nutrition (ASPEN) have identified six criteria measures for malnutrition, and the presence of two criteria measures may indicate malnutrition.3, 4 Some of the criteria on the MNA, SGA, and the PG-SGA align with criteria in the Academy/ASPEN indicators for malnutrition (AAIM).5

      For a truly effective, robust, and broad impact on large populations of older adults living in long-term care, a coordinated effort aimed toward infrastructure including administrative support, organizational policies, procedures, and integrated electronic health record information systems is required. Information systems, including interoperability between diverse organizations, will allow for the desired significant and sustained impact on patient care, resource utilization, costs, and improved health outcomes for older adults. Data obtained from the MNA and SGA complements existing LTC documentation requirements and demonstrates additional evidence to support clarification of the patient nutrition status. The MNA is free to incorporate into the electronic health records with permission; the SGA and PG-SGA offer mechanisms to also incorporate.  

      Nutrition care provided in the community often results in minimal interaction with dietitians. If nutrition assessments are performed, they are often performed by community care providers. Furthermore, nutrition screening tools are often used as assessment tools that may lead to inaccurate results for malnutrition diagnosis. Dietitians play a critical role in the decision to utilize appropriate tools in the community, such as the MNA or SGA, to help ensure positive outcomes for these individuals.

      Acceptability 

      No studies were identified that evaluated the perspectives of older adults in regard to nutrition assessment. However, a qualitative systematic review was conducted by Bullock et al. 20216 to evaluate the views and experiences of patients, family and caregivers on nutrition screening. Authors concluded that participants found the nutrition screening process acceptable. However, participants misunderstood the causes and consequences of malnutrition. Misunderstanding of malnutrition led to reduced risk perception and disbelief of nutrition screening results.  

      Implementation

      Table: Barriers and Facilitators for implementation of the Mini-Nutritional Assessment (MNA), Subjective Global Assessment (SGA) or Patient-Generated Subjective Global Assessment (PG-SGA) into daily practice living in Long-Term Care or Community Settings.

      Barriers Facilitators
       The setting unfamiliar with preventative malnutrition care.
      •  Education and training by dietitians to increase understanding of the depth of malnutrition
       Settings resistant to adding malnutrition assessment if screening is already in place
      •  Including all stakeholders in program development and clinical offices to create a seamless workflow and with minimal additional workload.
       Insufficient knowledge or competence of the workforce to use MNA and SGA.
      •  Training on the use of MNA, SGA, and increased familiarity with Academy/ASPEN Consensus characteristics for dietitians.
       Lack of consistency of care from acute settings to the community.
      •  Incorporation and interoperability of the MNA or SGA in electronic health records.
       Lack of time to use MNA and SGA by a practitioner
      •  The estimated time to perform MNA or SGA is approximately 10 to15 minutes. Materials and actions appropriate for risk severity can be developed and integrated for easy access within an integrated information system health record workflow.
       Difficulty adhering to and sustaining the incorporation of malnutrition assessment in daily practice.
      •  Collaborative, focused teams, including use of implementation science approaches, leaders, and change agents such as dietitians, information system analysts, physicians, nurse practitioners, physician assistants, administrators, nurses, front line caregivers, and insurance coverage benefits for medical nutrition therapy.
       Lack of Medicare coverage for Medical Nutrition Therapy provided by dietitians.
      •  Engage other health professionals in education and for appropriate triage and preventative education for lower-risk and generally healthy patients, and to refer higher risk patients or failed lower risk clients to qualified dietitians for intervention and management.
       Inequity for patients and clients who cannot understand MNA and SGA contents and who do not have the opportunity to be assessed by these tools.
      •  MNA, SGA and PG-SGA are available in multiple languages. Integrated into electronic information systems, and sustained care pathways for ambulatory and community clients to create equity of care by providing reliable and fair questions to all clients.
       Cost for applying MNA, SGA or PG-SGA into daily practice.
      •  Engage with skilled analysts and programmers within their organization for requirements to advance clinical programs.

