EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To develop and test an instrument for identifying actual and potential undernutrition among elderly patients in clinical nursing care.

Inclusion Criteria:

All subjects were hospitalized in the ward during a study period of four months
Older than 65 years of age
Lucidity
Ability to communicate
Informed consent.

Exclusion Criteria:

None specifically mentioned
Amputees were at first included in the study, but because it was difficult to compute the BMI and weight index of these patients, only five individuals from this group participated.

Description of Study Protocol:

Recruitment

58 consecutively chosen elderly patients in a geriatric rehabilitation ward in western Sweden were asked to participate between August 1998 and November 1998.

Design

Cross-sectional study.

Statistical Analysis

Data were mainly analyzed with non-parametric statistical methods
Spearman's rank correlation coefficients were computed between each item
Reliability as homogeneity of the scale was also estimated using Cronnbach's alpha coefficient
Validity was addressed as face validity and criterion-related validity, including concurrent and predictive validity and construct validity.

Data Collection Summary:

Timing of Measurements

A Likert-type scale consisting of 15 items was constructed and elderly patients were interviewed with the instrument. Measurements were made either upon admission, after three weeks or upon discharge.

Dependent Variables

Nutritional status
Weight
Height
Serum albumin levels.

Independent Variables

15 items reflecting issues considered to be of importance: Weight loss, changes in dietary intake, appetite, intake of cooked food, portion size, intake of fruit and vegetables, possibility to obtain food products, company at meals, activity, tooth or mouth and swallowing difficulties, fluid intake, gastrointestinal problems, help with eating, number of drugs and health status.

Control Variables

Data about background variables (age, sex, marital status, former profession, main medical diagnosis and medication) were collected from patients or from patient records.

Description of Actual Data Sample:

Initial N: 58 elderly patients were asked to participate
Attrition (final N): 56 participated (15 males, 41 females). Two patients did not want to participate due to little interest in the study.
Age: 78±6.7 years
Location: Western Sweden.

Summary of Results:

Item-total Score Correlations (Spearman Rank)

Variables	R Value	P-value
Weight loss	0.42	<0.005
Changes in dietary intake	0.45	<0.001
Appetite	0.64	<0.001
Intake of cooked food	0.09	NS
Portion size	0.57	<0.001
Intake of fruit and vegetables	0.39	<0.005
Possibility to obtain food products	---	---
Company at meals	0.27	<0.05
Activity	0.28	<0.05
Tooth or mouth and swallowing difficulties	0.29	<0.05
Fluid intake	0.21	NS
Gastrointestinal problems	0.24	NS
Help with eating	0.04	NS
Number of drugs	0.10	NS
Health state	0.66	<0.001

Other Findings

The results showed that the instrument was a fairly reliable scale with a Cronbach's alpha coefficient of 0.72
Face validity was reflected in the participants' views concerning the scale's capability to give a significant estimate of their nutritional status
About half of the participants (54%) found that the scale, to a very high degree, gave such an estimate, while 41% found that the scale, to some extent, gave a meaningful estimate of their nutritional status
Concurrent validity, assessed as the correlation between the patients' views of their own nutritional status and the total score reached a value of R=-0.72 (P<0.001).
Predictive validity of the instrument was reflected in the difference between mean total score at admission for the patients who at discharge had a normal nutritional status (mean, 8.8±4.0) and those who had a lowered nutritional status (mean, 14.0±2.9). The difference was significant (P<0.01).

Author Conclusion:

In conclusion, the results of this study showed that the Nutritional Form for the Elderly (NUFFE) was a fairly reliable instrument for group level comparisons. Evidence of validity concerning face validity, criterion-related validity (including concurrent and predictive validity) and construct validity was shown in the study group. However, further testing is required if the instrument is to be used in clinical nursing care and research.

Funding Source:

Other:

Not reported

Reviewer Comments:

Relatively small sample size. Instrument was based on self-reported data.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		???
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		???
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	???
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	???
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		???
	7.1.	Were primary and secondary endpoints described and relevant to the question?	N/A
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	???
	7.5.	Was the measurement of effect at an appropriate level of precision?	???
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	N/A
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		???
	9.1.	Is there a discussion of findings?	No
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	No
	10.2.	Was the study free from apparent conflict of interest?	Yes