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Systematic review of nutritional status evaluation and screening tools in

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The Journal of Nutrition, Health & Aging©
Volume , Number , 2006

THE JOURNAL OF NUTRITION, HEALTH & AGING©

SYSTEMATIC REVIEW OF NUTRITIONAL STATUS EVALUATION

AND SCREENING TOOLS IN THE ELDERLY

L.M. DONINI, C. SAVINA1, A. ROSANO2, C. CANNELLA

Istituto di Scienza dell’Alimentazione, University “La Sapienza”, Rome (Italy). 1. Istituto Clinico Riabilitativo “Villa delle Querce” – Nemi (RM – Italy). 2. Istituto Italiano di
Medicina Sociale, Rome (Italy). Mailing Address: Lorenzo M. Donini, Università degli Studi di Roma "La Sapienza", Istituto di Scienza dell'Alimentazione, P.le Aldo Moro, 5. 00185
Rome (Italy). Fax: +3906/4991-0699. e-mail: Lorenzomaria.Donini @ uniroma1.it

Abstract: One univocal definition for nutritional status (NS) does not exist. One set of generally accepted
standards for assessing the nutritional status does not exist, either. The NS assessment is absolutely necessary
because it drives to identify malnutrition which is a potential cause and or an aggravation of morbidity and
mortality. Since malnutrition shows a high prevalence in the elderly, literature about the validation of tools
exploring single or complex NS parameters in the elderly has been systematically review. 115 papers, published
from January 1st 1990 to July 31st 2003, have been identified: among them, just 9 complied with the established
quality criteria and were suitable to be systematically reviewed. Parameters and diagnosis protocols to assess NS
used in the selected papers were not homogeneous. Two implications arise from this evidence: - as regards
clinical practice: an assessment on NS in clinical practice is complex, but not impossible. Hopefully, despite the
absence of a sure reference, nutritionists, during their own clinical practice, ought to choose a validated on their
own population and complete tool (considering as NS indicators both dietetic, anthropometric and functional
parameters) for NS assessment, among all the redundant set of tools proposed until now; - respecting a scientific
point of view, there is the necessity for calling a consensus conference in order to establish an initial consensus to
diagnose malnutrition in the elderly and to promote, therefore, a validation study.

Key words: Nutritional status, elderly, systematic review.

Any nutritional intervention should be preceded and
followed, over time, by the assessment of the clinical condition
to be treated and, more specifically, of the Nutritional Status
(NS). Unfortunately, the history of Nutritional Science and that
of clinical nutrition, like the extra-clinical value of feeding,
have often led to an "avoidance" of making a diagnosis before
the intervention. Thus, hypo-caloric diets are commonly
prescribed on the basis of a definition of obesity based on the
mere relationship between weight and height without any
consideration of the fat mass that should be the target of the
treatment. Likewise, artificial nutrition is nearly always
prescribed only when the patient cannot feed himself
spontaneously. Scientific Society of Artificial Nutrition
recommend a nutritional risk evaluation (1) dedicating very
little area to the NS assessment moreover, as a matter of fact,
do not codify the procedure.
One of the justification for these behaviors is that the NS
assessment is difficult to achieve for the following reasons.
First of all, the NS definition is not yet generally accepted in
the scientific environment. In fact, NS components are not yet
clear as also what the parameters used till now to represent
them. Furthermore, the reference values for each nutritional
parameter in different age ranges, in physiological or
pathological conditions, as a function of the ethnic minority or
of the sex do not exist.
All this implies inaccurate results. As stated by Joosten E.
(2), the application of different reference methods and
parameters for the assessment of NS (all previously validated in
different situations) to a sample of elderly subjects led to a
measure of the prevalence of Malnutrition (M) ranged between
6.5% to 85%.
Malnutrition in the elderly is shown in a very high number
of subjects (the prevalence spreads from 10 to 85% depending
on the parameters used and according to their living setting -
homes or institutions) with sometimes dramatic consequences
(3-6). In fact, the NS is one of the factors that determine the
frailty of the elderly and the M, as reported in a number of
studies, may also have an impact on morbidity, on
immunocompetence, on the appearance of pressure sores or
septic status, on the outcome of the rehabilitation programs and,
as a consequence, on mortality (7-11).
In response to the problems mentioned above, a critical
review by CCH Chen (12) was recently published. It has the
purpose of clarifying the "definition of malnutrition in the
elderly" and of developing consistent theoretical supports in
order to establish the baselines for further studies. Also in the
same work, and as stated by Bedogni G et al., (13) the NS is
characterized as a result of the interaction of three variables:
food intake, absorption and utilization of nutrients. Thus, it is
possible to define NS through:
1. The energetic balance and the balance of any single
nutrient, or the difference between the quantity of energy and
nutrients introduced and that consumed by the organism. This
is a component considered responsible for the short-term
changes in NS.
2. The body composition, which is considered as a long-term
indicator for the NS since it reflects the previous availability of
energy and nutrients

