A Systematic Review of Malnutrition Screening Tools for the Nursing Home Setting

Published:December 02, 2013DOI:



      Malnutrition screening among nursing home residents is often performed with tools developed for use among older subjects, and sometimes with tools designed for an adult population. Only a few tools have been designed specifically for the nursing home setting. This systematic review assesses the criterion and predictive validity of malnutrition screening tools used in nursing homes.


      The databases MEDLINE, CINAHL, and EMBASE were searched on January 30, 2013, for manuscripts including search terms for malnutrition, screening or assessment tools, and setting. Articles were eligible for inclusion if they expressed criterion validity (how well can a tool assess nutritional status) or predictive validity (how well can a tool predict clinical outcome) of malnutrition screening tools in a nursing home population. Included were articles that had been published in the English, German, French, Dutch, Spanish, or Portuguese language.


      The search yielded 8313 references. Of these, 24 met the inclusion criteria and were available; 2 extra manuscripts were retrieved by reference checking. Twenty tools were identified. Seventeen studies reported on criterion validity, and 9 on predictive validity. Four of the tools had been designed specifically for use in long term care. None of the tools, not even the ones specifically designed for the nursing home setting, performed (on average) better than “fair” in either assessing the residents' nutritional status or in predicting malnutrition-related outcomes.


      The use of existing screening tools for the nursing home population carries limitations, as none performs better than “fair” in assessing nutritional status or in predicting outcome. Also, no superior tool can be pointed out. This systematic review implies that further considerations regarding malnutrition screening among nursing home residents are required.


