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18
Nutrition Monitoring and Research Studies: Nutrition
Screening Initiative

Ronni Chernoff

The Nutrition Screening Initiative

Screening for Malnutrition
Malnutrition is not a condition that occurs rapidly; it is a chronic condition that develops
slowly over time. It is widely accepted that malnutrition from any etiology is not a positive
factor in health status, and may have a negative impact on other health conditions. There
have been many reports of the health consequences of malnutrition, particularly in hos-
pitalized individuals where poor nutritional status has been associated with increased
lengths of hospital stay, co-morbidities, complications, readmissions, and mortality.1-6 This
is particularly profound because it has been estimated that 85% of noninstitutionalized
older adults have one or more chronic conditions, many of which are related to nutritional
status.7 If it is possible to identify indicators of risk for the development of malnutrition,
and these factors are reversible conditions, then interventions that will alleviate risk can
be instituted before malnutrition becomes overt and worsens chronic conditions.
Nutritional screening is of value if 1) it reliably identifies the existence of risk factors
for malnutrition; 2) it recognizes the existence of poor nutritional status; 3) it contributes
to the avoidance of malnutrition; 4) it will minimize suffering; and 5) the condition of
malnutrition can be reversed.6,8 Reuben et al.8 describe criteria necessary to define the
potential effectiveness of interventions; these criteria are whether or not identification of
malnutrition can be achieved more accurately with screening than without it, and whether
or not individuals who have malnutrition detected early have a better outcome than those
who have malnutrition detected later in the course of their illness.
Rush9 defines the role of nutrition screening in older adults in different terms. He
describes another criteria set for screening including specificity, sensitivity, inexpensive
screening devices, and interventions where health benefit is not sacrificed by not treating
those who are at moderate or low risk. He indicates that screening is appropriate where
there is a relatively small but important proportion of the population that is affected,
where those who are affected can be identified by an easily applied tool, and where there
is an effective intervention.

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464 Handbook of Nutrition and Food

Developing a Tool
Keeping these criteria in mind, and looking for a way to make both professional and
volunteer care providers more attentive to the malnutrition risks encountered by older
adults, the Nutrition Screening Initiative (NSI) was established in 1990 as a public aware-
ness tool for use by community and health care workers who have regular contact with
older adults. The tools were developed as a joint venture of the American Dietetic Asso-
ciation, the American Academy of Family Physicians, and the National Council on the
Aging. The premise of the Nutrition Screening Initiative is that if factors associated with
malnutrition risk are identified early, interventions can be instituted that may delay or
avoid the progression of the risk factors towards overt malnutrition.10
The NSI was developed as a nested set of tools that identify risk factors for poor
nutritional status and then diagnose malnutrition. There are three tiers: a checklist, level
II, and level III screens.11 The items on the tools were developed by reviewing the
literature and developing consensus by a technical advisory committee of experts. The
checklist was tested using a follow-up sample from a previous study of nutritional status
in older people.12

The Checklist
The checklist was created as a public awareness screening tool for use by health care and
social services personnel and other providers who work in community-based programs
in which older adults participate. It was conceived and designed to bring awareness to
nutritional issues that may impact on the health status of elderly clients. The checklist is
widely available for reproduction and information collection, and permission to use it in
non-profit settings is not required.11
The checklist was titled “Determine Your Nutritional Health” based on a mnemonic that
contains the risk factors for malnutrition listed on the reverse side of the checklist. (Figures
18.1a and b). The checklist is a one-page questionnaire that can be used in community, long
term care, or acute health settings by volunteers, health aides, or health professionals. The
objective of awareness of potential nutritional problems in older people was easily achieved;
those who have been critical have built their criticisms on the basis of assumptions that
have gone farther than the original intent of the tool or the NSI campaign.13
The items on the checklist were developed using reference literature, expert opinion,
existing databases, and pilot testing.12 Using biochemical or laboratory parameters to
define nutritional status may be misleading because the most commonly used measures,
such as serum proteins, are affected by so many different factors independent of diet or
nutritional status.9