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The Journal of Nutrition, Health & Aging©
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SYSTEMATIC REVIEW OF NUTRITIONAL STATUS EVALUATION AND SCREENING TOOLS IN THE ELDERLY
3. Body functionality intended as the whole of functions
that, for their execution, need macro and micronutrients
(energetic and non energetic nutrients) in a different measure
according to the function considered; the body functionality is
considered as an intermediate indicator between the two
previous components and the health status
The importance of the topic (either considering quantitative
– prevalence of M in geriatric age – or qualitative viewpoint –
the role of the NS has in conditioning morbidity and mortality)
and the absence of generally accepted guidelines stimulated the
present study with the purpose to come to evidence about the
topic after at least 30 years of debate. In particular, the study
aims to verify, through a systematic review of the literature, the
state of the art in the assessment of geriatric NS.
Material and Methods
The most powerful scientific method for this survey is
Systematic Review (SR) (14). The SR is a widely used method
as the Evidence Based Medicine has recently given emphasis to
it because of the efficiently and reliable synthesis of the wider
literature it supplies (15,16).
The SR was carried out on the basis of the following steps
codified by Egger M et al. (17) and Cochrane Methodology
(18):
Configuration of a work group: three operators of whom
one methodological operator (expert in statistics), two clinical
operators (of whom one senior researcher experienced in
clinical nutrition in geriatric age);
Formulation of the revision question on the basis of the
considerations made in the introduction: "validation studies of
assessment procedures of the nutritional status in elderly";
Identification of relevant studies: a research strategy was
planned, with time limits since 1/01/1990 to 31/03/2004:
- On medical BD that work on systematic revisions
(Cochrane Database of Systematic Reviews)
- On PubMed (http://www.ncbi.nlm.nih.gov/PubMed
/medline.html) [the Public Medline run by the National Center
of Biotechnology Information (NCBI) of the National Library
of Medicine of Bethesda (USA), that uses Entrez software
(19)], through:
• Definition of the key words (nutritional status, evaluation
studies, aged), that allow the definition of the interest field of
the documents to search, grouped in inverted commas (“…”)
and used separately or in combination;
• Use of:
* MESH terms (Medical Subject Headings), terms used to
index the articles in Medline;
* The Boolean AND operator, that allows the
establishment of logical relations among concepts;
• Research modalities:
2
* Advanced Search;
- Manual (performed by the senior researcher experienced in
geriatric clinical nutrition) through:
• Manual revision of reviews and individual articles on
Nutrition and Geriatrics published: 1. on clinical nutrition
reviews (Nutrition, American Journal of Clinical Nutrition,
Nutrition Reviews, British Journal of Nutrition, Journal of
Nutrition Health & Aging, …); 2. geriatric reviews (Age &
Aging, J Am Geriatric Society), also qualified in the Index
Medicus that is a list of international biomedical reviews,
also published by NLM (20, 21) containing the most useful
medical literature for Index Medicus users (physicians,
publishers of medical reviews, librarians of medical
libraries).
• Identification of the articles according to the correspondence
of the title with the question of systematic review;
Definition of the selection criteria of the studies to be
included in the SR:
- NS (according Bedogni’s definition) assessment validation
studies exploring:
• For energy and nutrients balance: energy and nutrients intake
as to the recommended needs for the population studied,
number of daily complete meals, daily helpings of fruit and
vegetables, refusal to feed or to hydrate oneself, appetite;
• For body composition: weight or weight variations, body
mass index, triceps and sub-scapular skinfolds thickness
(TSF and SSSF), arm circumference (AC), mid-arm muscle
circumference or area (MAMC or MAMA);
• For organ functionality:
* Biochemical parameters: albumin, transferrin, retynol-
binding protein (RBP), prealbumin, cholesterol,
cholinesterase, mucoproteins, C-reactive protein (CRP),
hemochrome;
* Functional parameters:
- Cause of malnutrition: cognitive status, mood,
autonomy in daily activities (feeding, ability to shop,
…), chewing function, set of teeth and deglutition,
muscular strength, number and type of drugs,
intestinal functionality (nausea, vomiting, diarrhea);
- Consequence of malnutrition: lymphocytes, skin-test,
anemia, cheilosis, glossitis, number, typology and
severity of acute or sub-acute pathologies, pressure
ulcers;
- Participants: studies concerning geriatric patients (≥ 60
years old);
- Design: observational, transversal, retrospective,
longitudinal studies;
- End-point: diagnostic and prognostic defined;
- Outcome: studies identifying parameters:
• to evaluate NS or
• correlated with consequences of malnutrition (such as death,
systemic infections, dependency in one or more activities of
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daily living, pressure sores, acute events, need for assistance,
number of re-admissions, hospitalization stay, number of
visits to the physician – general practitioners or specialists);
The quality of the studies revised was further assessed
considering the following explicated characteristics:
• duration of the study [temporal, up to an event (dismissal,
death, …)];
• enrolment criteria (random, all present at a certain time, all
the candidates for a certain therapeutic procedure, …);
• dimension of the sample and of the drop-outs;
• analysis of the interaction or confounding factors
conditioning the NS [sex, age, marital status, economic
level, pathologies (number or severity of current
pathologies), drugs (number and typology of drugs
prescribed), mood, exploration of senses of smell and taste,
…];
Analysis and presentation of the outcomes: the data
extrapolated from the revised studies were collected in tables in
order to allow comparison among them; in particular, for each
study was specified: the author, the name of the journal in
which the study was published and the year of publication,
study characteristics (design, setting, …), the NS assessment
tool to be validated, the tool versus which the instrument
studied was validated;
Statistics
- since they are all qualitative data, the analysis carried out is
in the form of a narrative résumé of the reports, since the
statistic method of the meta-analysis used for the combination
of quantitative data – coming from studies that are independent
one from the other – could not be applied;
- the percentage of the subjects included in the study was
calculated on the total of those enrolled.
Results
Identification and selection of the studies
The research strategy applied allowed to identify 115
studies: 22 were found through manual research and 93 on
PubMed.
The selection of the studies carried out subsequently led to
the exclusion of 83 studies found on PubMed. Of them: 72
were not validation studies (nutrition evaluation tools were
considered effective a priori and used to assess the presence of
malnutrition); 5 were not carried out on geriatric population; 2
were further editions of studies already published; 3 could not
be located in the libraries in Italy nor through a personal
application to the authors; 1 was incomprehensible to the
authors of the SR since it was published into Polish.
According to the NS definition, 23 studies were further
excluded. In 10 of these studies only two of the three
parameters needed for the definition of NS (body composition,
energy and nutrients balance, organ functionality) were taken
3
into examination while 13 studies considered only one of those
parameters.
Therefore, the SR was performed on 9 studies: 5 were
identified on PubMed and 4 through manual research.
Validated NS assessment tools
Two studies validated the NST (Nutritional Screening Tool)
(22, 23). Other studies examined: the NSI C (“Determine Your
Nutritional Health” Checklist) (24), the RAI (Resident
Assessment Instrument) (25), the MDS (Minimum Data Set)
(26), the SGA (Subjective Global Assessment) (27), the MNA
(Mini Nutritional Assessment) (28), the IPST (Initial Protein
Energy Malnutrition Screening Tool) (29), the NRI (Nutritional
Risk Index) (30).
For NSI, MNA and SGA we took into consideration also the
original publication of the nutritional assessment tool (31-33).
Structural characteristics of validated tools for NS
assessment are reported in Table 1.
General characteristics of the studies included in the SR
The details of each study such as author, review, year of
publication, NS assessment validated tool, design and setting
of the study are summarized in Table 2.
In particular, the validation of the NS assessment tool had
been performed in 7 studies vs. other nutritional parameters
(diagnostic studies), while in 2 studies vs. the appearance of
adverse clinical events correlated with malnutrition or vs. the
mortality (prognostic studies)
Other characteristics of the studies included in the SR
Table 3 shows the sample selection criteria, the percentage
of subjects included in the study versus those enrolled, the
analysis of the cases lost and of the confounding factors.
The selection criteria of the sample was quite varied. In one
study a sample of Danish elderly subjects enrolled in SENECA
[Survey Europe on Nutrition in the Elderly: a Concerted
Action, it is a multicentric European study on the nutritional
status and health in the elderly, carried out in 1988: it is a
remarkable part of another European study, the EURONUT
(European Community Concerted Action on Nutrition and
Health (24)] was studied. In six studies the subjects were those
admitted subsequently to the unit or randomly selected. Finally,
the selection criteria in 2 studies were not mentioned.
The percentage of the subjects included in the study as
regards the total of subjects selected reached 100% in 3 studies
only. In other cases ranged from 91.6 to 46.2%. Moreover,
since the number of the subjects enrolled is not reported in one
study (28) it was not possible to calculate this percentage.
Analysis of lost cases: it was performed just in 1 of the 5
studies in which the percentage of subjects included in the
study was not 100%. Since in 1 study the selection criteria were
not cited it was not possible to evaluate the data and therefore
the percentage of subjects included in the study.
 Table 1
Nutritional Status (NS) Evaluation tools included in the systematic reviews: structural characteristics

