a scoping review

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Nursing minimum data sets for documenting nutritional care for adults in primary healthcare: a scoping review Sasja Jul Ha˚konsen 1,2  Preben Ulrich Pedersen 1,2  Merete Bjerrum 1,2,3  Ann Bygholm 4  Micah D.J. Peters 5 1

Centre of Clinical Guidelines – Danish National Clearing house, Department of Health Science and Technology, University of Aalborg, Denmark, Danish Centre of Systematic Reviews: a Joanna Briggs Institute Centre of Excellence, 3Department of Public Health, Section of Nursing Science, Aarhus University, Aarhus, Denmark, 4Department of Communication and Psychology, University of Aalborg, Aalborg, Denmark, and 5The Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia 2

ABSTRACT Objective: To identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity.

Introduction: Within health care, there is an urgent need for the systematic collection of nursing care data in order to make visible what nurses do and to facilitate comparison, quality assurance, management, research and funding of nursing care. To be effective, nursing records should accurately and comprehensively document all required information to support safe and high quality care of patients. However, this process of documentation has been criticized from many perspectives as being highly inadequate. A Nursing Minimum Data Set within the nutritional area in primary health care could therefore be beneficial in order to support nurses in their daily documentation and observation of patients. Inclusion criteria: The review considered studies that included adults aged over18 years of any gender, culture, diagnosis and ethnicity, as well as nutritional experts, patients and their relatives. The concepts of interest were: the nature and content of any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare; and the views and opinions of eligible participants regarding the appropriateness of nutritional assessment were the concept of interest. Studies included must have been conducted in primary healthcare settings, both within home care and nursing home facilities. Methods: This scoping review used a two-step approach as a preliminary step to the subsequent development of a Nursing Minimum Data Set within the nutritional area in primary healthcare: i) a systematic literature search of existing nutritional screening tools validated in primary health care; and ii) a systematic literature search on nutritional experts opinions on the assessment of nutritional nursing care of adults in primary healthcare as well as the views of patients and their relatives. Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemedþ, MedNar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents) were searched from their inception to September 2016. Results: The results from the studies were extracted using pre-developed extraction tools to all three questions, and have been presented narratively and by using figures to support the text. Twenty-nine nutritional screening tools that were validated within a primary care setting, and two documents on consensus statements regarding expert opinion were identified. No studies on the patients or relatives views were identified.

Conclusions: The nutritional screening instruments have solely been validated in a over 55 population. Construct validity was the type of validation most frequently used in the validation process covering a total of 25 of the 29 tools. Two studies were identified in relation to the third review question. These two documents are both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts find it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily the elderly’s nutritional status in primary health care.

Correspondence: Sasja Jul Ha˚konsen, [email protected] Conflicts of interest: The author MDJP declares that he is an Associate Editor of the JBI Database of Systematic Reviews and Implementation Reports and that he has had no input into the editorial process for this manuscript. DOI: 10.11124/JBISRIR-2017-003386 JBI Database of Systematic Reviews and Implementation Reports

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Keywords nursing minimum data set; nutrition assessment; nutrition screening; nutritional care JBI Database System Rev Implement Rep 2017; 16(1):1–23.

Introduction ithin health care, there is an urgent need for the systematic collection of nursing care data in order to make visible what nurses do and to facilitate comparison, quality assurance, management, research and funding of nursing care. To be effective, nursing records should accurately and comprehensively document all required information to support safe and high quality care of patients.1 The accurate transfer of patient information is fundamental to supporting continuity of care and delivering quality nursing care. Poor communication, in a broader sense, is known to contribute significantly to the occurrence of adverse events in healthcare and is therefore an important target of initiatives to improve patient safety.1 Patients’ nutritional status can be compromised by a number of factors, including poor recording of information about patients’ nutritional status. Several studies describe the lack of important nutritional notes in the patients’ nursing records.1,2 In some studies nurses routinely document (although with low rates of compliance ranging from 22% to 68%) about nausea/vomiting, ability to eat/drink and diarrhea, while energy intake and body mass index are rarely documented.3 In other studies the measurable and objective facts such as body mass index and weight loss are the most frequent reported data.4 Overall, the majority of the studies conclude that assessment and documentation of the patient’s nutritional care are not routinely performed well, as evidenced by a lack of structure in nursing documentation concerning nutritional care.1-6 A nursing documentation model called VIPS (an acronym for wellbeing, integrity, prevention and security) follows the structure of the nursing process and is widely used in Scandinavian countries.7,8 Despite the demands on documentation and the use of the VIPS model as well as other documentation models, nutritional issues are still sparsely documented. This overall generic framework for nursing documentation includes documentation models such as VIPS, which often do not specify what data nurses have to collect and what nurses need to document about nutrition.8 Using general terms like ‘‘nutrition’’, ‘‘appetite’’, ‘‘diet’’ etc. does not guide nurses

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to make adequate, systematic and relevant observations about the patient’s nutritional status. This can be linked to the low frequency of documentation, as the patient’s nutritional problems simply remain unidentified by the nurses, as they are unaware of what is important to document.9 The role and importance of nutritional care among nurses appear to be varied. Some studies have reported that some nurses may not consider the nutritional care of patients as being of significant importance.10 In other studies nurses themselves indicate that while they know that nutrition is important, they have difficulties identifying what needs to be documented about patients’ nutritional care in terms of what is relevant and important.3,11-13 Overall, there seems to be both a lack of nutritional knowledge and understanding among nurses about how to prioritize nutritional care.14 Therefore, there is a clear need for a structured, relevant and detailed documentation model that supports nurses in their nutritional care planning. In 2012 some of the authors of this review published an article in which a Nursing Minimum Data Set (NMDS) based on a scientific approach to identify core elements of nutritional care within the hospital setting was developed.15 The aim of a NMDS is to use the minimum number of items to best capture the nursing contribution to patient care. A NMDS is comprised of ‘‘essential nursing data’’ which are defined as ‘‘those specific items of information that are needed on a regular basis by the majority of nurses across all settings in the delivery of care’’.16(p.97) Uniform definitions and categories are used to describe these items of information, and the aim is to meet the information needs of various data users in healthcare systems.17 It is important to highlight that a NMDS is not a screening tool, but a minimum number of data/items which can be of significant importance to a particular clinical focus, for example, nutrition. A NMDS within the nutritional area in primary health care could therefore be beneficial in order to support nurses in their daily documentation and observation of patients, as it also aims to establish comparability of nursing data across clinical populations and settings, describe ß 2017 THE JOANNA BRIGGS INSTITUTE