Implementation Strategies
Screening can be conducted in many settings, and by health professionals as well as health
care workers or lay volunteers. Involving interested participants (nurses, aides, admission
clerks, etc.) will increase the likelihood that data collection (weights, heights, completion
of screening instruments) will be more complete.
Modifications that allow the screening tools to be used in different settings and for
unique purposes make this approach and this instrument user friendly, applicable, and
relevant. A tool that is flexible, valid, and reliable and allows different applications in
diverse settings is very valuable. The easier and less time consuming it is to collect data
that give insights into an individual’s nutrition and health status, the more valuable the

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Nutrition Monitoring and Research Studies: Nutrition Screening Initiative 465

The warning signs of poor nutritional

health are often overlooked.
Determine
Use this checklist to find out if you Your
or someone you know is at risk.
Nutritional
Read the statements below. Circle the number in
the yes column for those that apply to you or Health
someone you know. For each yes answer, score the
number in the box. Total your nutritional score.

YES
I have an illness or condition that made me change the kind and/or amount of food I eat. 2

I eat fewer than 2 meals per day. 3

I eat few fruits or vegetables, or milk products. 2

I have 3 or more drinks of beer, liquor, or wine almost every day. 2

I have tooth or mouth problems that make it hard for me to eat. 2

I don't always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I take 3 or more different prescribed or over-the-counter drugs a day. 1

Without wanting to, I have lost or gained 10 pounds in the last 6 months. 2

I am not always physically able to shop, cook, and/or feed myself. 2

TOTAL

Total Your Nutritional Score. If it's - These materials developed and distributed by
the Nutrition Screening Initiative, a project of:

0-2 Good!Recheck your nutritional score in 6 months. AMERICAN ACADEMY

OF FAMILY PHYSICIANS

3-5 You are at moderate nutritional risk. THE AMERICAN

DIETETIC ASSOCIATION
See what can be done to improve your eating habits and
lifestyle. Your office on aging, senior nutrition program, NC NATIONAL COUNCIL
OA ON THE AGING
senior citizens counter, or health department can help.
Recheck your nutritional score in 3 months.
Remember that warning signs
6 You are at high nutritional risk. suggest risk, but do not represent
or Bring this checklist the next time you see your doctor, diagnosis of any condition.
more
dietitian, or other qualified health or social service Turn this page to learn more
professional. Talk with them about any problem you about the warning signs of poor
may have. Ask for help to improve your nutrition health. nutritional health.

FIGURE 18.1
Determine your nutritional health.

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466 Handbook of Nutrition and Food

The Nutrition Checklist is based on the Warning Signs described below.

Use the word DETERMINE to remind you of the Warning Signs.
DISEASE
Any disease, illness, or chronic condition which causes you to change the way you eat, or makes it hard for
you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affect-
ed by diet. Confusion or memory loss that keep getting worse is estimated to affect one out of five or more
older adults. This can make it hard to remember what, when, or if you've eaten. Feeling sad or
depressed which happens to about one in eight older adults, can cause big changes in appetite, digestion,
energy level, weight, and well-being.

EATING POORLY
Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not
eating fruit, vegetables, and milk products daily will also cause poor nutritional health. One in five adults
skips meals daily. Only 13% of adults eat the minimum amount of fruit and vegetables needed. One in four
older adults drinks too much alcohol. Many health problems become worse if you drink more than one or
two alcoholic beverages per day.

TOOTH LOSS/MOUTH PAIN

A healthy mouth, teeth, and gums are needed to eat. Missing, loose, or rotten teeth, or dentures which don't
fit well or cause mouth sores make it hard to eat.

ECONOMIC HARDSHIP
As many as 40% of older Americans have incomes of less that $6000 per year. Having less - or choosing to
spend less - than $25 to 30 per week for food makes it very hard to get the foods you need to stay healthy.

REDUCED SOCIAL CONTACT

One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being,
and eating.

