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Screening for Protein Energy Malnutrition

Course Authors

John E. Morley, M.D.

During the last three years, Dr. Morley has received grant/research support from Vivus, Merck & Co., Upjohn, B. Braun McGaw, Bayer Corp and Nestec, Ltd. He has also served on the Speakers' Bureau for LXN, Organon, Ross, Pharmacia & Upjohn, Glaxo Wellcome, Hoechst Marion Roussel, Searle, Merck & Co., Roche, Bristol-Myers Squibb, Novartis, Pratt, B. Braun McGaw, Pfizer and Parke-Davis.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Understand the need for screening for protein energy malnutrition in older persons

  • Understand the tools available to screen for malnutrition

  • Recognize that depression is the most common cause of protein energy undernutrition in older persons.

 

Older persons often have a tendency to physiological anorexia.(1) This places them at high risk for developing protein energy malnutrition when they develop a disease process. A number of studies have pointed out that physicians often overlook this problem and, so, fail to treat malnutrition in older persons.(2).(3),(4) Yet many causes of malnutrition are highly reversible and the use of caloric supplements is efficacious in improving nutritional status.(5),(6),(7)

Because protein energy malnutrition is poorly recognized by physicians, some screening instruments to increase awareness of malnutrition have been developed. The foremost and simplest screening tool is the ability to recognize weight loss. Provided the person is weighed at the same time of the day, a loss of weight of 2% in a month or 5% in six months is highly significant and should be explored.

Protein energy malnutrition has a number of deleterious effects:

  1. Pressure ulcers
  2. Anemia
  3. Immune dysfunction
    • decreased CD3 and CD4 cell number
    • lymphopenia
    • decreased T-cell proliferative response
    • decreased IL-1, IL-2, IL-6
    • decreased antibody responses to vaccines
  4. Infections
  5. Falls
  6. Hip fracture
  7. Dehydration
  8. Cognitive problems
  9. Decreased strength
  10. Death

Screening Tests

Three screening tests for protein energy malnutrition have been widely circulated:

  • The Nutrition Screening Initiative (NSI)(8)
  • The Mini-Nutritional Assessment (MNA)(9)
  • SCALES(10)

Nutritional Screening Initiative Checklist

Illness affects diet Eat <2 meals/day
Lost or gained 10 lb/6 mos. >3 alcohol drinks/day
Tooth/mouth problems impair eating Not enough money for food
Eat alone most of time >3 drugs/day
Eat few fruits, vegetables or milk products Unable to shop, cook, and/or feed myself

The NSI was developed by a consortium funded by Ross Laboratories as a tool to increase nutritional awareness by seniors. It can be self-administered and scored. It has never been adequately validated. It has been used for epidemiological studies in New England, St. Louis (among African Americans) and Russia.(11),(12),(*) Though it does increase nutritional awareness, the NSI appears to have poor specificity.

Mini-Nutritional Assessment

The MNA was developed by Professor Vellas from Toulouse and Yves Guigoz from Nestle, Switzerland. It was designed as a 30 point scale similar to the Mini-Mental Status Examination. It has been well validated both in France and the United States. It has been translated into multiple languages. A recent conference on the MNA was held in Switzerland. The MNA has been used in multiple research projects and appears to be highly correlated with nutritional status but, also, with the development of decreased functional status. Low MNA scores correlate with prolonged hospital stays and increased costs. The MNA improves with improved nutritional status. The widespread use of the MNA throughout the world has made it the screening test of choice, which allows communication of nutritional status in a qualitative form.

Because of its length, the MNA has been seen as cumbersome to administer by some clinicians. Larry Rubenstein, M.D. at Sepulveda VAMC has developed a short form of the MNA, known by the mnemonic, SCALES, that can be used as a screening test to trigger the use of the full form. The full form is not only a useful screening tool but also provides good insights into the development of a management plan.

SCALES

Sadness
Cholesterol < 4.14 mmol/L (160 mg/dL)
Albumin < 40 g/L (4 g/dL)
Loss of weight
Eating problems (cognitive or physical)
S:hopping problems or inability to prepare a meal

Any 2 = high nutritional risk

SCALES was developed at St. Louis University based on clinical experience and the recognition that depression is the most common cause of protein energy malnutrition. SCALES is well correlated with MNA (unpublished data). Like the MNA, it is associated with poorer functional status and predicts falls. The MNA requires no laboratory tests and, as such, is an appropriate screening test to be used before SCALES.

While good clinical judgment often is sufficient to diagnose malnutrition ("when you see it, you know it"), the fact that it is so often overlooked strongly supports the need for the regular use of nutritional screening tools.

Common Reversible Causes of Malnutrition

While this Cyberounds® concentrates on screening instruments for malnutrition as a teaser for a future segment, I will include a popular mnemonic for the treatable causes of malnutrition, viz. MEALS ON WHEELS.

Medications
Emotional (depression)
Alcoholism/anorexia tardive/abuse
Late life paranoia
Swallowing difficulties

Oral problems
No money (poverty)

Wandering and other dementia-related behaviors
Hyperthyroidism, hypercalcemia
Enteric problems (gluten enteropathy)
E ating problems
Low salt, low cholesterol diet
Stones (gallstones)
Footnotes

*
1Morley JE. Anorexia of aging - Physiologic and pathologic. Am J Clin Nutr 1997; 66(4):760-773.
2Wilson MM, Morley JE, Miller DK. Malnutrition in elderly outpatients. Am J Med. In press, 1997.
3Mowe M, Bohmer T. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalized elderly patients. J Am Geriatr Soc 1991; 39(11):1089-92.
4Miller DK, Morley JE, Rubenstein LZ, Pietruszka FM, Strome LS. Formal geriatric assessment instruments and the care of older general medical outpatients. J Am Geriatr Soc 1990; 38(6):645-51.
5Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335(8696):1013-6.
6Tkatch L, Rapin CH, Rizzoli R, Slosman D, Nydegger V, Vasey H, Bonjour JP. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr 1992; 11(5):519-25.
7Larson F, Unosson M, Ek AC. Effect of dietary supplementation on nutritional status and clilnical outcomes in 501 geriatric patients - a randomized controlled trial. Br Med J 1983; 287:1589-1592.
8White JV, Dwyer JT, Posner BM, Ham RJ, Lipschitz DA, Wellman NS. Nutrition screening initiative: development and implementation of the public awareness checklist and screening tools. J Am Diet Assoc 1992; 92(2):163-7.
9Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini-Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996; 54:S59-65.Morley JE. Why do physicians fail to recognize and treat malnutrition in older persons? J Am Geriatr Soc 1991; 39:(11):1139-40.
10Posner BM, Jette AM, Smith KW, Miller DR. Nutrition and health risks in the elderly: the nutrition screening initiative. Am J Public Health 1993; 83(7):972-8.
11Coulston AM, Craig L, Voss AC. Meals-on-wheels applicants are a population at risk for poor nutritional status. J Am Diet Assoc 1996; 96(6):570-3.
12Miller DK, Carter ME, Sigmund RH, Smith JQ, Miller JP, Bentley JA, McDonald K, Coe RM, Morley JE. Nutritional risk in inner-city-dwelling older black Americans. J Am Geriatr Soc 1996; 44(8):959-62.