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the nursing care of patients, stimulate nursing research and provide data about nursing care to influence clinical and health policy decision-making. Specifically for primary health care the proposed benefits of a NMDS will be improved data for quality insurance, hence improving health care quality and patient outcome and reducing health care costs. In this scoping review primary health care refers to a broad range of health services most often delivered in community-based settings. Primary health care services seek to intervene early to maximize health and wellbeing outcomes and prevent or slow the progression of ill health.18 Primary health care encompasses both ‘‘home care’’ and ‘‘nursing home’’.18 Minimum Data Sets (MDSs) can be developed in several ways and have been undertaken in many countries within different health disciplines, e.g. nursing, midwifery, medicine and physiotherapy.17 Work conferences (based on expert opinions and experiences) and formal consensus techniques (e.g. Delphi consensus technique) are often used to develop specific or generic MDSs.19 The authors have examined several databases (TRIP, PubMed, CINAHL and Embase) and were unable to identify any existing NMDSs developed by combining data from both a consensus based and a scientific based approach. This scoping review aims therefore to contribute to the development of NMDSs in the future with a new rigorous and evidence-informed approach. This scoping review follows the Joanna Briggs Institute approach to the conduct and reporting of scoping reviews.20 Scoping reviews are an ideal approach for the identification, collation and synthesis of evidence to meet objectives that may be beyond the scope of more precisely focused systematic reviews. By following a rigorous and systematic approach to searching and study selection based on pre-specified inclusion criteria, scoping reviews are able to capture and map a wide variety of relevant evidence sources. This is particularly useful for developing understanding based on fields of literature that may be disparate. Following an initial search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library and PROSPERO, no other scoping reviews that have been carried out on this topic were identified. The objectives, approach to searching, inclusion criteria JBI Database of Systematic Reviews and Implementation Reports

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and methods of analysis for this review were specified in advance and documented in a published protocol.20,21 This scoping review used the following approaches as a preliminary step to the subsequent development of an NMDS within the nutritional area in primary healthcare: i A systematic literature search of existing nutritional screening tools that are validated in primary health care that map and present the identified tools as well as their psychometric validity. The purpose of this approach was to obtain an overview of: a) the number of existing nutritional screening tools within this context, b) how they are validated, and c) the age groups for whom these tools are validated. This information is a vital aspect of the process of developing the NMDS. The two main requirements in psychometric validation are that the tool measures what it is intended to measure and that the tool measures the same way each time it is used. These concepts are known as validity and reliability, respectively.22 In this review only the psychometric validity of the nutritional screening instruments was explored. There are several types of validity, such as face validity, content validity, construct validity and criterion validity. Face validity refers to the test looking like it should be measuring what it is intended to measure. A tool is likely to have little credibility if it does not possess this characteristic.22 Content validity refers to the tool possessing sufficient breadth to ensure all relevant aspects of the construct under investigation are included and that aspects irrelevant to the constructs are not included.22 Construct validity refers to whether scales purported to measure the same attribute actually measure the same attribute. Pearson’s correlation coefficient is used to test for construct validity. Generally, a test will have good construct validity if it correlates well with other tools that also measure that construct (i.e. convergent validity) and correlates less well with tools that do not measure the same construct (i.e. discriminant validity). Construct validity is generally considered good if correlations related to convergent validity exceed those related to discriminant validity. Factor analysis is also a statistical ß 2017 THE JOANNA BRIGGS INSTITUTE

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technique involved in the establishment of construct validity. A set of items in a tool usually combines to provide a measurement of a particular construct. Factor analysis is used to determine which items are associated with the measurement of a construct. Evidence for a construct being valid is provided if the same items are associated with the same construct across a number of different samples, conditions, etc. When this occurs, the tool is said to have a stable factor structure.22 Criterion validity (predictive validity and concurrent validity) discriminates between groups known to differ with respect to attributes being measured. The tests generally used to assess criterion validity are tests of differences between groups such as analysis of variance and the Kruskal-Wallis test. Criterion validity is often divided into ‘‘concurrent’’ and ‘‘predictive’’ subtypes of validity. The term is reserved for demonstrations relating a measure to other concrete criteria assessed simultaneously to the degree in which any measure can predict future or independent past events.22 ii An examination of the results of a systematic literature search for qualitative/textual papers on nutritional experts opinions on the assessment of the nutritional nursing care of adults in primary healthcare as well as the views of patients¼ and/ or their relatives. The results of this scoping review are expected to inform the development of a NMDS within the nutritional area that will be set out in a subsequent analytic article. The resulting NMDS will be designed to inform nurses in primary healthcare of core elements in their daily documentation and patient observation, but could be equally valuable to other healthcare professionals such as general practitioners who are involved in the assessment and observation of the nutritional status of patients in primary care.

as to what was viewed as appropriate to assess about adults’ nutritional care in primary healthcare. Furthermore, published evidence of adult patients’ and their relatives’ views of nutritional assessment and documentation were also sought for inclusion. Specifically the review questions were: 1. What nutritional screening instruments have been validated for use in the adult population in primary healthcare settings? 2. What is the psychometric validity of these nutritional screenings tools? 3. What do nutritional experts, patients and/or their relatives find appropriate to assess about adults’ nutritional status in primary healthcare? In this scoping review, the term ‘‘appropriate’’ refers to what patients, their relatives and experts consider ‘‘suitable’’ or ‘‘relevant’’ to assess about adults’ nutritional status.

Review question

Concept

The primary objective of the present scoping review was to identify all published nutritional screening instruments that had been validated in the adult population in primary healthcare settings and to report on their psychometric validity. The scoping review also sought to include published evidence from the perspective of relevant experts in the field

For question 1 and 2, studies that reported on the nature and content of any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare were sought for inclusion. Only studies that reported on the psychometric validity of the nutritional screening tools were considered for inclusion to answer question 2.

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Inclusion criteria Participants For questions 1 and 2, this scoping review included studies with participants who were adults (aged >18) of any gender, culture, diagnosis and ethnicity. For question 3, studies that reported on the views and opinions of nutritional experts as well as the views of patients (defined above) and their relatives were sought. In this scoping review nutritional experts are were defined as persons with knowledge within the nutritional area. It is not limited to a formal education such as a registered dietician/nutritionist or nutritional therapist. It also encompasses persons who have researched within the nutritional area. Therefore, a nutritional expert is not just a person with a formal educational qualification and includes a large range of persons with knowledge about nutrition relevant to the topic area. In this scoping review relatives are defined as persons who are connected to patients either through blood or marriage.

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For question 3, the views and opinions of eligible participants regarding the appropriateness of nutritional assessment were the concept of interest. This included studies of patients and/or their relatives’ views of assessment of adult’s nutritional status in primary healthcare on both an individual and/or group basis. Furthermore consensus statements, reports, interviews, etc. from nutritional experts on the same concept of interest were also included.

Context Studies sought for inclusion must have been conducted in primary healthcare settings. This included studies both within home care and nursing home facilities.