MULTIPLE MEDICINES
Many older Americans must take medicines for health problems. Almost half of older Americans take multi-
ple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take,
the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation,
weakness, drowsiness, diarrhea, nausea, and others. Vitamins or minerals when taken in large doses act like
drugs and can cause harm. Alert your doctor to everything you take.

INVOLUNTARY WEIGHT LOSS/GAIN

Losing or gaining a lot of weight when you are not trying to is an important warning sign that must
not be ignored. Being overweight or underweight also increases your chance of poor health.

NEEDS ASSISTANCE IN SELF CARE

Although most older people are able to eat, one of every five has trouble with walking, shopping, and buying and
cooking food, especially as they get older.

ELDER YEARS ABOVE AGE 80

Most older people lead full and productive lives, but as age increases, risk of frailty and health problems
increase. Checking your nutritional health regularly makes good sense.

The Nutrition Screening Initiative, 1010 Wisconsin Avenue, NW, Suite 800, Washington, D.C. 20007
The Nutrition Screening Initiative is funded in part by a grant from Ross Laboratories, a division of Abbott Laboratories.

FIGURE 18.1
Determine your nutritional health. (Continued.)

information. One example is the slight modifications made to the Nutrition Screening
Initiative Checklist for use in a dental office14,15 (Figure 18.2). Dental professionals are in
a unique position to monitor their patients’ nutritional status since many of the conse-
quences of poor nutrition manifest themselves in the oral cavity (bleeding or swollen
gums; pain in mouth, teeth, gums; angular cheilosis; alterations in the surface of the
tongue). Additionally, oral health problems may contribute to the development of inade-
quate nutritional status due to lesions, loose or missing teeth, poorly fitting dentures, dry
mouth, tooth decay or disease, and difficulty in chewing or swallowing.

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Nutrition Monitoring and Research Studies: Nutrition Screening Initiative 467

The warning signs of poor nutritional health are often overlooked. A checklist can help determine
if someone is a nutritional risk:

Read the statements below. Circle the number in the yes column for those that apply to you. For each yes answer,
score the number in the box. Total your nutritional score.
YES
An illness or condition makes me change the kind and/or amount of food I eat. 2

I avoid eating a food group, i.e., meat, dairy, vegetables, and/or fruit. 2

I have two or more drinks of beer, liquor, or wine almost every day 2

I have tooth pain or mouth sores that make it hard to eat or make me avoid certain foods. 2

I snack or drink sweetened beverages two or more times per day between meals. 2

I had three or more new cavities at a recent dental check-up 2

I don’t always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I have a dry mouth, which makes me drink or use gum, hard candy, cough drops, or mints to moisten 1
my mouth two or more times per day.

I take three or more different prescription or over-the-counter drugs daily. 1

Without wanting to, I have lost or gained 10 pounds in the last six months. 2

I am not always physically able to shop, cook, and/or feed myself. 2

TOTAL

Total your nutritional Score. If it is:

0–2 Good! Recheck your nutritional score in 6 months.

3–5 You are at moderate nutritional risk. Try to improve your eating habits and lifestyle.
6 or more You are at high nutritional risk. Talk with your doctor, dental hygienist, or dietitian about any
problems you may have. Ask for help to improve your nutritional health.

FIGURE 18.2
Determine your nutritional health checklist, modified for use in a dental office.

The checklist can also be modified for use in specialized community or clinical settings.
One example is use in a rural community setting as reported by Jensen et al.16 They found
that the checklist items indicating poor appetite, eating problems, low income, eating
alone, and depression were associated with functional limitation.

Implementation Partners
Nurses are essential partners and participants in nutrition screening. They are the best
individuals to gather anthropometric data and health history information. They are well-
positioned to evaluate individuals’ functional status by assessing ability to engage in
activities of daily living (self care) and instrumental activities of daily living (managing
independence). Clinical nurse specialists (CNS) are uniquely positioned to conduct health
and nutrition screenings in clinic settings, particularly to identify risk factors that are
modifiable before nutritional status begins a slippery slope downward. The advantage of
implementing health promotion programs before or concurrently with the emergence of
risk-associated conditions should be apparent.17
Other health practitioners (dentists, social workers, physical therapists, speech pathol-
ogists, etc.) may also use the screening tool for clients who may have risk factors for the

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468 Handbook of Nutrition and Food

development of malnutrition. Community workers who run senior centers, senior meal
programs, home health agencies, etc. can also use the checklist to help identify clients
who may require more attention to their dietary intake, social circumstance, and chronic
disease management.