Acronym
Volume , Number , 2006

NST NST is a tool for the identification of patients who are malnourished at the moment of hospitalisation, or those at risk to become malnourished in the course of the
hospitalisation. It explores the following variables: age, sensorial (alert and oriented, moderately confused, confused and not collaborating, comatose), food intake
(quantitative evaluation, hydration), anthropometric indices (weight, weight loss), functional indices (mastication, deglutition, autonomy in feeding, functionality of the
digestive tract (diarrhoea, vomiting, nausea)), clinical status (current pathologies)
NSI Checklist It is a self-administered assessment tool that includes a 10 items list (with a different weight) with a dichotomous response (yes - no). The items assess dietetic indices (I have
The Journal of Nutrition, Health & Aging©

less than two meals a day (yes = score 3), I eat a little fruit and vegetables and cheese products (yes = score 2), …), anthropometric indices (without wanting it I gained or lost
10 lbs in the last 6 months (yes = score 2)), functional indices (I take 3 or more than 3 drugs OTC a day or prescribed by the physician (yes = score 1), I have an illness that
made me change the type and quantity of the foods I eat (yes = score 2), …)
RAI RAI is made up of two components:
1) The MDS (Minimum Data Set), central component containing all the items necessary to make a global assessment of the patient and a list of “triggers” for malnutrition in
the elderly;
2) The RAPs (Resident Assessment Protocols), protocols developed for each of the 18 problematic areas associated with the institutionalised subjects (such as: delirium,
communication, falls, psycho-social well-being, cognitive status,…); each RAP provides the guidelines for the development of treatment strategies, including updates on the
state of art of the area treated.
The list of “triggers” is validated. For the subjects residing in Nursing-Homes it is made up of 4 items, while for those who have home-care 7 items are taken into
consideration. Triggers include: dietetic (loss of appetite in 2 out of the last 7 days, alterations in taste), anthropometric (weight loss >5% in the last 30 days or >10% in the
last 180 days) and functional indices (presence of pressure sores, difficulties in 3 or more of the following abilities: preparation of meals, mastication, deglutition, …).
MDS It is the core of the Resident Assessment Instrument. It allows the collection of a series of data that affect the NS such as factors related with feeling (set of teeth, ability in

4
mastication and in deglutition, food intake, feeding autonomy), functional characteristics Activities of Daily Living, cognitive status and behaviour disorders, affective status,
sub-acute or chronic diseases (infections of the urinary tract, pressure sores)
SGA It is a global and subjective assessment, made up of two sections: one is self-administered, and the other is filled up by a health-care professionals (physician, nurse, physical
therapist). The self-administered section collects: 1) the history of weight (current weight, height, weight over the last 6-12 months, course of the weight over the last 2
weeks), 2) history of the symptoms (no problems with feeding, anorexia, nausea, vomiting, diarrhoea, ulcers of the oral cavity, pain, alteration of the taste,…), 3) food intake
history (variations over the previous month (unvaried, increased, decreased), typology and amounts of the foods currently eaten (little and solid foods, only liquid, only
nutritional supplement, very little of everything)), 4) history of the functional capabilities referred to the previous month (normal activity with no functional limitations, able
to get out of bed but with a reduced functional capability compared to the typical one, that, anyhow, allows the performance of normal activities, activities without big
problems, to feel oneself incapable of performing most of the normal activities and the necessity of staying in bed half-day, …, substantially bed-ridden).
The section completed by the health-care professionals requires that one of them write down the primary diagnosis and the stage of the primary pathology (if known) and give
a judgment about the metabolic requirements of the patient (stress: absent, low, moderate, high), about the loss of the sub-cutaneous tissue of the triceps and of the thorax,
about quadriceps and deltoid muscle wasting, to the presence of malleolus and sacral oedema, of ascites (with a response for each item codified as normal, slight, moderate,
severe). Finally, the health-care operator will give a judgment on the NS of the patient citing one of the responses codified (normal NS, moderate malnutrition or at risk for it,
severe malnutrition).
MNA It is a tool made up of 18 items: 4 of the anthropometric section (BMI, arm and calf circumferences, weight loss in the last 3 months), 6 of the functional section (n° of drugs,
acute events, autonomy in daily life and in transfers, pressure ulcers, cognitive status), 6 of the dietetic section (n° of daily meals, n° of daily proteic meals, n° of daily meals
based on vegetables and fruit, reduction of appetite, hydration, feeding autonomy) 2 of the subjective section (patient’s perception of his/her own NS (severe or moderate
malnutrition, or normal NS), and of his/her own health status compared to the other elderly persons) .
IPST It is a tool that explores 9 risk factors for M: 2 anthropometric indices (BMI, % weight lost), 1 biochemical index (albumin), 2 dietetic indices (appetite loss, oral cavity
disorders) 1 functional index (feeding autonomy), current pathologies .
NRI It is a NS evaluation tool made up of 16 items: an anthropometric index (weight loss or gain in the last 30 days), 3 dietetic indices (refusal to eat some kinds of foods, special
diets, reduction of appetite), 12 functional indices (mastication and deglutition disorders, n° of drugs prescribed by the physician and those not taken in the last month,…).
SYSTEMATIC REVIEW OF NUTRITIONAL STATUS EVALUATION AND SCREENING TOOLS IN THE ELDERLY

