Malnutrition screening in community living older adults

286 Pages·2017·4.2 MB·English

University of Wollongong
Research Online
University of Wollongong Tesis Collection
University of Wollongong Tesis Collections
1954-2016
2015
Malnutrition screening in community living older
adults: towards beter service delivery models
Aliza Haslinda Hamirudin
University of Wollongong
Unless otherwise indicated, the views expressed in this thesis are those of the author and do
not necessarily represent the views of the University of Wollongong.
Recommended Citation
Hamirudin, Aliza Haslinda, Malnutrition screening in community living older adults: towards beter service delivery models, Doctor
of Philosophy thesis, School of Medicine, University of Wollongong, 2015. htps://ro.uow.edu.au/theses/4553
Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library:
MALNUTRITION SCREENING IN COMMUNITY LIVING
OLDER ADULTS: TOWARDS BETTER SERVICE DELIVERY
MODELS

This thesis is presented as part of the requirements for the
award of the Degree of

DOCTOR OF PHILOSOPHY

of the

UNIVERSITY OF WOLLONGONG

By

Aliza Haslinda Hamirudin
BSc (Hons) Health Sciences, Dietetics
MSc Nutrition

School of Medicine
Faculty of Science, Medicine and Health

2015
ABSTRACT
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-
i
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.

ii
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.

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DEDICATION
To my husband and son, who have experienced this colourful journey with me.
Thank you for your patience and understanding.
You are the reasons for me to keep on battling towards the finishing line.

To my mum, dad, sisters and in-laws.
Thank you for all your support and encouragement.

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ACKNOWLEDGEMENTS
My deepest gratitude to my primary supervisor, Associate Professor Karen Charlton
for her guidance, critical appraisal and support during my PhD candidature. You are
truly a researcher at heart, a wonderful supervisor and mentor; who provided me with
various opportunities and skills in the research world.

I would like to extend my sincere appreciation to my secondary supervisor, Associate
Professor Karen Walton who I’ve known since my Master’s degree. You are my
inspiration and truly an amazing academic; who continuously is an attentive listener
and rendered me with constructive feedback.

I would like to thank my research team who worked on the IHMRI funded clinical
research projects in General Practice. My special thanks to Illawarra and Southern
Practice Research Network (ISPRN), especially to the chairman Professor Andrew
Bonney for a lifetime opportunity to work with the General Practices. Thank you to
Dr George Albert and Dr Adam Hodgkins, for your practices’ participation and
continuous support to nutrition screening projects. My greatest thanks also goes to Dr
Andrew Dalley, Professor Jan Potter, Dr Marianna Milosavljevic and Abhijeet
Ghosh for being terrific team members. The projects could have not been completed
without your support and invaluable feedback.

To the DVA research team, thank you very much for giving me an opportunity to
work with you. My sincere appreciation goes to Professor Jan Potter, the Principal
Investigator and Ms Mandy Carrie, the project manager.

Thank you to my friends and fellow postgraduate students who had shared the ups
and downs together throughout my candidature. You know who you are mates! My
thoughts and memories of you are always close to my heart.

To others who have either directly or indirectly had contributed to my PhD journey,
my sincere thanks to you.

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CERTIFICATION
I, Aliza Haslinda Hamirudin declare that this thesis, submitted in fulfilment of the
requirements for the award of Doctor of Philosophy, in the School of Medicine,
Faculty of Science, Medicine and Health, University of Wollongong, is my own
work unless otherwise referenced or acknowledged. This document has not been
submitted in whole, or in part, for qualifications at any other academic institution.

Aliza Haslinda Hamirudin
March 2015

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PUBLICATIONS

Peer reviewed journal publications in support of this thesis
1. Hamirudin, A. H., Charlton, K., Walton, K., Bonney, A., Albert, G.,
Hodgkins, A., Potter, J., Milosavljevic, M. & Dalley, A. ‘We are all time
poor’ Is routine nutrition screening of older patients feasible? Australian
Family Physician. 2013;42:321-6.