Subjective Global Assessment (SGA)

Another tool devised by a group of clinicians in Canada uses a brief set of history and
physical assessment items to make an evaluation of nutritional status.18 The Subjective
Global Assessment (SGA) includes an analysis of weight changes, dietary change, gas-
trointestinal symptoms, functional capacity, medical status, and physical assessment (Fig-
ure 18.3). This tool relies on a subjective rating by using clinical judgment on weight loss,
dietary intake, loss of subcutaneous tissue, functional capacity, fluid retention, and appar-

(Select appropriate category with a checkmark, or enter numerical value where indicated by “#.”)

A. History
1. Weight change
Overall loss in past 6 months: amount = # ____________ kg; % loss = # ____________
Change in past 2 weeks: ____________ increase
____________ no change
____________ decrease
2. Dietary intake change (relative to normal)
____________ No change
____________ Change Duration = # ____________ weeks
Type: ____________ suboptimal solid diet ____________ full liquid diet
____________ hypocaloric liquids ____________ anorexia
3. Gastrointestinal symptoms (that persisted for >2 weeks)
__________ none __________ nausea __________ vomiting __________ diarrhea __________ anorexia
4. Functional capacity
____________ No dysfunction (e.g., full capacity)
____________ Dysfunction Duration = # ____________ weeks
Type: ____________ working suboptimally
____________ ambulatory
____________ bedridden
5. Disease and its relation to nutritional requirements __________________________________________
Primary diagnosis (specify) ____________
Metabolic demand (stress): ____________ no stress ____________ low stress
____________ moderate stress ____________ high stress
B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)
# ____________ loss of subcutaneous fat (triceps, chest)
# ____________ muscle wasting (quadriceps, deltoids)
# ____________ ankle edema
# ____________ sacral edema
# ____________ ascites
C. SGA rating (select one)
____________ A = Well nourished
____________ B = Moderately (or suspected of being) malnourished
____________ C = Severely malnourished

FIGURE 18.3
Features of Subjective Global Assessment (SGA).

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Nutrition Monitoring and Research Studies: Nutrition Screening Initiative 469

ent muscle wasting.8,18 This tool has been successfully adopted and used by physicians
and nurses in clinical settings. It has been tested in the clinical setting with different
assessors, with a high degree of interrater reliability (0.91).19,20 Most of validity reports of
the SGA were conducted on hospitalized subjects with mean ages of 50 years or older,
which may contribute to some questions about its general applicability. However, the
addition of laboratory values to the SGA did not improve its validity.19
Although the SGA is a short tool that can be used successfully by health practitioners,
there are limitations to its use as a screening tool. It requires a trained clinician to admin-
ister, since there is some clinical judgment involved that would not be expected in someone
who is not a health professional. It requires that the individual being assessed is undressed
and able to be turned, which does not lend itself to community-based assessment pro-
grams. Also, its validation has been demonstrated on middle-aged, rather than elderly,
subjects.8

Mini Nutritional Assessment (MNA)

The Mini Nutritional Assessment (MNA) is a tool developed to easily evaluate the nutri-
tional status of frail elderly individuals.21 This instrument was developed to meet a
perceived need to go beyond the DETERMINE checklist developed by the NSI, which
was designed to raise the awareness of potential malnutrition risks, and the SGA, which
was designed for use with hospitalized individuals. The MNA, therefore, was created to
complement the screening tools already described.
The objectives for the MNA were to meet the following criteria:

• Be a reliable instrument
• Define thresholds
• Be used with minimal training
• Be free of rater bias
• Be minimally intrusive to patients
• Be inexpensive