Legend: NS: nutritional status, M: malnutrition; BMI: Body mass index; NST: Nutritional Screening Tool; NSI C: Nutrition screening index checklist; RAI: Resident Assessment Instrument; MDS: Minimum Data Set; SGA:
Subjective Global Assessment; MNA: Mini Nutritional Assessment; IPST: Initial Protein Energy Malnutrition Screening Tool; NRI: Nutritional Risk Index
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Table 2
Description of the validation studies included in the systematic reviews

Author Arronym Design Setting

Beck AM NSI Checklist cohort Free-living elderly

(B J Nut, 1999) (24)
Original paper: Posner BM et al,
1993 (31
Beck AM RAI cohort Patients living in nursing homes and people receiving home care
(Age & Aging, 2001) (25)
Blaum CS MDS cross-sectional Long-term care facilities
(Am J Clin Nutr, 1997) (26)
Burden ST NST cross-sectional Medical, surgical and elderly wards
(J Hum Nutr Diet, 2001) (22)
Duersken DR
(Nutrition, 2000) (27) SGA cohort Rehabilitation and geriatric wards
Original paper: Detsky AS et al, 1987 (33) (original paper: gastrointestinal surgery hospitalized patients)
Guigoz Y MNA cross-sectional Free-living elderly, outpatients patients, patients living in nursing
(Nutr Rev, 1996) (28) homes
Original paper: Guigoz Y et al, 1994 (32)
Laporte M IPST cross-sectional Acute care and long-term care facilities elderly
(Can J Diet Prec Res, 2001) (29)
Mackintosh MA NST cross-sectional Geriatric day-hospital
(J Hum Nutr Diet, 2001) (23)
Wolinsky FD NRI cross-sectional Free-living elderly
(J Nutr, 1990) (30)

Legend: NST: Nutritional Screening Tool; NSI C: Nutrition screening index checklist; RAI: Resident Assessment Instrument; MDS: Minimum Data Set; SGA: Subjective Global
Assessment; MNA: Mini Nutritional Assessment; IPST: Initial Protein Energy Malnutrition Screening Tool; NRI: Nutritional Risk Index

Table 3
Other characteristics of the studies included in the systematic reviews

Author Selection criteria Subjects included Drop out analysisS Interaction and
of the studied sample in the study (%) confounding
factors analysis

Beck AM Danish enrolled in the SENECA study 56.9 yes*

(Br J Nut, 1999) (24) (original study: participants in the 1990 (77% in the original study) (not in the original study) no
Original paper: Posner New England Elders Dental Study)
BM et al, 1993 (31)
Beck AM ND 56 no
(Age & Aging, 2001) (25)
Blaum CS Random 46.2-99.4 no
(Am J Clin Nutr, 1997) (26)
Burden ST Consecutive patients admitted 100 -
(J Hum Nutr Diet, 2001) (22)
Duersken DR Consecutive patients admitted 91.6 no no
(Nutrition, 2000) (27) (100% in the original study)
Original paper: Detsky AS et al, 1987 (33)
Guigoz Y ND Data not calculable as enrolled Not assessable
(Nutr Rev, 1996) (28) subjects number was not available
Original paper: Guigoz Y et al, (100% in the original study)
1994 (32)
Laporte M Consecutive patients admitted 100 -
(Can J Diet Prec Res, 2001) in acute care ward, randomly in
(29) long-term facilities
Mackintosh MA Consecutive patients admitted 100 -
(J Hum Nutr Diet, 2001) (23)
Wolinsky FD (J Nutr, 1990) (30) Random 64-66 No

ND = sample selection criteria not described in the primary study; * = a portion of the 13.9% of patients classified at high risk of malnutrition in the primary study incurred acute adverse
events during 6 months proceeding the follow-up (p<0.001).

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Table 4
Body composition assessment in the studies included in the systematic reviews

Author Body composition assessment

Beck AM • weight gain or loss in the last 6 months (± 10 lbs)

(Br J Nut, 1999) (24)
Original paper: Posner BM et al, 1993 (31)
Beck AM • weight loss (> 5% in the last month and > 10% in the last 180 days)
(Age & Aging, 2001) (25)
Blaum CS • weight loss in the last 30 days (≥ 5%)
(Am J Clin Nutr, 1997) (26)
Burden ST • weight (emaciated, underweight, weight loss < 3.5 kg in the last month, usual weight and steady)
(J Hum Nutr Diet, 2001) (22)
Duersken DR • current weight and height (reported data)
(Nutrition, 2000) (27) • weight in the last 6 and 12 month (reported data)
Original paper: Detsky AS et al, 1987 (33) • weight changing (gain, unchanged, loss)
Guigoz Y • BMI (BMI<19, 19<BMI<21, 21<BMI<23, BMI≥23)
(Nutr Rev, 1996) (28) • mid arm circumference (MAC<21, 21£MAC£23, >23)
Original paper: Guigoz Y et al, 1994 (32) • calf circumference (CC<31, CC≥31)
• recent weight loss (weight loss>3kg, does not know, 1<weight loss<3, no weight loss);
Laporte M • body mass index
(Can J Diet Prec Res, 2001) (29) • weight loss in the last week, in the last month, in the last 3 months, in the last 6 months, unlimited
time frame
Mackintosh MA • weight (usual weight steady, recent weight loss of 7 lbs, underweight or overweight, recent
(J Hum Nutr Diet, 2001) (23) changing of 7-14 lbs)
Wolinsky FD (J Nutr, 1990) (30) • weight changing in the last 30 days (> 10 lbs)