Types of studies This scoping review considered all quantitative, qualitative studies of any design or methodology, and text and opinion sources. Quantitative studies included, but were not limited to, experimental and observational study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, cohort studies, case-control studies, and cross sectional studies. Qualitative studies included, but were not limited to, phenomenology, grounded theory, ethnography, action research and feminist research. Text and opinion papers included, but were not limited to, consensus papers, discussion papers, position papers and other text. Sources of secondary evidence, for example systematic reviews and literature reviews, were not considered for inclusion.

Methods Search strategy The search strategy aimed to find both published and unpublished studies. Databases were searched from their inception to September 2016. The search sought all published and unpublished studies. Studies published in English, German, Danish, Swedish and Norwegian were considered for inclusion in this review as members of the review team have expertise in each of these languages. A three-step search strategy was utilized in this review. Stage 1 involved an initial search of PubMed and CINAHL using preliminary keywords drawn from the natural language terms of the topic, followed by an analysis of the text words contained in the title and abstracts, and of the index terms used to describe the articles. JBI Database of Systematic Reviews and Implementation Reports

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The preliminary keywords searched were: Nutrition Screening Nutritional screening Instrument Nutritional assessment Malnutrition Adult Primary care Nursing Minimum Data Set Consensus/expert opinion/work conference For stage 2, the text words contained in the title and abstract of relevant articles, along with the controlled language index terms used to describe the papers, were then analyzed to develop keywords for stage 2. Search terms were chosen in discussion with a research librarian with the aim of identifying the maximum number of articles. A second extensive search was then undertaken of all keywords and index terms identified as relevant to the review across all included databases. The databases searched for published material included: PubMed, CINAHL, Embase, Scopus, Swemedþ, Mednar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents. The search strategy used for PubMed, CINAHL and Embase are provided in Appendix I. In stage 3 references from retrieved articles were then searched for additional studies. Reference software was used to manage the list of all citations retrieved and all unnecessary duplications were removed. Articles searched were then assessed for relevance to the review based on the information provided in the title, abstract and descriptor/MeSH terms by two independent reviewers. Where any doubt existed, the full article was retrieved. The full article was retrieved for all studies that appeared to meet the inclusion criteria of the review. Based on full texts, two reviewers examined independently whether the studies conformed to the inclusion criteria. Disagreement was resolved by discussion with a third reviewer. Multiple articles by the same authors that reported findings from the same study were assembled and the information was used for decisions concerning which studies were eligible for inclusion. Studies identified from reference list searches were assessed for relevance based on the study title. The full article was retrieved for all          

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studies that appeared to meet the inclusion criteria of the review.

Extracting the results

Identification

For question 1, data was extracted from the included papers pertaining to the type of nutritional screening instrument discussed. Two reviewers extracted data independently. Disagreement was resolved by discussion with a third reviewer. Details that were extracted included instrument, author/year of publication, population and content/components of the nutritional screening/assessment instrument (see Appendix II). For Question 2, data was extracted from the included papers pertaining to the psychometric validity of nutritional screenings tools. Two reviewers extracted data independently. Disagreement was resolved by discussion with a third reviewer. Details that were extracted included instrument, author/year of publication, population, context, type of validation (see Appendix III). For Question 3, data was extracted pertaining to the views of nutritional expert, patients and/or their Records idenfied through database searching (n = 3001)

relatives regarding what they found appropriate to assess regarding adults’ nutritional status in primary health care contexts. Two reviewers extracted data independently. Disagreement was resolved by discussion with a third reviewer. Details that were extracted included author/year of publication, source of point of view/opinion/statement, population, point of view/opinion/statement and finding (see Appendix IV).

Results Study selection The database searches yielded a total of 2594 studies after duplicates were removed. The titles and abstracts of these 2594 studies were screened and 94 studies were considered for further detailed assessment of the full paper, yielding a total of 35 original studies for inclusion in this review (33 for question 1 and 2 and 2 for question 2). None were located through hand searching. A flow chart showing the number of studies at each stage is detailed below (Figure 1). Addional records idenfied through other sources (n = 0)

Eligibility

Screening

Records aer duplicates removed (n = 2594)

Records screened (n = 2594)

Records excluded (n = 2500)

Full-text arcles assessed for eligibility (n = 94)

Full-text arcles excluded (Total: n = 59) Reason for exclusion: wrong

Included

context/seng (not primary care)

Citaons included for Q1 and Q2

Citaons included for Q3

(n = 33)

(n = 2)

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097.

Figure 1: Flowchart of study selection and inclusion process JBI Database of Systematic Reviews and Implementation Reports

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Review questions 1 and 2: What nutritional screening instruments have been validated for use in the adult population in primary healthcare settings? What is the psychometric validity of these nutritional screenings tools? Appendices II and III present relevant data from the studies included in this review related to review questions 1 and 2. Under data extraction tool 1 (Overview of published nutritional screening instrument within a primary care setting) in Appendix II, the type of instrument, author, year of publication, population as well as the content and single components of the nutritional screening tools are described. Under extraction tool 2 (Overview of the type of validation of nutritional screening instruments validated in a primary care context) in Appendix III, the type of instrument, author, year of publication, population, context, face validation, content validation, construct validation and criterion validation of the nutritional screening tools are described. Twenty-nine nutritional screening/assessment instruments that have been tested and validated within a primary care setting have been identified. The included studies were published between 1996 and 2013. Participants and context included in the studies The majority of the included studies have included patients aged 65 years or older. Eighteen (62%) of the nutritional screening tools have solely been tested in a population >65 years.23,25,29,31,35,37,40-45,47-52

Five (17%) of the nutritional screening tools have been tested in a population of>60 years 31,32,36,50 Four (13%) of the nutritional screening tools have been tested in a population of >55 years.26,27,51,52 One (3.5%) nutritional screening tool has been tested in a mean age of 79.2 and one (3.5%)39 has been tested in a population of >84 years.38 The majority (62%) of the nutritional screening tools have been tested in a nursing home care setting.23-28,31,33-37,40,42-44 Typically, a nursing care home is characterized in the studies as a long-term care facility with multiple levels of care, with residents ranging from functional to very debilitated. Twenty-one percent of the nutritional screening tools have been tested in a community dwelling population. In these studies, the population have typically been recruited from a geriatrician’s clinic in a community or by other health care professionals either providing home care for the elderly or meeting the elderly in the local community center.30,50-54 The remaining nutritional screening tools (17%) have been tested in elderly care facilities, aged care residents and elderly residents typically recruited using multiple sources such as facility databases, newspaper advertising or thorough local contact in elderly care facilities such as assisted living facilities.29,32,38,39,41,45-49,55 The included studies were conducted in the following countries: Spain,33,40 USA,25,30,42,45,46,54 Australia,26,31,37,48,49,53 Greece,32 Canada,51,52 The Netherlands,28,29 Hong Kong,23,24 France,27,44 Sweden,35,43 Italy,34 Brazil36 and United Kingdom.47,55