The tool was designed to collect 18 items that combine objective and subjective data. These
data include simple anthropometric measures (height, weight, arm and calf circumfer-
ences, and weight loss), general geriatric assessment items, a brief general dietary assess-
ment, and self-assessment of health and nutrition perception (Figure 18.4).
This tool has been validated in several studies by comparing the scores to the judgments
of trained nutrition clinicians and to a comprehensive nutritional assessment that collected
in-depth data about the nutritional status of the subjects.22 These studies found that the
threshold for well-nourished on this instrument with a 30-point scale was 22 to 24 points;
the threshold for malnutrition was 16 to 18 points on this scale.
The MNA meets its objectives of being a practical, non-invasive tool that contributes to
the rapid evaluation of an elderly subject’s nutritional status, contributing early interven-
tion to correct nutritional deficits. This tool is easily used in a variety of settings including
hospitals, nursing homes, physician offices, or clinics.

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470 Handbook of Nutrition and Food

MINI NUTRITIONAL ASSESSMENT

MNATM ID#

Last Name: First Name: M.I. Sex: Date:

Age: Weight,kg: Height, cm: Knee Height, cm:

Complete the form by writing the numbers in the boxes. Add the numbers in the boxes and compare the total assessment to the
Malnutrition Indicator Score.

ANTHROPOMETRIC ASSESSMENT
1. Body Mass Index (BMI) (weight in kg) / (height in m)2 Points 12. Selected consumption markers for protein intake Points
a. BMI < 19 = 0 points . At least one serving of dairy products (milk,
b. BMI 19 to < 21 = 1 points cheese, yogurt) per day? yes no
c. BMI 21 to < 23 = 2 points
d. BMI >
_ 23 = 3 points
. Two or more servings of legumes or eggs per week?
yes no
2. Mid-arm circumference (MAC) in cm . Meat, fish, or poultry every day? yes no
a. MAC < 21 = 0.0 points a. if 0 or 1 yes = 0.0 points
b. MAC 21 <_ 22 = 0.5 points b. if 2 yes = 0.5 points
c. MAC > 22 = 1.0 points c. if 3 yes = 1.0 points
3. Calf circumference (CC) in cm 13. Consumes two or more servings of fruits or
a.CC < 31 = 0 points b. CC >
_ 31 = 1 point vegetables per day?
a. no = 0 points b. yes = 1 point
4. Weight loss during last 3 months
a. weight loss greater than 3kg (6.6 lbs) = 0 points 14. Has food intake declined over the past three
b. does not know = 1 point months due to loss of appetite, digestive problems,
c. weight loss between 1and 3 kg chewing or swallowing difficulties?
(2.2 and 6.6 lbs) = 2 points a. severe loss of appetite = 0 points
d. no weight loss = 3 points b. moderate loss of appetite = 1 point
c. no loss of appetite = 2 points
GENERAL ASSESSMENT
15. How much fluid (water, juice, coffee, tea, milk,...)
5. Lives independently (not in a nursing home or hospital)
is consumed per day? (1 cup = 8 oz.)
a. no = 0 points b. yes = 1 point
a. less than 3 cups = 0.0 points
6. Takes more than 3 prescription drugs per day b. 3 to 5 cups = 0.5 points
a. yes = 0 points b. no = 1 point c. more than 5 cups = 1.0 points