Table 5
Food intake assessment in the studies included in the systematic reviews

Author Food intake assessment

Beck AM • anorexia: I eat less than 2 meals per day

(Br J Nut, 1999) (24) • food and drinks intake : I eat few fruits and vegetables (< 150 g/die) or milk products (< 150 g/die), I
Original paper: Posner BM et al, 1993 (31) have 3 or more drinks of beer, liquor or wine almost every day
Beck AM • intake of 1 (or fewer) meal per day in at least 4 of the last 7 days
(Age & Aging, 2001) (25) • loss of appetite in at least 2 of the last 7 days
• more than > 25% of the food served remains on the plate
Blaum CS (Am J Clin Nutr, 1997) (26) • “poor oral intake”
Burden ST • dietary intake nutritional support (total parenteral or enteral feeding, nothing by mouth, refuses meals
(J Hum Nutr Diet, 2001) (22) and/or drinks; leaves most meals and reluctant to drink; eats only small meals/snacks and preference for
modified consistency; eats most meals) 4 levels of food intake per os
Duersken DR
(Nutrition, 2000) (27) • food intake in the last month as compared to normal (unchanged, more or less than usual)
Original paper: Detsky AS et al, 1987 (33) • kinds of token foods (little solid food, only liquids, only nutritional supplements, very little of
anything)
Guigoz Y • n° of full meals per day
(Nutr Rev, 1996) (28) • consumption (n° of servings per day) of fruits and vegetables, eggs and legumes, poultry and fish,
Original paper: Guigoz Y et al, 1994 (32) consumption of 2 or more servings of fruits and vegetables per day
• loss of appetite in the last 3 months (severe, moderate, no loss of appetite)
• hydration (n° of cups per day)
• mode of feeding (unable to eat without assistance, self-fed with some difficulty, self-fed without any
problem)
Laporte M • loss of appetite over a given frame time
(Can J Diet Prec Res, 2001) (29) • n° of meals and snacks eaten per day
Mackintosh MA • appetite (good, reduce, “poor”, little or no appetite)
(J Hum Nutr Diet, 2001) (23) • food intake (eats at least 3 meals per day, eats mainly snacks type meals, restricted food intake meals
unfinished, meals frequently missed needs encouragement)
• fluid intake in n° of cups per day (≥8, 6-7, 4-5, <3)
Wolinsky FD • food not eaten as not agreeable
(J Nutr, 1990) (30) • special diets

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Table 6
Functional status assessment in the studies of the systematic reviews

Author Functional status assessment

Beck AM • presence of disorders reducing food intake

(Br J Nut, 1999) (24)
Original paper: Posner BM et al, 1993 (31)
Beck AM
(Age & Aging, 2001) (25)
Blaum CS
(Am J Clin Nutr, 1997) (26)
Burden ST
(J Hum Nutr Diet, 2001) (22)
Duersken DR (Nutrition, 2000) (27)
Original paper: Detsky AS et al,
1987 (33)
Guigoz Y
(Nutr Rev, 1996) (28)
Original paper: Guigoz Y et al,
1994 (32)
Laporte M
(Can J Diet Prec Res, 2001) (29)
Mackintosh MA
(J Hum Nutr Diet, 2001) (23)
Wolinsky FD
(J Nutr, 1990) (30)
• ≥ 3 drugs
• problems in 3 or more of the following areas (loneliness, meals preparation, chewing, swallowing, autonomy in
activity of daily living, low physical fitness)
• change in taste
• presence of pressure sores;
• chronic and subacute conditions,
• feeding dependency
• cognitive status (comatose, confused or depressed or un-co-operative with eating, apathetic and mildly confused,
alert oriented and co-operative)
• feeding dependency (dependent, with chewing and swallowing problems, needs assistance, self-fed)
• gut function (severe diarrhoea (> 4 stools per day) and/or vomiting, diarrhoea (< 4 stools per day) and/or
vomiting, feels nauseous, normal gut function)
• medical conditions (acute renal failure or post major surgery or severe infection or pressure sores or delayed
wound healing, cancer or gastrointestinal disease or long bone fracture or burns > 15%, post minor surgery or
urinary or respiratory trait infections o unstable diabetes mellitus or dialysis, uncomplicated medical condition)
• evaluation of the level of physical activity over the last month (normal without no limitations, not my normal
self but able to be up and about with fairly normal activities, not feeling up to most things but in bed less than half
the day, able to do little activity and spend most of the day in bed or chair, pretty much bedridden)
• lives independently (yes, no)
• takes more than 3 prescription drugs (yes, no)
• has suffered psychological stress or acute disease in the last months (yes, no)
• neuropsychological problems (severe dementia or depression, mild dementia or depression, no psychological
problems)
• albumin,
• medical condition associated to protein-energy malnutrition
• feeding dependency
• feeding dependency (consistent chewing/swallowing problems or unable to eat independently, difficulties with
chewing and swallowing problems or difficulties to prepare to meals, poor dentition and slow eater, able to eat
independently)
• medical condition (not interrupting food intake, repeated/short term infections or nausea, rehabilitation or
diarrhoea or tremor, multi medical condition, cancer, sepsis, fracture, marked tremor, pressure sores)
• chewing/swallowing disorders
• gastrointestinal problems
• takes prescribed drugs
• wears dentures
•…