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        • Joosten E.
        • Vanderelst B.
        • Pelemans W.
        The effect of different diagnostic criteria on the prevalence of malnutrition in a hospitalized geriatric population.
        Aging (Milano). 1999; 11: 390-394
        • Diekmann R.
        • Winning K.
        • Uter W.
        • et al.
        Screening for malnutrition among nursing home residents—a comparative analysis of the mini nutritional assessment, the nutritional risk screening, and the malnutrition universal screening tool.
        J Nutr Health Aging. 2013; 17: 326-331
        • Suominen M.
        • Muurinen S.
        • Routasalo P.
        • et al.
        Malnutrition and associated factors among aged residents in all nursing homes in Helsinki.
        Eur J Clin Nutr. 2005; 59: 578-583
        • Blaum C.S.
        • O'Neill E.F.
        • Clements K.M.
        • et al.
        Validity of the minimum data set for assessing nutritional status in nursing home residents.
        Am J Clin Nutr. 1997; 66: 787-794
        • Woo J.
        • Chumlea W.C.
        • Sun S.S.
        • et al.
        Development of the Chinese Nutrition Screen (CNS) for use in institutional settings.
        J Nutr Health Aging. 2005; 9: 203-210
        • Wilson M.M.
        • Thomas D.R.
        • Rubenstein L.Z.
        • et al.
        Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents.
        Am J Clin Nutr. 2005; 82: 1074-1081
        • Kruizenga H.M.
        • De Vet H.C.W.
        • Van Marissing C.M.E.
        • et al.
        The SNAQ(RC), an easy traffic light system as a first step in the recognition of undernutrition in residential care.
        J Nutr Health Aging. 2010; 14: 83-89
        • Guilford J.P.
        Fundamental Statistics in Psychology and Education.
        McGraw-Hill, New York1956
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Lok K.
        • Woo J.
        • Hui E.
        • Kwok T.
        Usefulness of the Chinese Nutrition Screening (CNS) tool in predicting 12 month mortality in elderly Hong Kong Chinese living in institutions.
        J Nutr Health Aging. 2009; 13: 96-101
        • Isenring E.A.
        • Banks M.
        • Ferguson M.
        • Bauer J.D.
        Beyond malnutrition screening: Appropriate methods to guide nutrition care for aged care residents.
        J Acad Nutr Diet. 2012; 112: 376-381
        • Rolland Y.
        • Perrin A.
        • Gardette V.
        • et al.
        Screening older people at risk of malnutrition or malnourished using the simplified nutritional assessment questionnaire (SNAQ): A comparison with the mini-nutritional assessment (MNA) tool.
        J Am Med Dir Assoc. 2012; 13: 31-34
        • Kruizenga H.M.
        • Seidell J.C.
        • de Vet H.C.W.
        • et al.
        Development and validation of a hospital screening tool for malnutrition: The Short Nutritional Assessment Questionnaire (SNAQ).
        Clin Nutr. 2005; 24: 75-82
        • White J.V.
        • Dwyer J.T.
        • Posner B.M.
        • et al.
        Nutrition screening initiative: Development and implementation of the public awareness checklist and screening tools.
        J Am Diet Assoc. 1992; 92: 163-167
        • Charlton K.E.
        • Nichols C.
        • Bowden S.
        • et al.
        Older rehabilitation patients are at high risk of malnutrition: Evidence from a large Australian database.
        J Nutr Health Aging. 2010; 14: 622-628
        • Bouillanne O.
        • Morineau G.
        • Dupont C.
        • et al.
        Geriatric nutritional risk index: A new index for evaluating at-risk elderly medical patients.
        Am J Clin Nutr. 2005; 82: 777-783
        • Poulia K.A.
        • Yannakoulia M.
        • Karageorgou D.
        • et al.
        Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly.
        Clin Nutr. 2012; 31: 378-385
        • Guigoz Y.
        • Vellas B.
        • Garry P.J.
        Mini nutritional assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology.
        Nutrition. 1994; (Supplement): 15-58
        • Cereda E.
        • Valzolgher L.
        • Pedrolli C.
        Mini nutritional assessment is a good predictor of functional status in institutionalised elderly at risk of malnutrition.
        Clin Nutr. 2008; 27: 700-705
        • Christensson L.
        • Unosson M.
        • Ek A.C.
        Evaluation of nutritional assessment techniques in elderly people newly admitted to municipal care.
        Eur J Clin Nutr. 2002; 56: 810-818
        • Ferreira L.S.
        • Nascimento L.F.C.
        • Marucci M.F.N.
        Use of the mini nutritional assessment tool in elderly people from long-term institutions of southeast of Brazil.
        J Nutr Health Aging. 2008; 12: 213-217
        • Tarazona-Santabalbina F.J.
        • Belenguer Varea A.
        • Domenech Pascual J.R.
        • et al.
        [Validation of MNA scale score as a nutritional risk factor in institutionalized geriatric patients with moderate and severe cognitive impairment].
        Nutr Hosp. 2009; 24 (Spanish): 724-731
        • Visvanathan R.
        • Penhall R.
        • Chapman I.
        Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes.
        Age Ageing. 2004; 33: 260-265
        • Rubenstein L.Z.
        • Harker J.O.
        • Salva A.
        • et al.
        Screening for undernutrition in geriatric practice: Developing the short-form mini-nutritional assessment (MNA-SF).
        J Gerontol A Biol Sci Med Sci. 2001; 56: M366-M372
        • Kaiser M.J.
        • Bauer J.M.
        • Ramsch C.
        • et al.
        Validation of the mini nutritional assessment short-form (MNA-SF): A practical tool for identification of nutritional status.
        J Nutr Health Aging. 2009; 13: 782-788
        • Garcia-Meseguer M.J.
        • Serrano-Urrea R.
        Validation of the revised mini nutritional assessment short-forms in nursing homes in Spain.
        J Nutr Health Aging. 2013; 17: 26-29
      1. Elia M. The 'MUST' report. Nutritional screening of adults: A multidisciplinary responsibility. Worcs, United Kingdom: BAPEN Redditch: 2003.