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25

20

15

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0 Face

Content

Criterion

Construct

Figure 2: Overview of types of validation in included studies (y-axis [vertical]: number of studies; X-axis [horizontal]: type of validation) JBI Database of Systematic Reviews and Implementation Reports

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Types of studies included The studies included in this scoping review consists of a wide range of study designs within the observational field, typically cross-sectional studies and prospective cohort studies. Type/s of validation Under data extraction tool 2 (Overview of the type of validation of nutritional screening instruments validated in a primary care context) in Appendix III, the name of the nutritional screening instrument and how it is validated in this particular context is shown. As presented in the Figure 2, all 29 nutritional screening instruments that have been identified in this scoping review have been validated at some level in a primary care context. Construct validation is the type of validation most frequently investigated in these validation studies. Thirty percent of the screening instruments have only been validated on one level (e.g. content validated).40,41,42,44,50,52,55 Thirty-one percent of the screening instruments have been validated on two levels (e.g. content validated and criterion validated).23-27,32,37,42,51,54 Thirty-three percent of the instruments have been validated on three levels (e.g. face validated, content validated and construct validated).26,28-37,39,53 Only 6% (two instruments) have been validated on all four levels (face validated, content validated, criterion validated and construct validated).28,32,35,39,42

Review question 3: What do nutritional experts, patients/and their relatives find appropriate to assess about adults nutritional status in primary healthcare? Appendix IV presents data from the studies included in this review related to review question 3 Under data extraction tool 3 (Overview of the views of nutritionals experts, patients/and their relatives) in Appendix IV, the author/year of publication, source of point of view/opinion/statement, population, point of view and number of findings are described. Only two documents on the views of nutritional experts (consensus documents) were identified. No studies including patients or relatives views or opinions about the assessment of adults’ nutritional status in primary health care were identified. The included studies were published in 201258 and 2013.56 JBI Database of Systematic Reviews and Implementation Reports

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Type of study, aim and study population The first consensus document was published in 2012 by Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (ASPEN).58 A workgroup of both the Academy and ASPEN aimed to describe characteristics for the identification and documentation of malnutrition in adults in all settings. The second consensus document focuses on assessment and treatment of malnutrition in Dutch geriatric practice.56 It is a consensus approach through a modified Delphi method, with the participation of 11 geriatricians with special interest in malnutrition and practicing in the field under consideration. A nutritionist supervised the process and analyzed the data from the Delphi study. A Delphi study is a qualitative, systematic and interactive research method, which relies on a panel of experts.56 In this case they assessed specific actions towards geriatric patients. Statements The Dutch study the panel reached the consensus that malnutrition should be considered a geriatric syndrome.56 The nutritional status should be assessed using the Mini Nutritional Assessment combined with a Comprehensive Geriatric Assessment (CGA). Nutritional interventions should be combined with interventions targeting underlying factors. According to the experts, malnutrition is best managed by a multidisciplinary team with specific roles and responsibilities for each team member. At discharge, written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals. The Academy and ASPEN working groups agreed on the following statements58: Characteristics recommended for the identification of malnutrition in adults are:  Insufficient energy intake: % nutrients consumed/administered versus requirement.  Unintended weight loss: can occur at any body mass index.  Physical examination: loss of muscle mass, loss of subcutaneous fat, evidence of fluid accumulation (localized or generalized).  Diminished physical function: hand grip strength, SPPB (Short Physical Performance Battery) for elderly patients, other. ß 2017 THE JOANNA BRIGGS INSTITUTE

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A positive finding in any of two characteristics indicates malnutrition.58 Key findings A group of nutritional experts found it appropriate to conduct a Comprehensive Geriatric Assessment (CGA) (assessment from a bio-psycho-social perspective). A CGA was designed to provide insight into the multiple co-morbidities and risk factors that underlie malnutrition on the somatic, mental, functional and social domain.56 Comprehensive Geriatric Assessment consists of the following elements: a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging. It requires the evaluation of multiple issues, including physical, cognitive, affective, social, financial, environmental and spiritual components that influence an older adult’s health. Comprehensive Geriatric Assessment is based on the premise that a systematic evaluation of frail, older persons by a team of health professionals may identify a variety of treatable health problems and lead to better health outcomes (e.g. nutritional related issues).56 The CGA should be used in combination with the Mini Nutritional Assessment (MNA) to assess the nutritional status.56 The Academy and ASPEN find it appropriate to use a validated screening tool.58 They recommend the use of either the Malnutrition Screening Tool (MST), Screening – 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST) or Short Nutritional Assessment Questionnaire (SNAQ).58 The integrity of the central and peripheral nervous system, the individual’s level of physical activity, multiple hormones and inflammation are also deemed to be important determinants for the patient’s nutritional status. It is also important to recognize that an adequate nutrient intake is necessary, but not sufficient, to maintain body mass and normal physiologic function, and that additional intake is required to replete established deficits. The assessment of the patient’s nutritional status incorporates history and clinical diagnosis, clinical signs and physical examination, anthropometric data, laboratory indicators, dietary assessment and functional outcomes.58 JBI Database of Systematic Reviews and Implementation Reports

Comprehensive geriatric assessment

Use of a validated nutrional screening instrument

History and clinical diagnosis. physical examinaon and dietary assessment

What nutrional experts find appropriate to assess about adults' nutrional status in primary healthcare Figure 3: Overview of key findings from two consensus documents (appropriateness) Figure 3 presents the key findings from the two consensus documents.

Discussion This scoping review aimed to develop the foundation for the development of an NMDS within the nutritional area in primary health care. The data collected and mapped in this scoping review consists of both information from nutritional experts as well as information from identified nutritional screening instruments validated in primary care practice. The strength of this scoping review lies in its ability to examine a broad variety of literature to find information from validated nutritional screening instruments, information from nutritional experts as well as information from patients and relatives. It therefore sought to encompass scientific evidence, clinical experience and judgment, and patient preference and values, hence encompassing the evidence based decision making process. Unfortunately no records were found on patients’ (or relatives’) views of what they find appropriate to assess about their nutritional status, which of course limits the interpretation of the results. Further primary research and engagement with health consumers is apparently required in this area. ß 2017 THE JOANNA BRIGGS INSTITUTE

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A limitation of the sources included in this scoping review is the study population. Even though the systematic literature search had broad inclusion criteria for the patient population (aged >18), the nutritional screening tools identified within a primary setting context were exclusively tested and validated within a population of >55 years. These findings should probably be seen in the light of the fact that nutritional issues most frequently occur in this population (>55 years). All of the included studies were cross culture, gender, diagnoses and ethnicity. Furthermore, it may come as a surprise that face validation was the type of validation that occurred the least in the studies, as this is the easiest type of validation to conduct and a tool is likely to have little credibility if it does not possess this characteristic. However, it is important to point out that many of the nutritional screening tools were not originally developed and validated within this context and population. Since a majority already have been validated – also face validated – it makes sense that the focus when validating in a different population and context is criterion and construct validity.