Analysis of confounding factors: confounding factors
analysis that is an analysis of factors that, other than NS, can
affect the patient's prognosis was performed in none of the two
prognostic studies.
NS assessment indices and reference values of the
nutritional parameter
The indices for the assessment of NS (body composition,
food intake, organ functionality), their reference values and the
criteria proposed by each tool included in SR are described in
Tables 4-6. In each of the revised tools different dietetic,
anthropometric and functional parameters for the assessment of
the nutritional status were used, moreover they had different
reference values.
Criteria used for NS definition according each tool
included in the SR
For each tool the authors foresaw the calculation of a score
on the basis of the judgment assigned to the answers to the
parameters explored by the tool itself. In most of the revised
tools the answers were codified with a structured modality
(dichotomous or multiple). Finally, the total score is often
correlated with a judgment on NS, in order to allow a clinical
interpretation.
Validation of the tool used for NS assessment in the
elderly
The “diagnostic” tools for the NS assessment in elderly were
validated versus the criteria listed in Table 7. The validation
was performed via univariate analysis (ANOVA, odds ratio,
…) in all papers. In three studies (22, 23, 29) the predictive

7

Author
Beck AM
(Br J Nut, 1999) (24)
Original paper: Posner BM
et al, 1993 (31)
Beck AM
(Age & Aging, 2001) (25)
Blaum CS
(Am J Clin Nutr, 1997) (26)
Burden ST
(J Hum Nutr Diet, 2001) (22)
Duersken DR
(Nutrition, 2000) (27)
Original paper: Detsky AS et al, 1987 (33)
Guigoz Y
(Nutr Rev, 1996) (28)
Original paper: Guigoz Y et al,
1994 (32)
8
Laporte M
(Can J Diet Prec Res, 2001) (29)
Mackintosh MA
(J Hum Nutr Diet, 2001)
(23)
Wolinsky FD
(J Nutr, 1990) (30)
Legend: BMI: body mass index; MAMA: mid-upper arm muscle area; MAMC: mid-upper arm muscle circumference, TSF: triceps skinfold; SSSF: subscapular skinfold; CRP: C-reactive protein
Beck AM (Age & Aging, 2001) (25)
Blaum CS (Am J Clin Nutr, 1997) (26)
Burden ST (J Hum Nutr Diet, 2001) (22)
Guigoz Y (Nutr Rev, 1996) (28)
Original paper: Guigoz Y et al, 1994 (32)
Laporte M (Can J Diet Prec Res, 2001) (29)
Wolinsky FD (J Nutr, 1990) (30)
Table 7
Parameters used to assess the Nutritional Status of the studies included in the systematic reviews
Parameters used for the validation of Nutritional Status tools
Body Composition Food Intake Functional Status
Volume , Number , 2006
weight loss daily energy intake (< 1,4 (the lowest acceptable physical activity needs for assistance (subjects that have been received home-
level according to Sandström et al., 1996 )*Basal Metabolic Rate care during 1991-1993); acute events (subjects that have
(%)); daily protein intake < Recommended Daily Allowances (%) been suffered from flu, cough, respiratory trait problems,
(<0.8g/kg/die according to WHO, 1985) fever, or bed bound for more than 3 days for an infectious
disease)
The Journal of Nutrition, Health & Aging©
BMI Energy intake < energy intake estimated in accordance
Schoefield’s equation (WHO, 1985); Protein intake
< 0.8 g/kg/die (Sandström, 1996)
BMI, MAMA, TSF, BIA
BMI, MAMC, Food intake < 25 % del EAR-Estimated Average Requirement
Weight loss (Department of Health, 1991)
BMI, MAMA, Albumin, cholesterol, haemoglobin, lymphocyte
TSF e SSSF
Weight, BMI, MAMC Albumin , prealbumin, CRP, a1-acid glycoprotein, grip
Calf circumference, TSF e SSSF strength
weight loss, BMI, Energy and Protein Intake Albumin, prealbumin, transferrin, haematology
MAMA
Weight, BMI, MAMA
S skinfolds
BMI <20 (at risk) Daily food record Albumin, lymphocytes, haemoglobin, hematocrit, serum
protein, S of parameters resulting < than the lower value, S
of taken drugs influencing Nutritional Status
Table 8
Body Mass Index (BMI) risk cut-off considered in the studies included in the systematic review
BMI Risk cut-off
<18.5: malnutrition ; <20: underweight
Lower quartile
< 20: malnutrition
<19: 0 points; 19< <21: 1 points, 21< <23: 2 points; ≥23: 3 points
SYSTEMATIC REVIEW OF NUTRITIONAL STATUS EVALUATION AND SCREENING TOOLS IN THE ELDERLY
<18.3: 3 points; 18.4–20.9: 2 points; 21.0–23.9: 1 points
<20: at risk
The Journal of Nutrition, Health & Aging©
Volume , Number , 2006
THE JOURNAL OF NUTRITION, HEALTH & AGING©
value (sensitivity, specificity and predictive accuracy) was
calculated. Even though in the tools for validating all
dimensions of NS are considered (food intake, body
composition and organ functionality), the validation occurred
nearly always versus parameters that considered only one or
two dimensions of NS.
As regards prognostic studies included in the SR (table 8):
- the validated tool cannot predict the mortality in 5 years (non
significant p), while it is significantly correlated (p<0.001)
with the prevalence of acute events (24)
- the validated tool cannot predict the morbidity in 6 months,
while there is a correlation between malnutrition and
mortality and the data is significant (p<0.05) (27).
Discussion
Definition of malnutrition
The definitions of malnutrition can differ among institutions,
disciplines, and cultures. Malnutrition is an overall term,
encompassing: (1) undernutrition resulting from insufficient
food intake, (2) overnutrition caused by excessive food intake,
(3) specific nutrient deficiencies and (4) imbalance because of
disproportionate intake (34). Although there are health
consequences of nutritional excesses for the aged, this
systematic review examines the studies carried out for the
validation of nutritional status evaluation tools dedicated to
undernutrition in the elderly.
In the literature, there are two clinical approaches to define
malnutrition in the elderly. The first definition characterizes
malnutrition as any insufficient dietary intake among essential
nutrients (12). With this approach, the researchers generally
define malnutrition as dietary intake below the recommended
dietary allowance (35, 36). The second approach refers to
malnutrition as protein-caloric malnutrition: the progressive
loss of both lean body mass and adipose tissue resulting from
insufficient consumption of protein and energy, with
impairment of protein metabolism (generally characterised by
hypoalbuminemia). In our study we tried to combine both
these definitions since both situations are normally combined
and represent the two sides of a single coin.
Nutritional status components
Nutritional status results from the intake, absorption and
utilisation of nutrients. The interaction of these three
components can be assessed through the evaluation of energy
balance (responsible for the short-term changes in NS), the
body composition (long-term indicator for the NS since it
reflects the previous availability of energy and nutrients), body
functions (the whole of functions that, for their execution, need
macro and micronutrients: energetic and non energetic
nutrients) through biochemical indices (an intermediate