        • Wolinsky F.D.
        • Coe R.M.
        • McIntosh W.A.
        • et al.
        Progress in the development of a nutritional risk index.
        J Nutr. 1990; 120: 1549-1553
        • Soderhamn U.
        • Soderhamn O.
        Developing and testing the nutritional form for the elderly.
        Int J Nurs Pract. 2001; 7: 336-341
        • Soderhamn U.
        • Soderhamn O.
        Reliability and validity of the nutritional form for the elderly (NUFFE).
        J Adv Nurs. 2002; 37: 28-34
        • Laporte M.
        • Villalon L.
        • Payette H.
        Simple nutrition screening tools for healthcare facilities: Development and validity assessment.
        Can J Diet Pract Res. 2001; 62: 26-34
        • Laporte M.
        • Villalon L.
        • Thibodeau J.
        • Payette H.
        Validity and reliability of simple nutrition screening tools adapted to the elderly population in healthcare facilities.
        J Nutr Health Aging. 2001; 5: 292-294
        • Ferguson M.
        • Capra S.
        • Bauer J.
        • Banks M.
        Development of a valid and reliable malnutrition screening tool for adult acute hospital patients.
        Nutrition. 1999; 15: 458-464
        • Isenring E.A.
        • Bauer J.D.
        • Banks M.
        • Gaskill D.
        The malnutrition screening tool is a useful tool for identifying malnutrition risk in residential aged care.
        J Hum Nutr Diet. 2009; 22: 545-550
        • Reilly H.M.
        • Martineau J.K.
        • Moran A.
        • Kennedy H.
        Nutritional screening—evaluation and implementation of a simple nutrition risk score.
        Clin Nutr. 1995; 14: 269-273
        • Kondrup J.
        • Rasmussen H.
        • Hamberg O.
        • Stanga Z.
        Nutritional risk screening (NRS 2002): A new method based on analysis of controlled clinical trials.
        Clin Nutr. 2003; 22: 321-336
        • Baker J.P.
        • Detsky A.S.
        • Wesson D.E.
        • et al.
        Nutritional assessment: A comparison of clinical judgement and objective measurements.
        N Engl J Med. 1982; 306: 969-972
        • Cereda E.
        • Zagami A.
        • Vanotti A.
        • et al.
        Geriatric nutritional risk index and overall-cause mortality prediction in institutionalised elderly: A 3-year survival analysis.
        Clin Nutr. 2008; 27: 717-723
        • Cereda E.
        • Pusani C.
        • Limonta D.
        • Vanotti A.
        The association of geriatric nutritional risk index and total lymphocyte count with short-term nutrition-related complications in institutionalised elderly.
        J Am Coll Nutr. 2008; 27: 406-413
        • Chan M.
        • Lim Y.P.
        • Ernest A.
        • Tan T.L.
        Nutritional assessment in an Asian nursing home and its association with mortality.
        J Nutr Health Aging. 2010; 14: 23-28
        • Sharifi F.
        • Ghaderpanahi M.
        • Fakhrzadeh H.
        • et al.
        Older people's mortality index: Development of a practical model for prediction of mortality in nursing homes (Kahrizak elderly study).
        Geriatr Gerontol Int. 2012; 12: 36-45
        • Torma J.
        • Winblad U.
        • Cederholm T.
        • Saletti A.
        Does undernutrition still prevail among nursing home residents?.
        Clin Nutr. 2013; 32: 562-568
        • Sacks G.S.
        • Dearman K.
        • Replogle W.H.
        • et al.
        Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents.
        J Am Coll Nutr. 2000; 19: 570-577
        • Kuikka L.K.
        • Salminen S.
        • Ouwehand A.
        • et al.
        Inflammation markers and malnutrition as risk factors for infections and impaired health-related quality of life among older nursing home residents.
        J Am Med Dir Assoc. 2009; 10: 348-353
        • Meijers J.M.
        • van Bokhorst-de van der Schueren M.A.
        • Schols J.M.
        • et al.
        Defining malnutrition: Mission or mission impossible?.
        Nutrition. 2010; 26: 432-440
        • Fielding R.A.
        • Vellas B.
        • Evans W.J.
        • et al.
        Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International Working Group on Sarcopenia.
        J Am Med Dir Assoc. 2011; 12: 249-256
        • Chen C.C.
        • Bai Y.Y.
        • Huang G.H.
        • Tang S.T.
        Revisiting the concept of malnutrition in older people.