7. Has suffered psychological stress or acute 16. Mode of feeding

disease in the past 3 months a. Unable to eat without assistance = 0 points
a. yes = 0 points b. no = 2 points b. self-fed with some difficulty = 1 point
c. self-fed without any problem = 2 points
8. Mobility
a. bed or chair bound = 0 points SELF ASSESSMENT
b. able to get out of bed/chair but does
17. Do they view themselves as having nutritional problems?
not go out = 1 point
a. major malnutrition = 0 points
c. goes out = 2 points
b. does not know or moderate malnutrition = 1 point
9. Neuropsychological problems c. no nutritional problem = 2 points
a. severe dementia or depression = 0 points
18. In comparison with other people of the same age. how
b. mild dementia = 1 point
do they consider their health status?
c. no psychological problems = 2 points
a. not as good = 0.0 points
10. Pressure sores or skin ulcers b. does not know = 0.5 points
a. yes = 0 points b. no = 1 point c. as good = 1.0 points
d. better = 2.0 points
DIETARY ASSESSMENT
ASSESSMENT TOTAL (max.30 points):
11. How many full meals does the patient eat daily?
a. 1 meal = 0 points
MALNUTRITION INDICATOR SCORE
b. 2 meals = 1 point
c. 3 meals = 2 points _ 24 points
> well-nourished
17 to 23.5 points at risk of malnutrition
< 17 points malnourished

FIGURE 18.4
The Mini Nutritional Assessment form.

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Nutrition Monitoring and Research Studies: Nutrition Screening Initiative 471

Nutritional Assessment in Older Adults

The descriptions of the screening tools used to define nutritional status among elderly
people highlight the fact that one of the more difficult determinations in elderly people
is the accurate assessment of their nutritional status. This evaluation is more challenging
in older adults because of the physiologic changes that occur with normal aging. Many
of the commonly used assessment standards are not reliable in this population for a variety
of reasons.23

Anthropometric Measures
Anthropometric measures, including height, weight, and skinfold measures, are usually
important components of a nutritional assessment. These parameters are the ones most
affected by the aging process.24 The most apparent age-related change occurs in height.
Height decreases as people get older due to changes in skeletal integrity, most noticeably
affecting the spinal column. Loss of height may be due to thinning of the vertebrae,
compression of the vertebral discs, development of kyphosis, and the effects of osteoma-
lacia and osteoporosis.25 Loss of height occurs in both males and females, although it may
happen more rapidly to elderly women with osteoporosis. Therefore, stature changes and
body appearance may be altered and, as older people lose their ability to stand erect, the
organs in the thoracic cavity will become displaced and breathing and gastrointestinal
problems may ensue.26,27
Height is difficult to measure in individuals who are unable to stand erect, cannot stand
unaided, cannot stand at all due to neuromuscular disorders, paralysis, or loss of lower
limbs, or are bedbound due to other medical problems. One estimate of stature in these
individuals is to measure their recumbent height or the bone lengths of extremities.23,28
This estimate of stature may not be very reliable, but it provides some estimate of height
to help determine whether body weight is appropriate for height.
Weight is another important anthropometric measure that is altered with advancing age.
Weight changes occur at different rates among elderly people. Use of most standard height
and weight tables is not valid in older people since most reference tables do not include
elderly people in their subject pool, and most are not age-adjusted.
Body mass index (BMI) is a commonly-used measure to evaluate relative weight for
height using a mathematical ratio of weight (in kilograms) divided by height (in square
meters).

Wt (Kg)/Ht (M)2

This formula yields a whole number that should be greater than 21 and less than
approximately 35.10 Nomograms and tables are available that minimize the need for
calculation. There is some controversy among experts regarding the range of acceptable
BMI measures in elderly people.4,29
Skinfold measurements (triceps, biceps, subscapular, suprailiac, thigh) are often
included in a thorough nutritional assessment. However, loss of muscle mass, shifts in
body fat compartments, changes in skin compressibility and elasticity, and lack of
age-adjusted references serve to decrease the reliability of skinfold measures in the assess-
ment of nutritional status in elderly people.30

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472 Handbook of Nutrition and Food