Conclusions A total of 29 nutritional screening instruments validated within a primary health care practice were identified in this scoping review. The nutritional screening instruments have solely been validated in a population of >55 years. Construct validity was the type of validation most frequently used in the validation process covering 25 of the 29 tools. One third of the screening instruments had undergone only one type of validation, another one third of the instruments were validated in two ways and the final one third of the instruments were validated on three levels. Only one out of 29 instruments were validated on all four levels. A total of two studies were identified in relation to question 3. These two documents were both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts found it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily elderly’s nutritional status in primary health care. JBI Database of Systematic Reviews and Implementation Reports

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No studies were identified on the views of patients and relatives within this area.

Recommendations for research In this review the sources included provides an insight into the knowledge gaps within this area; which is a key characteristic of scoping reviews. The lack of information regarding health consumers’ perspectives about what is or may be appropriate to assess about adults’ nutritional status in primary health care underpins the need for further research around these perspectives within the nutritional area. As health consumers have the right to be involved in deciding what the standards of care should be, gaining insights into patients’ and relatives’ perspectives on what is appropriate to assess about nutrition seems both reasonable and required. Future research within the perspectives area are therefore recommended. As described earlier, the foundation of a NMDS within the nutritional area is developed in this scoping review, and an article which presents the developed and finalized NMDS through an analytic process will be published.

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48. Lipski PS. Australian Nutrition Risk Screening Initiative. J Aging 1996;15(1):14–7. 49. Patterson AJ, Young AF, Powers JR, Brown WJ, Byles JE. Relationship between nutrition screening checklists and the health and well-being of older Australian women. Public Health Nutr 2002;5(1):65–71. 50. Shaha S, Dixon RA, Earland J. Development of a screening tool for detecting undernutrition and dietary inadequacy among rural elderly in Malaysia: simple indices to identify individuals at high risk. Int J Food Sci Nutr 1999;50(6):435–44. 51. Keller HH, Goy R, Kane S-L. Validity and reliability of SCREEN II (Seniors in the Community: Risk evaluation for eating and nutrition, Version II). Eur J Clin Nutr 2005;59(10):1149–57. 52. Keller HH. The SCREEN I (seniors in the community: risk evaluation and eating nutrition) index adequately represents nutritional risk. J Clin Epi 2006;59(8):836–41. 53. Charlton KE, Kolbe-Alexander TL, Nel JH. Development of a novel screening tool for use in elderly south Africans. Public Health Nutr 2005;8(5):469–79. 54. Posner BA, Jette AM, Smith KW, Miller DR. Nutrition and health risk in the elderly: the nutrition screening initiative. Am J Pub Health 1993;83(7):972–8. 55. Weekes CE, Elia M, Emery PW. The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN). Clin Nutr 2004;23(5):1104–12. 56. van Asselt DZB, van Bokhorst-de van der Schueren, van der Cammen TJM, Disselhorst LGM, Janse A, Lonterman-Monasch S, et al. Assessment and treatment of malnutrition in Dutch geriatric practice: consensus through a modified Delphi study. Age Aging 2012;41(3):399–440. 57. Jensen GL, Compher C, Sullivan DH, Mullin GE. Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. JPEN J Parenter Enteral Nutr 2013;37(6):802–7. 58. White JW, Guenter P, Jensen G, Malone A, Schofield M. The Academy Malnutrition Work Group, The A.S.P.E.N Malnutrition Task Force, A.S.P.E.N Board of Directors, 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). JPEN J Parenter Enteral Nutr 2012;112(5):730–8.

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Appendix I: Search strategy CINAHL Limits: Adults Date of search: 15 September 2016 Search period: from database inception – September 2016 S1

nutritional care

S2

nutr

S3

appro

S4

work conference

S5

nursing minimum data set

S6

nutrition assessment

S7

nutrition screening

S8

expert opinion

S9

consensus

S10

relatives

S11

malnutri

S12

primary health care

S13

patient experience

S14

or/1–13

S15

subjective global assessment

S16

mini nutriitonal assesment

S17

valid

S18

screening in practice

S19

short nutritional assessment questionnaire

S20

nutritional screening tools

S21

nutritional risk screening

S22

or/15–21

S23

S14 AND S22

PubMed Limits: Adults Date of search: 16 September 2016 Search period: from database inception – September 2016

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S1

nurs minimum data set

S2

nutr

S3

nutri care

S4

expert

S5

opinion

S6

S1 AND S2 AND S3 AND S4 AND S5

S7

relatives

S8

citizens Schema: nomesh

S9

primary health care

S10

community

S11

S6 AND S7 OR S8 AND S9 AND S10

S12

‘‘Nutritional Support’’[Mesh]

S13

S.J. Ha˚konsen et al.

work conference

S14

S11 AND S12 AND S13

S15

S6 AND S11 AND S14

S16

or/S1-S15

S17

malnutrition universal screening tool

S18

screening in practice SIP

S19

Mini Nutritional Assessment Short Form

S20

Mini Nutritional Assessment

S21

short nutritional assessment questionnaire

S22

nutrition screening tools NST

S23

nutritional risk screening NRI

S24

subjective global assessment

S25

CNAQ

S26

nutritional assessment (Mesh)

S27

screening

S28

assessment

S30

instrument

S31

nutritional status

S32

validity

S33

psychometric validation

S34

psychometric evaluation

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S35

nutritional status (Mesh)

S36

nutritional sciences (Mesh)

S37

reproducibility of results (Mesh)

S38

nutritional screening instruments

S39

or/S17-S38

S40

or/S17-S25 AND or/S26-S31 AND or/S32-S38

S41

S15 AND S40

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Embase Limits: Adults Date of search: 17 September 2016 Search period: from database inception – September 2016 S1

nutrition/exp

S2

screening

S3

assessment

S4

nursing minimum data set

S5

approproateness

S6

primary health care

S7

statement

S8

work conference

S9

nutritional care

S10

expert opinion

S11

consensus

S12

or/S1-S11

S13

S1 AND or/S2-S3 AND or/S4-S5 AND S6 AND or/S7-S11

S14

malnutrition universal screening

S15

WAASP

S16

SIP screening practice

S17

mini nutritional assessment

S18

nutrition screening tool

S19

nutritional risk screening AND NRI

S20

nutritional screening tools AND NST

S21

subjective global assessment

S21

or/S14-S21

S22

or/S1-S21

S23

S13 AND S21

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Appendix II: Data extraction tool 1 Overview of published nutritional screening instrument within a primary care setting Instrument