indicator between the two previous components and the health
status) (13).
Some researchers defining malnutrition have used the
9
combination of these assessments, and most nutritional
assessment instruments also utilize all three aspects of
measurement plus some clinical assessment such as anorexia or
co-morbid conditions (12). This is probably the best way to
define nutritional status since, to date, no single measurement
has emerged as optimal in defining malnutrition in the elderly.
Methodological limits of SR
As often happens when performing a revision of literature
about a topic it was difficult to find identified articles since they
were not available in libraries (3 identified articles resulted not
to be found in the libraries of Rome and of Italy) for different
reasons (interruption of the subscription, missing volume), and
it was not possible to obtain it from the authors.
Linguistic bias was another limitation of the present study.
In fact, it seems that the revision of articles only published into
English is more a limit of who carries out SR than the author’s.
This assumption arise when interesting studies, even if they do
not produced significant results, are published in the mother
tongue of the author (as for example the article written in
Polish) and included national indexed reviews (37). It is a
complicated problem to solve since the language universally
recognized for scientific literature is British English.
Manual research was also used and it let us to find studies
not listed in the electronic databases or that, even if they were
included, may not be found since they are indexed with
different terms from the key words selected. It seems to be
clear that this research strategy requires a knowledge of the
topic of the survey and of the journals where the subject of the
interest area in question was probably published. Therefore, it
is important that this step is carried out by an experienced
operator on 4-5 journals (a number that is sufficient when the
enquiry is well defined). Manual research increased the total
number of the studies revised allowing to identifying studies
not included in electronic database and it resulted to be an
accurate (none of the studies identified by manual research was
excluded following the initial selection performed) but
subjective (depending on the choosen references and on the
“random” collection of the journals) and “time-consuming”
procedure. Manual research was carried out on reviews
included in the Index Medicus (20, 21).
Single exclusion criteria to select the studies was that of
eliminating studies in which NS assessment was not performed
according to the criteria proposed by Bedogni, Battistini et al.
Methodological limits of the studies (lack of details such as:
the duration of the study; the enrolment criteria; the size of the
sample and number of drop-outs; omitted analysis of the
confounding or interacting factors) did not lead to their
exclusion from the SR (7 out of 9 of the studies reviewed could
have been excluded), but were cited anyway (tab 3). An
analysis of the sensitivity (repeating the analysis on the 2
studies left) and a critical appraisal, that is a critical evaluation
of a study by checklist (based on the plan of the study) in which
– for each of the 7 research studies that have methodological
The Journal of Nutrition, Health & Aging©
Volume , Number , 2006
SYSTEMATIC REVIEW OF NUTRITIONAL STATUS EVALUATION AND SCREENING TOOLS IN THE ELDERLY
limits – all the characteristics a good quality study should have
are listed (38) it is going to be performed as soon as. The
critical appraisal helps the reader to identify studies producing
inaccurate and useful information. Validity, reliability and
applicability of the study is carefully assessed analyzing
elements such as: the consistency between the descriptions of
the methodology and the results, the non distortion of the
selected sample, the potency of the study, the levels of outcome
generalizability. For this purpose, specific checklists for the
type of study analyzed were constructed, in order to orient the
evaluator giving criteria as homogeneous as possible.
It is well-known that the outcomes of a study are
generalizable to the population that has the same characteristics
as the sample examined, when the sampling has been
performed correctly. In the studies where the percentage of
patients included in the research do not match the number of
the subjects enrolled, it is important to perform the analysis of
the cases lost. It is possible, if not likely, that the subjects that
did not participate to the study had different characteristics –
from a nutritional stand point – than those who were instead
actually enrolled. In fact, it is not possible to know whether
those who did not participate were sicker, older or more
socially isolated than the sample selected. As a matter of fact,
this happened just in the single case in which this analysis was
performed; in particular, in the study of Beck AM (24), some of
the patients enrolled who did not participate in the study were
classified in the high or moderate malnutrition risk class (16,
37).
The state of art in NS assessment in elderly
The NS assessment in the elderly is performed using
different tools and only in few cases, as results from the present
analysis, the parameters proposed (energy balance, body
composition, body functionality) are used in the same time (13,
39).
Also in the revision done by CCH Chen “A concept analysis
of malnutrition in the elderly” the assessment of the NS, for the
diagnosis of M in the elderly, should be based on the study of
three determinants: foods intake, biochemical and
anthropometric indices. It is ascertained the none of the three
dimensions characterizing the NS, taken separately, can
measure or assess a complex variable such as NS (12).
The studies included in this SR, other than referring – from
case to case – to different parameters (of the three determinants
that define the NS) also use different reference values and
different diagnostic criteria. For example, to define malnutrition
or underweight status, various authors use a cut-off with the
lower limit ranging from 18.3 to 20 Kg/m2, for the BMI (table
8).
The same parameters are sometimes used improperly as
happens for the BMI - that was created as an epidemiological
tool (40), and instead it is used in a single patient for a
diagnosis positioning the lean mass and the fat mass are on the
same level and presuming a “correct” distribution between
10
these two components and a balanced variation of them in case
of weight oscillation. Moreover, the BMI loses most of its
validity since height is difficult to measure due to frequent
alterations in the spine and in the large joints of the lower limbs
in the elderly population.
Other anthropometric measures in the elderly may also lose
their reliability, if measured in a none too accurate way or
without considering the peculiarities of the geriatric subject. In
fact, the reliability is a function of the body composition that
varies with age (the adipose tissue is re-distributed, especially