Biochemical Measures
Biochemical assessment parameters are also affected by advancing age.23 Laboratory mea-
sures may reflect an age-related decline in renal function, fluid imbalances or hydration
status, or the effects of long-term chronic illnesses. Among the commonly used biochemical
markers of nutritional status, serum transferrin is one that is markedly affected by advanc-
ing age. Since tissue iron stores increase with age, circulating serum transferrin levels are
reduced. A lower than normal serum transferrin should be evaluated in relation to other
biochemical measures and serum iron levels, if obtainable.31
The most reliable predictor of nutritional status in elderly people is serum albumin. A
serum albumin below 4.0 g/dl (depending on local laboratory normal ranges) is not usual
in an older person unless the subject is overhydrated, has cancer, renal or hepatic disease,
or is taking medications that may interfere with hepatic function. Recent evidence suggests
that serum albumin is a prognostic indicator of potential infectious complications and
other nosocomial problems in hospitalized, frail, or dependent elderly individuals.32 A
depressed serum albumin seems to be a primary prognostic indicator of rehospitalization,
extended lengths of stay, and other complications associated with protein energy malnu-
trition in elderly people.33,34 Unless there are medical reasons, most biochemical measures
should remain within normal limits.
Serum cholesterol has been considered in the risk for coronary heart disease, but a
depressed serum cholesterol is also associated with poor health status in older people.35
It may be predictive of impending mortality36 and should be evaluated carefully within
the context of other health measures.

Immunologic Assessment
Tests for immunocompetence are often included as part of a nutritional assessment because
malnutrition results in compromised host-defense mechanisms. However, the incidence
of anergy is reported to increase with advanced age, and the response to skin test antigens
appears to peak after longer intervals in older people.37 The value of these tests is limited
in elderly people.

Socioeconomic Status
Social history, economic status, drug history, oral health condition, family and living
situations, and alcohol use should be evaluated along with the physical and physiologic
measures usually assessed.23 It is also useful to assess elderly individuals using instru-
ments that evaluate how well they perform activities of daily living. Available tools assess
the capability of an individual in managing the activities necessary for independence;
these tools add another valuable dimension to the assessment of elderly people.38,39 (See
Tables 18.1 and 18.2.)

Summary
Nutrition monitoring, screening, and assessment in the older adult population pose chal-
lenges to health care professionals due to the heterogeneity of this group. It has been said
that the older we become, the more unique we are. The difficulty in using the tools

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Nutrition Monitoring and Research Studies: Nutrition Screening Initiative 473

TABLE 18.1
Activities of Daily Living

Toileting

Cares for self; no incontinence

Needs to be reminded or needs help with cleanliness; accidents rare
Soiling or wetting at least once a week
No control of bladder or bowels

Feeding

Eats without assistance

Eats with minor assistance or with help with cleanliness
Feeds with assistance or is messy
Requires extensive assistance with feeding
Relies on being fed

Dressing

Independent in dressing and selecting clothing

Dresses and undresses with minor assistance
Requires moderate assistance with dressing and undressing
Needs major assistance with dressing but is helpful
Completely unable to dress and undress oneself

Grooming

Always neatly dressed and well groomed

Grooming adequate; may need minor assistance
Requires assistance in grooming
Needs grooming care but is able to maintain groomed state
Resists grooming

Ambulation

Totally independent
Ambulates in limited geographical area
Ambulates with assistance (cane, wheelchair, walker, railing)
Sits unsupported in chair or wheelchair but needs help with motion
Bedridden

Bathing

Bathes independently
Bathes self with help getting into bath or shower
Washes hands and face but needs help with bathing
Can be bathed with cooperation
Does not bathe and is combative with those trying to help
Adapted from M.P. Lawton, The functional assessment of elderly
people, Journal of the American Geriatrics Society 19: 4465, 1971.

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474 Handbook of Nutrition and Food

TABLE 18.2
Instrumental Activities of Daily Living
Ability to use telephone
Shopping
Food preparation
Housekeeping
Laundry
Mode of transportation
Responsibility for own medications
Ability to handle finances
Adapted from M.P. Lawton, The functional
assessment of elderly people, Journal of the
American Geriatrics Society 19: 4465, 1971.

discussed here is that people age at different rates and in different ways related to their
health status, their lifestyle, and their genetic inheritance. Although a variety of reasonable
approaches to nutrition assessment and monitoring in the older population exist, it is wise
for the clinician to understand that the definitive tool or definition of malnutrition in older
people has yet to be reported and that there are vast opportunities for research in this area.

References
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