Author/year of publication

Population

Content/components of the nutritional screening/assessment instrument (1)

CNS (Chinese Nutrition Screen)

Woo J (2005)23 Lok K (2009)24

Elderly (þ65 Y)

a) Changes in food intake b) Changes in body weight c) Activity level d) Acute illness (within 3 months) e) State of happiness f) Living alone g) Daily consumption of medication h) Presence of pressure sores, inflamed skin or skin ulcer i) No. of daily meals intake j) Daily consumption of liquid k) Feeding status (assistance, independent etc.) l) Self-rated health status m) BMI n) Diagnosis o) Loss of subcutaneous fat p) Muscle wasting/ ankle or sacral oedema, ascites q) Gastro intestinal symptoms r) Nutritional status

MDS (weight, height and BMI from Minimum Data Set)

Blaum CS (1997)25

Elderly (þ65 Y)

a) Weight, height and BMI

SNAQ (Short Nutritional Assessment Questionnaire)

Isenring EA (2012)26 Roland Y (2012)27

Older adults (þ55 Y)

a) Appetite status b) Feelings when eating (feel full, hardly ever full) c) Taste of food d) No. of daily meals intake

SNAQRC (Short Nutritional Assessment Questionnaire for Residential Care þ BMI

KruizengaHM (2010)28

Elderly (Mean age ¼ 84 Y)

a) Unintentionally weight loss of more than 3 kg in the past month b) Unintentionally weight loss of more than 6 kg in the past 6 months c) Feeding or drinking assistance d) Decreased appetite in the past month e) BMI

SNAQ65þ (Short Nutritional Assessment Questionnaire for people ages 65þ)

Wijnhoven HAH (2011)29

Elderly (þ65 Y)

a) Unintentionally weight loss of more than 4 kg in the past 6 months b) Mid upper arm circumference c) Appetite d) Mobility e) BMI

CNAQ (Nutrition Appetite Questionnaire)

Wilson MG (2005)30

Elderly (mean 79.2 a) Appetite status Y) b) Feelings when eating (feel full, hardly ever full) c) Feeling hungry (rarely, most of the time) d) Taste of food e) Taste of food compared to previous years f) Normal food consumption g) Gastrointestinal symptoms when eating h) Mood

DETERMINE (Nutrition Checklist for Older Adults)

Charlton KE (2007)31

Elderly (þ60 Y)

a) Presence of disease b) Eating Poorly c) Tooth loss/Mouth pain d) Economic hardship e) Reduced social contact f) Multiple medications g) Involuntary weight loss/gain h) Needs assistance in self-care i) Age (>80 years)

GNRI (Geriatric Nutritional Risk Index)

Poulia KA (2012)32

Elderly (þ60 Y)

a) Serum albumin b) Weight alterations

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(Continued) Instrument

Author/year of publication

MNA (Mini Nutritional Assessment)

Tarazona-Saltababina FJ (2009)33

Elderly (þ70 Y)

Cereda E (2008)34

Elderly (Mean age 80)

MNA-SF (Mini Nutritional Assessment-Short Form)

Population

Christensson L (2002)35

Elderly (þ65 Y)

Ferreira LS (2008)36

Elderly (þ60 Y)

Visvanathan R (2004)37

Elderly (þ65 Y)

Kruizenga HM (2010)38

Elderly (Mean age ¼ 84 Y)

Isenring EA (2012)26

Older adults (þ55Y)

Poulia KA (2012)32

Elderly (þ60 Y)

Kruizenga HM (2010)38

Elderly (Mean age ¼ 84 Y)

Isenring EA (2009)39

Elderly (Mean age ¼ 84 Y)

Content/components of the nutritional screening/assessment instrument (1) a) Decline of food intake due to: - loss of appetite - digestive problems - chewing or swallowing difficulties b) Weight loss c) Mobility d) Psychological stress or acute disease e) Neuropsychological problems f) BMI g) Calf þ mid arm circumference h) Lives independently i) Daily consumption of medication j) Pressure sores or skin ulcers k) Daily full meal consumption l) Daily intake of protein m) Daily intake of fruit/vegetables n) Daily intake of fluids o) Feeding status (assistance, independent etc) p) Self-view of nutritional status q) Self-rated heath status a) Decline of food intake due to: - loss of appetite - digestive problems - chewing or swallowing difficulties b) Weight loss c) Mobility d) Psychological stress or acute disease e) Neuropsychological problems f) BMI g) Calf circumference

Revised MNA-SF (Revised Mini Garcia-Mesenguer MJ (2013)40 Nutritional Assessment-Short Form)

Elderly (þ65 Y)

a) Decline of food intake due to: - loss of appetite - digestive problems - chewing or swallowing difficulties b) Weight loss c) Mobility d) Psychological stress or acute disease e) Neuropsychological problems f) BMI OR g) Calf circumference

Self-MNA (Self-administered Mini Nutritional Assessment)

Huhmann MB (2013)41

Elderly (þ65 Y)

a) Decline of food intake due to: - loss of appetite - digestive problems - chewing or swallowing difficulties b) Weight loss c) Mobility d) Psychological stress or acute disease e) Neuropsychological problems f) BMI g) Calf circumference

MUST (Malnutrition Universal Screening Tool)

Diekmann R (2013)42

Elderly (þ65 Y)

Isenring EA (2012)26 -

Older adults (þ55 Y)

a) Weight, height, BMI, unplanned weight loss b) Considerations of acute disease effect c) Risk of malnutrition

Poulia KA (2012)32

Elderly (þ60 Y)

Kruzienga HM (2010)38

Elderly (mean age ¼ 84 Y)

Poulia K-A (2012)32

Elderly (þ60 Y)

NRI (Nutritional Risk Index)

JBI Database of Systematic Reviews and Implementation Reports

a) Serum albumin concentration and the ratio of present weight to usual weight

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(Continued) Instrument

Author/year of publication

Population

Content/components of the nutritional screening/assessment instrument (1)

NUFFE (Nutritional Form for the Elderly)

Soderhamn U (2001)43 Elderly (þ65 Y)

a) Weight loss and changes in dietary intake b) Appetite c) Food and fluid intake d) Eating difficulties e) Possibility of obtaining food products f) Company at meals g) Activity h) No. of drugs