      MNA=Mini-Nutritional Assessment; SGA=Subjective Global Assessment; PG-SGA=Patient Generated Subjective Global Assessment

      References

      1. Skipper A, Coltman A, Tomesko J, et al. Adult Malnutrition (Undernutrition) Screening: An Evidence Analysis Center Systematic Review. J Acad Nutr Diet. 2020;120(4):669-708.
      2. Skipper A, Coltman A, Tomesko J, et al. Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults. J Acad Nutr Diet. 2020;120(4):709-713.
      3. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
      4. Hand RK, Murphy WJ, Field LB, et al. Validation of the Academy/A.S.P.E.N. Malnutrition Clinical Characteristics. J Acad Nutr Diet. 2016;116(5):856-864.
      5. Jimenez EY, Long JM, Lamers-Johnson E, et al. Academy of Nutrition and Dietetics Nutrition Research Network: Rationale and Protocol for a Study to Validate the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus-Derived Diagnostic Indicators For Adult And Pediatric Malnutrition and to Determine Optimal Registered Dietitian Nutritionist Staffing in Acute Care Hospital Settings. J Acad Nutr Diet. 2022;122(3):630-639.
      6. Bullock AF, Greenley SL, Patterson MJ, McKenzie GAG, Johnson MJ. Patient, family and carer experiences of nutritional screening: a systematic review. J Hum Nutr Diet. 2021;34(3):595-603.

    • Potential Costs Associated with Application

      Time and cost may be necessary to train dietitians to perform the MNA or SGA. Both MNA, SGA, and PG-SGA have readily available online training materials and dietitians are typically familiar with these resources, or they are readily discoverable.  Additional costs may be required for incorporating MNA or SGA into electronic health records or implementation into existing practices or procedures. 

    • Recommendation Narrative

      Accurate and timely diagnosis of malnutrition for older adults living in LTC is essential for early nutrition intervention to decrease poor outcomes associated with malnutrition such as decreased physical function, quality of life,  and increased risk of mortality. Early diagnosis may also enable appropriate allocation of resources for nutrition care because resources in LTC are often limited compared to acute care. Currently, there are a wide variety of tools and processes used to assess nutrition status in older adults living in LTC.

      The Evidence Analysis Center conducted systematic reviews to identify valid and reliable tools to assess nutritional status. Eleven studies that evaluated the validity and reliability of malnutrition assessment tools in LTC were included in the systematic review (Munoz et al 2019, Cerda et al 2011, Cerda et al 2009, Chan et al 2010, Diekmann et al 2013, Donini et al 2011, Kaiser et al 2009, Tsai et al 2008, Tsai et al 2010, Veronese et al 2013, Keller, et al 2019, Christenson, et al 2002). Only two studies evaluated the concurrent validity of Mini-Nutritional Assessment (MNA) for diagnosing malnutrition, and no studies were identified that evaluated reliability. The MNA was found to have low validity for assessing malnutrition in older adults living in LTC (low certainty evidence) (Munoz 2019, Christens on 2002). Nine studies evaluated the predictive validity of MNA for mortality or hospitalization (Cerda 2009, Cerda 2011, Chan 2010, Diekamann 203, Donini 2011, Kaiser 2009, Tsai 2008, Tsai 2011, Veronese 2013). The MNA can predict mortality among older adults living in LTC (moderate certainty), and the predictive ability for hospitalization was unclear (very low certainty). No studies were identified that evaluated the ability of MNA to predict physical function in older adults living in LTC. 

      Two studies evaluated the validity of the SGA (Munoz 2019, Keller 2019),  and one study evaluated the validity of PG-SGA (Keller 2019) for the assessment of malnutrition in older adults in LTC (very low certainty). No studies were identified that evaluated the reliability or predictive validity of SGA or PG-SGA in LTC.

    • Recommendation Strength Rationale

      The evidence supporting the recommendations is based on Grades B (Moderate) and D (Very Low).

    • Minority Opinions

      None.