        J Clin Nurs. 2007; 16: 2015-2026
        • Chang S.
        • Beason T.S.
        • Hunleth J.M.
        • Colditz G.A.
        A systematic review of body fat distribution and mortality in older people.
        Maturitas. 2012; 72: 175-191
        • Beck A.M.
        • Ovesen L.
        • Schroll M.
        Validation of the resident assessment instrument triggers in the detection of under-nutrition.
        Age Ageing. 2001; 30: 161-165
        • Wijnhoven H.A.
        • Schilp J.
        • van Bokhorst-de van der Schueren M.A.
        • et al.
        Development and validation of criteria for determining undernutrition in community-dwelling older men and women: The short nutritional assessment questionnaire 65+.
        Clin Nutr. 2012; 31: 351-358
        • Morley J.E.
        Anorexia of aging: Physiologic and pathologic.
        Am J Clin Nutr. 1997; 66: 760-773
        • Tieland M.
        • Borgonjen-Van den Berg K.J.
        • van Loon L.J.
        • de Groot L.C.
        Dietary protein intake in community-dwelling, frail, and institutionalized elderly people: Scope for improvement.
        Eur J Nutr. 2012; 51: 173-179
        • Wendland B.E.
        • Greenwood C.E.
        • Weinberg I.
        • Young K.W.
        Malnutrition in institutionalized seniors: The iatrogenic component.
        J Am Geriatr Soc. 2003; 51: 85-90
        • Neelemaat F.
        • van Bokhorst-de van der Schueren M.A.
        • Thijs A.
        • et al.
        Resting energy expenditure in malnourished older patients at hospital admission and three months after discharge: Predictive equations versus measurements.
        Clin Nutr. 2012; 31: 958-966
        • Wolfe R.R.
        • Miller S.L.
        • Miller K.B.
        Optimal protein intake in the elderly.
        Clin Nutr. 2008; 27: 675-684
        • Bauer J.
        • Biolo G.
        • Cederholm T.
        • et al.
        Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group.
        J Am Med Dir Assoc. 2013; 14: 542-559
        • Milne A.C.
        • Potter J.
        • Vivanti A.
        • Avenell A.
        Protein and energy supplementation in elderly people at risk from malnutrition.
        Cochrane Database Syst Rev. 2009; 2: CD003288
        • Nijs K.A.
        • de Graaf C.
        • Siebelink E.
        • et al.
        Effect of family-style meals on energy intake and risk of malnutrition in Dutch nursing home residents: A randomized controlled trial.
        J Gerontol A Biol Sci Med Sci. 2006; 61: 935-942
        • Ulger Z.
        • Halil M.
        • Kalan I.
        • et al.
        Comprehensive assessment of malnutrition risk and related factors in a large group of community-dwelling older adults.
        Clin Nutr. 2010; 29: 507-511
        • Saka B.
        • Kaya O.
        • Ozturk G.B.
        • et al.
        Malnutrition in the elderly and its relationship with other geriatric syndromes.
        Clin Nutr. 2010; 29: 745-748
        • van Asselt D.Z.
        • van Bokhorst-de van der Schueren M.A.
        • van der Cammen T.J.
        • et al.
        Assessment and treatment of malnutrition in Dutch geriatric practice: Consensus through a modified delphi study.
        Age Ageing. 2012; 41: 399-404
        • Fearon K.
        • Strasser F.
        • Anker S.D.
        • et al.
        Definition and classification of cancer cachexia: An international consensus.
        Lancet Oncol. 2011; 12: 489-495
        • Good P.
        • Cavenagh J.
        • Mather M.
        • Ravenscroft P.
        Medically assisted nutrition for palliative care in adult patients.
        Cochrane Database Syst Rev. 2011; 4: CD006274
        • Dent E.
        • Visvanathan R.
        • Piantadosi C.
        • Chapman I.
        Nutritional screening tools as predictors of mortality, functional decline, and move to higher level care in older people: A systematic review.
        J Nutr Gerontol Geriatr. 2012; 31: 97-145
        • van Bokhorst-de van der Schueren M.A.
        • Guaitoli P.R.
        • Jansma E.P.
        • de Vet H.C.
        Nutrition screening tools: Does one size fit all? A systematic review of screening tools for the hospital setting.
        Clin Nutr. 2013;
        • Elia M.
        • Stratton R.J.
        An analytic appraisal of nutrition screening tools supported by original data with particular reference to age.
        Nutrition. 2012; 28: 477-494