Rapid Screen

Visvanathan R (2004)37

Elderly (þ65 Y)

a) Recent unintentionally weight loss b) BMI

Simple Screening Tool#1

Laporte M (2001)44

Elderly (þ65 Y)

a) BMI b) Weight loss c) Albumin

Simple Screening Tool#2

Laporte M (2001)44

Elderly (þ65 Y)

a) BMI b) Weight loss c) Albumin

MST (Malnutrition Screening Tool)

Isenring EA (2012)26

Older Adult (þ55 Y)

a) Involuntary weight loss b) Eating poorly because of decreased appetite

NRS (Nutritional Risk Screening)

Diekmann R (2013)42

Elderly (þ65 Y)

a) BMI b) Weight loss c) Reduced dietary intake d) Illness severity e) Age (>70 years)

NRS-2002 (Nutritional Risk Screening 2002)

Diekmann R (2013)42

Elderly (þ65 Y)

a) BMI b) Weight loss c) Reduced dietary intake d) Illness severity e) Age (>70 years)

SGA (Subjective Global Assessment)

Sacks GS (2000)45

Elderly (þ65 Y)

a) Weight change b) Dietary intake/change c) Gastrointestinal symptoms d) Functional capacity e) Subcutaneous fat f) Muscle wasting g) Edema/Ascites

NSI (Nutrition Screening Initiative)

Sahyoun NR (1997)46

Elderly (þ60 Y)

a) Medical conditions or factors interfering with appetite and eating habits b) Daily consumption of food c) Daily consumption of fruit/vegetables d) Alcohol consumption e) Biting, chewing or swallowing problems f) Economic issues hindering buying food g) Company at meals h) Consumption of prescribed drugs i) Unintentionally weight loss/gain j) Not able to shop, cook and/or eat food without help

NST (Nutrition Screening Tool

Wright (1999)47

Elderly (þ65 Y)

a) Unintentionally weight loss b) Unintentionally been eating les c) Weight/height/mid-arm circumference

ANSI (Australian Nutrition Screening Initiative)

Lipski (1996)48 Patterson (2002)49

Elderly (þ65 Y) Elderly (þ65 Y)

a) Weight change b) Frequency of intake c) Specific component intake/fluid intake d) Oral problems (chewing, swallowing) e) Ability to shop for food f) Presence or absence of disease g) Use of medication h) Social isolation i) Alcohol intake

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(Continued) Instrument

Author/year of publication

Population

Malaysian Tool

Shahar S (1999)50

Elderly (þ65 Y)

a) Weight change b) Frequency of eating/specific component intake c) Appetite d) Oral problems (chewing, swallowing) e) Access to food (financial dependence, transport) f) Presence or absence of disease g) Cigarette smoking

SCREEN I (Seniors in the Com- Keller H (2006)51 munity: Evaluation for Eating and Nutrition)

Elderly (þ65 Y)

a) Weight change b) Frequency of eating/specific component intake c) Food avoidances d) Use of meal replacements e) Appetite f) Oral problems (chewing, swallowing) g) Access to groceries and meal preparation h) Social isolation

SCREEN II (Seniors in the Community: Evaluation for Eating and Nutrition – Version II)

Keller H (2005)52

Elderly (þ65 Y)

a) Weight change b) Frequency of eating/specific component intake c) Food avoidances d) Use of meal replacements e) Appetite f) Oral problems (chewing, swallowing) g) Access to groceries and meal preparation h) Social isolation

South African Tool

Charlton K (2005)31

Elderly (þ65 Y)

a) BMI b) Mid upper arm circumference c) Frequency of eating d) Specific component intake e) Cognitive function f) Motor disability g) Food security h) Presence or absence of disease

JBI Database of Systematic Reviews and Implementation Reports

Content/components of the nutritional screening/assessment instrument (1)

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Appendix III: Data extraction tool 2 Overview of the type of validation of nutritional screening instruments validated in a primary care context

Instrument

Author/year of publication

Face validated (yes/no)

Content validated (yes/no)

Construct Criterion validated validated (yes/no) (yes/no)

Population

Context

23

Elderly (þ65 Y)

Nursing home population

No

No

Yes

Yes

Lok K (2009)24

Elderly (þ65 Y)

Nursing home population

No

No

No

Yes

MDS (weight, height and Blaum CS BMI from MDS) (1997)25

Elderly (þ65 Y)

Nursing home population

No

Yes

Yes

No

SNAQ (Simplified Nutrition Appetite Questionnaire)

Isenring EA (2012)26 Roland Y (2012)27

Older adults (þ55 Nursing home Y) population

No

No

Yes

No

No

No

Yes

No

SNAQ-RC (Short Nutritional Assessment Questionnaire for Residential Care þ BMI

Kruizenga HM (2010)28

Elderly (Mean age ¼ 84 Y)

Nursing home population

No

Yes

Yes

Yes

SNAQ65þ (Short Wijnhoven HAH Nutritional Assessment (2011)29 Questionnaire for people ages 65þ)

Elderly (þ65 Y)

Community Yes dwelling elderly

No

Yes

Yes

CNAQ (Nutrition Appetite Questionnaire)

Elderly (mean 79.2 Y)

Community dwelling adults and nursing home population

No

Yes

Yes

Yes

DETERMINE (Nutrition Charlton KE Checklist for Older (2007)31 Adults)

Elderly (þ60 Y)

Nursing home population

Yes

No

Yes

Yes

GNRI (Geriatric Nutritional Risk Index)

Poulia KA (2012)32

Elderly (þ60 Y)

Nursing home population

No

No

Yes

Yes

MNA (Mini Nutritional Assessment

Tarazona-Saltaba- Elderly (þ70 Y) bina FJ (2009)33

Nursing home population

No

Yes

Yes

Yes

Cereda E (2008)34 Elderly (Mean age Nursing home 80) population

No

No

Yes

No

Christensson L (2002)35

Elderly (þ65 Y)

Nursing home population

No

No

Yes

Yes

Ferreira LS (2008)36

Elderly (þ60 Y)

Nursing home population

No

Yes

Yes

Yes

Visvanathan R (2004)37

Elderly (þ65 Y)

Nursing home population

No

Yes

No

Yes

Kruizenga HM (2010)38

Elderly (Mean age ¼ 84 Y)

Nursing home population

No

Yes

Yes

Yes

Chinese Nutrition Screen Woo J (2005) (CNS)

Wilson MM (2005)30

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(Continued)

Instrument MNA-SF (Mini Nutritional AssessmentShort Form)

Face validated (yes/no)

Content validated (yes/no)

Construct Criterion validated validated (yes/no) (yes/no)

Nursing home population

No

Yes

Yes

No

Elderly (þ60 Y)

Nursing home population

No

No

Yes

Yes

Kruizenga HM (2010)38

Elderly (Mean age ¼ 84 Y)

Nursing home population

No

No

Yes

Yes

Isenring EA (2009)39

Elderly (Mean age ¼ 84 Y)

