Doctor of Philosophy
School of Medicine
Hamirudin, Aliza Haslinda, Malnutrition screening in community living older adults: towards better service delivery models, Doctor of Philosophy thesis, School of Medicine, University of Wollongong, 2015. http://ro.uow.edu.au/theses/4553
Malnutrition in community living older adults is under recognised and remains a problem; which leads to various adverse effects including recurrent hospital admission. Deterioration of older adults’ nutritional status during hospitalisation is well documented and integrated approaches between settings are needed to improve outcomes in this group. Nutrition screening is an initial procedure to identify malnutrition and has been recommended across all health care settings. However, it is not routinely conducted in community living older adults in Australia and is not implemented in Australian General Practice. This thesis has taken a mixed methods approach to evaluate model of nutritional care delivery of community living older adults.
In order to contextualize the progression of nutritional status of older adults following a hospital stay, a sample of Department of Veterans’ Affairs (DVA) clients was recruited to a three-month study. Participants were evaluated two weeks post discharge and again at three months, following an individualised home-based dietetic intervention. The purpose of this individualised intervention at home in this group of older adults was to better co-ordinate use of available community resources with the aim of improving their nutritional status post discharge and prevent hospital readmission; and to evaluate the effectiveness of this model of care. Mean body weight increased significantly from 67.1±13.5 kg to 68.0±13.7kg (p=0.048) and mean Mini Nutrition Assessment (MNA®) score improved significantly (p=0.000). Mean energy, protein and micronutrients intakes were adequate at both baseline and at three months, except for vitamin D. Dietetic intervention improved nutritional status three months after hospital discharge in this group of older adults living in the community.
Next, a three phased participatory action-based research programme was undertaken in General Practices with the results of each informing the next study development. The first study in the general practice setting was undertaken with staff from three participating General Practices in order to identify perceived barriers and opportunities related to the implementation of nutritional screening. Twenty five in-depth individual interviews were conducted and analysed thematically. Lack of time was identified as the major barrier. Incorporation of a validated short nutritional screening instrument into the existing Medicare Benefit Schedule (MBS) Health Assessment for people aged 75 +years (75+HA) was identified as the most feasible way to encourage uptake of nutrition screening in General Practice while overcoming the time constraints barrier. We conducted a detailed investigation of trends in uptake of the 75+HA by age-eligible Australians over a decade, according to state and identified that less than 20% of older adults had undergone the assessment.
The following study in general practice aimed to demonstrate the feasibility of including a validated nutrition screening tool, the Mini Nutrition Assessment-Short Form (MNA®-SF) and accompanying nutrition resource kit for use with older patients attending general practice. Ten doctors and eleven practice nurses from the three participating General Practices attended dietitian-led training sessions on how to perform the MNA®-SF. Nutrition screening skills and knowledge of General Practice staff were assessed at baseline and three months after the nutrition screening training. Within a 3 month period, General Practice staff had completed the MNA®-SF in 143 patients and identified n= 6 (4.2%) to be malnourished, n= 38 (26.6%) as at risk of malnutrition and the remainder (n= 99 (69.2%)) to be well-nourished. Mean skills and knowledge scores of staff had improved significantly three months after completing the workshop training (p=0.000).
The third and final phase of the nutrition screening study in general practice aimed to evaluate outcomes post nutrition screening between 6 months and one year; and patients’ perspectives related to their experiences of undertaking a nutrition screening process and the applicability of the accompanying nutrition resource kit. Of the 143 patients that had been screened at baseline, 72 patients (50.3%) underwent repeat screening. MNA®-SF score had improved in those identified as malnourished/at risk at baseline (p= 0.01); while no significant changes were detected for the well-nourished group (p=0.07). Referral to community services predicted malnutrition risk at follow-up (p= 0.031). Interviews indicated that the MNA®-SF process itself was well-received but that patients did not perceive themselves as being in need of additional nutrition support.
Implementation of routine identification of malnutrition in older adults attending general practice can be achieved with the incorporation of a rapid screening tool into general practice software. Further deterioration in nutritional status may then be prevented by following appropriate nutrition care pathways.