in an intra-abdominal level, where it tends to increase to the
detriment of the subcutaneous tissue of the limbs, making
improper the use of those reference values established for adult
populations), and of the hydration status, of the position
assumed during the measurement (many elderly are affected by
skeletal deformities or are obliged to antalgic postures that are
different from those proposed in the reference handbooks for
anthropometric standardization) (41). Weight loss at times
expressed in kilos and other times in pounds, in absolute value
or in percentage, referred to 1, 3, 6, 12 months is the
anthropometric index mostly assessed. The lack of uniformity
in the period in which the weight loss and the unity of
measurement is evident. The latter is oddly difficult to interpret,
taking into consideration the long transition time, that is
probably still ongoing in some countries, from the advent of the
International System of measurement units (42)!!
Concerning the food intake, roughly, the number of
complete meals taken, sometimes in the last week, sometimes
in the last month, the reduction or loss of appetite in a day time,
in one week or in three months, the number of drinks in a day
expressed in number of cups or glasses were the mostly
evaluated indices. Therefore, also food intake is assessed in a
various and imprecise way, hardly quantifiable. Thus, it is not
surprising that in only two cases (24, 28) is there an attempt to
define quantitatively the food intake as regards their typology
(fruit, vegetable, milk-by products, meat, legumes, fish). This is
an aspect that should not be underestimated in the elderly who
make their food choices not only on the basis of the preferences
for some foods [due to environmental factors (socio-
economical and cultural), personal factors (emotions and
attributes related to the food), biological factors (age, gender),
...] but also of their chewing capability (directly proportional to
the number of residual teeth, to the adequate oral cavity
hygiene, to the preparation of food) and of swallowing
capability (eventual presence of dysphagia or pathologies that
can determine it) (43).
The mostly considered organ functionality index in the
revised studies is autonomy in one or more activities in daily
life, followed by the number and type of current pathologies
that may influence the pathogenesis of malnutrition. The
autonomy – for one or for more daily activities – is generally
assessed on the basis of a uniform criterion (autonomous
patient, patient requiring help, completely dependent patient).
Instead, those that are scarcely assessed are: the level of
The Journal of Nutrition, Health & Aging©
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THE JOURNAL OF NUTRITION, HEALTH & AGING©
physical activity, the presence of polypharmacology and the
cognitive status or mood, for which there is not uniformity in
the criterion used. For example, as regards the
polypharmacology, there are two instruments that assess it on
the basis of the assumption of at least three drugs (24, 26),
while one instrument assesses it simply on the basis of the fact
the drugs were prescribed or not (30). Only the tool used by
Laporte assesses albuminemia (29), while none takes into
consideration immunocompetence. Data which is difficult to
interpret is also the type of indicator of organ functionality that
the revised tools take into consideration on a case to case basis.
In fact, sometimes are used the factors causing malnutrition
(cognitive status, mood, autonomy in daily life activities
(feeding, ability to do one’s own shopping, …), chewing
function, set of teeth and swallowing, muscular strength,
number and typology of drugs, intestinal function (nausea,
vomiting, diarrhea) that are probably more indicated in a tool
for assessing the risk for malnutrition and, therefore, that has a
prognostic value; in some other cases are used the factors that
are a consequence of malnutrition (number, typology and
severity of acute or sub-acute pathologies, pressure sores) that
are perhaps more appropriate in the structure of a diagnostic
tool; sometimes are used both as happens for a tool that
assesses independently, but at the same time, the risk for
malnutrition and an eventual ongoing malnutrition.
The tools revised – all heterogeneous among themselves –,
do not allow the performance of a differential diagnosis
between an endogenous malnutrition (hypercatabolic) or
exogenous (due to a mere progressive reduction in food intake)
and between caloric malnutrition (with a reduction of fat mass
especially and then that of lean mass) or protein-energy
malnutrition (in which there is also a reduced organ function)
that could be relevant in nutritional intervention planning, nor a
diagnosis of malnutrition in subjects with an increase of fat
mass (sarcopenic obesity) – that is a phenomenon increasingly
observed in geriatric rehabilitation units.
Conclusions
The SR carried out on the validation of the tools for the NS
assessment in the elderly brings out the following evidence:
• there is no gold standard for NS assessment, thus, it is
difficult to construct universally valid and validated tools for
NS;
• there is no uniformity in the parameters studied, neither for
their reference values, nor for the diagnostic criteria.
Two implications arise from this evidence: one for clinical
practice, the other for scientific research. An assessment on NS
in clinical practice is complex, but not impossible, when there
is no gold standard and when each new proposed tools with this
aim are validated versus a “non gold standard”. Hopefully,
despite the absence of a sure reference, each nutritionist ought
to choose a tool for NS assessment during their own clinical
11
practice, validating it on their own population, using the three
NS indicators among all the redundant set of tools proposed
until now.
Regarding the scientific implications, it is evident that future
efforts of the researchers should be oriented to research tools
for the assessment of the geriatric NS. Until now there are no
criteria that are unanimously shared or that assess only one of
the components of NS (body composition, food intake,…) and
therefore for the assessment of NS were used just imperfect
tools as for example the BMI useful when considered in clinical
epidemiology .
As codified by Jones JM (44, 45), it may be suitable to
imagine a pathway that, on the basis of an initial consensus and
involving the judgment of an expert group, identifies the “gold
standard”, defines the reference population, identifies the
variables associated with malnutrition in the target population
and promotes, therefore, the true validation study.
On the basis of the issues in the literature and partly from the
Systematic Revision carried out, the only point that seems clear
is that the ideal tool for NS assessment must include dietetic,
anthropometric and functional indices, and an assessment of the
risk from a nutritional point of view.
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