Nursing home population

No

No

Yes

Yes

Author/year of publication

Population

Context

Isenring EA (2012)39

Older adults (þ55 Y)

Poulia KA (2012)32

Revised MNA-SF (Revised Mini Nutritional AssessmentShort Form)

Garcia-Mesenguer Elderly (þ65 Y) MJ (2013)40

Nursing home population

No

No

No

Yes

Self-MNA (Selfadministered Mini Nutritional Assessment)

Huhmann MB (2013)41

Elderly (þ65 Y)

Elderly residents

No

No

Yes

Yes

MUST (Malnutrition Universal Screening Tool)

Diekmann R (2013)42

Elderly (þ65 Y)

Nursing home population

Yes

Yes

Yes

No

Isenring EA (2012)26

Older adults (þ55 Nursing home population Y)

No

No

Yes

No

Poulia K-A (2012)32

Elderly (þ60 Y)

Nursing home population

No

No

Yes

Yes

Kruzienga HM (2010)38

Elderly (mean age ¼ 84 Y)

Nursing home population

No

Yes

Yes

Yes

NRI (Nutritional Risk Index)

Poulia K-A (2012)32

Elderly (þ60 Y)

Nursing home population

No

Yes

Yes

Yes

NUFFE (Nutritional Form for the Elderly)

Soderhamn U (2001)43

Elderly (þ65 Y)

Nursing home population

No

Yes

Yes

No

Rapid Screen

Visvanathan R (2004)37

Elderly (þ65 Y)

Nursing home population

Yes

No

No

Yes

Simple Screening Tool#1 Laporte M (2001)44

Elderly (þ65 Y)

Nursing home population

No

No

Yes

No

Simple Screening Tool#2 Laporte M (2001)44

Elderly (þ65 Y)

Nursing home population

No

No

Yes

No

MST (Malnutrition Screening Tool)

Isenring EA (2012)26

Older adult (þ55 Y)

Aged care residents

Yes

Yes

Yes

No

NRS (Nutritional Risk Screening)

Diekmann R (2013)42

Elderly (þ65 Y)

Nursing home population

No

No

Yes

No

NRS-2002 (Nutritional Risk Screening 2002)

Poulia K-A (2012)32

Elderly (þ60 Y)

Elderly residents

No

No

Yes

Yes

SGA (Subjective Global Assessment)

Poulia K-A (2012)32

Elderly (þ65 Y9

Elderly residents

Yes

No

Yes

Yes

Christensson L (2002)35

Elderly (þ65 Y)

Nursing home population

No

Yes

Yes

Yes

Elderly (þ70 Y)

Community dwelling older population

No

No

Yes

Yes

NSI (Nutrition Screening Posner B (1993)54 Initiative)

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(Continued) Face validated (yes/no)

Content validated (yes/no)

Construct Criterion validated validated (yes/no) (yes/no)

Elderly care facilities

No

No

No

Yes

Community dwelling older population

No

No

Yes

No

Keller H (2005)51

Older adults (þ55 Community Y) dwelling older population

No

No

Yes

Yes

SCREEN II (Seniors in the Community: Evaluation for Eating and Nutrition – Version II)

Keller H (2006)52

Older adults (þ55 Community Y) dwelling older population

No

No

Yes

No

South African Tool

Charlton KE (2005)53

Elderly (þ60 Y)

No

Yes

Yes

Yes

Instrument

Author/year of publication

Population

Context

NST (Nutrition Screening Tool

Weekes C (2004)55

Older adults (Mean 59.6 Y)

Malaysian Tool

Shahar S (1999)50

Elderly (þ60 Y)

SCREEN I (Seniors in the Community: Evaluation for Eating and Nutrition)

JBI Database of Systematic Reviews and Implementation Reports

Community dwelling older population

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Appendix IV: Data extraction tool 3 Overview of the views of nutritionals experts, patients/and their relatives Author/year of publication Van Asselt DZB et al. (2012)56

White JV et al. (2012)58 Jensen GL et al. (2013)57 (these two references report exactly the same)

Source of point of view/ opinion/statement Population Consensus through a Geriatric modified Delphi study population with participation of eleven geriatricians with special interest in malnutrition. Focus of the Delphi study: assessment and treatment of malnutrition in Dutch geriatric practice.

The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) have published a consensus document that extends the approach to describe characteristics for the identification of malnutrition in adults. Nutrition screening tools are used to identify patients at nutrition risk and those who are likely to benefit from further assessment and intervention. Nutrition assessment serves to guide appropriate intervention. A systematic approach to nutrition assessment that supports the new diagnostic scheme and criteria from the Academy and ASPEN has recently been presented.

Adult population also including primary health care

Point of view/opinion/statement

Findings

The panel reached consensus that malnutrition should be considered a geriatric syndrome. The nutritional status should be assessed using the Mini Nutritional Assessment combined with comprehensive geriatric assessment. Nutritional interventions should be combined with interventions targeting underlying factors. Specific goals for nutritional therapy and ways to achieve them were agreed upon. According to the experts, malnutrition is best managed by a multidisciplinary team for whom roles and responsibilities were specified. At discharge written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals.

Comprehensive geriatric assessments (CGA) (assessment from a bio-psycho-social perspective).

Characteristics recommended for the identification of malnutrition in adults are: - Insufficient energy intake: % nutrients consumed/ administered vs requirement - Unintended weight loss: can occur at any body mass index - Physical examination jj Loss of muscle mass jj Loss of subcutaneous fat jj Evidence of fluid accumulation (localized or generalized) - Diminished physical function jj Hand grip strength jj SPPB (Short Physical Performance Battery) for elderly patients jj Other Positive finding in any 2 characteristics indicates malnutrition.

The use of validated screening tool is recommended: -Malnutrition Screening Tool (MST)

JBI Database of Systematic Reviews and Implementation Reports

CGA will provide insight into the multiple co-morbidities and risk factors that underlie malnutrition on the somatic, mental, functional and social domain. The Mini Nutritional Assessment (MNA) should be used to assess the nutritional status. For quick-and-easy to do case finding the SNAQ or MUST (inpatients) and MNA-sf (outpatients) may be considered

- Screening–2002 (NRS-2002) - Malnutrition Universal Screening Tool (MUST) - Short Nutritional Assessment Questionnaire (SNAQ) The integrity of the central and peripheral nervous system, the individual’s level of physical activity, multiple hormones, and inflammation are also important determinants. It is also important to recognize that an adequate nutrient intake is necessary, but not sufficient, to maintain body mass and normal physiologic function and that additional intake is required to replete established deficits. The assessment of patients nutritional status incorporates history and clinical diagnosis, clinical signs and physical examination, anthropometric data, laboratory indicators, dietary assessment, and functional outcomes

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