2. Hamirudin AH, Ghosh A, Charlton K, Bonney A, Walton K: Trends in
uptake of the 75+ health assessment in Australia: A decade of evaluation
Australian Journal of Primary Health 2014,
http://dx.doi.org/10.1071/PY14074.

3. Hamirudin, A. H., Charlton, K., Walton, K., Bonney, A., Potter, J.,
Milosavljevic, M., Hodgkins, A., Albert, G., Ghosh, A. & Dalley, A.
Feasibility of implementing routine nutritional screening for older adults in
Australian General Practices: A mixed-methods study. BMC Family Practice,
2014; 15, 186.

4. Hamirudin AH, Charlton KE, Walton K, Potter J, Milosavljevic M, Albert G,
Hodgkins A, Ghosh A, Dalley A, Bonney A. Implementation of nutrition
screening for older adults in General Practice: Patient perspectives indicate
acceptability The Journal of Aging Research & Clinical Practice. Accepted.

5. Hamirudin AH, Charlton KE, Walton K, Carrie A, Tapsell L, Milosavljevic
M, Pang G, Potter J, Home-Based Dietetic Intervention Improves the
Nutritional Status of Older Adults Post Hospital Discharge: A feasibility
study. Nutrition& Dietetics. In review.

6. Hamirudin AH, Charlton KE, Walton K. Outcomes Related to Nutrition
Screening in Community Living Older Adults: A Systematic Literature
Review. Archives of Gerontology and Geriatrics.2015 In press.
http://dx.doi.org/10.1016/j.archger.2015.09.007

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Conference presentations in support of this thesis

th
1. 16 International Congress of Dietetics, Sydney, Australia, 5-8
September 2012 (oral presentation)
Hamirudin, A. H., Charlton, K. E., Walton, K. L., Bonney, A., Potter, J.,
Milosavljevic, M., Albert, G., Hodgkins, A. & Dalley, A. 2012.
Title: ‘We are all time poor … but there is opportunity’: Targeting barriers to
routine nutrition screening of older adults in General Practice.

th
2. 36 Nutrition Society of Australia Annual Scientific Meeting, 27- 30
November 2012 (poster presentation)
Hamirudin AH, Charlton KE, Walton KL, Bonney A, Potter J, Milosavljevic
M, et al. What's on the menu for the 75+ Health Assessment?: An opportunity
for nutrition screening of older patients in General Practice. Australasian
Medical Journal (Online). 2012;5(12):712.

3. 2013 International Academy Nutrition and Aging (IANA) Meeting,

Seoul, Korea, 23 June 2013 (oral presentation)
Hamirudin A.H, Charlton K, Walton K, Bonney A, Albert G, Hodgkins A,
Potter, J., Milosavljevic, M. & Dalley, A. 2013. Towards routine nutrition
screening of older patients in Australian General Practice: Participatory
research needed to engage practitioners. The Journal of Frailty & Aging, 2
(2), 112.

th
4. 35 ESPEN Congress, Leipzig, Germany, 31 August - 3 September 2013
(poster presentation)
Hamirudin AH, Carrie A, Charlton K, Walton K, Tapsell L, Milosavljevic M,
Pang, G. & Potter, J. Milk And Oral Nutrition Supplements are the Preferred
Protein Sources Of Malnourished Older Adults Post Hospitalization. Clinical
Nutrition. 2013;32, Supplement 1(0):S39-S40.

5. 20th International Congress of Nutrition, Granada, Spain, 15- 20
September 2013 (poster presentation)
Hamirudin AH, Carrie A, Charlton K, Walton K, L.Tapsell, Milosavljevic M,
Pang, G. & Potter, J.Home-Based Dietetic Intervention Improves Nutritional
Status Post Hospital Discharge In Older People. Annals of Nutrition and
Metabolism. 2013;63(1):652.

6. Dietitians Association of Australia (DAA) 31st National Conference,
Brisbane, Australia, 15-17 May 2014 (poster presentation)
Hamirudin, A.H, Charlton, K., Walton, K., Bonney, A., Hodgkins, A., Albert,
G., Potter, J., Milosavljevic, M., Ghosh, A. & Dalley, A. (2014). Upskilling
of general practice staff to perform malnutrition screening in older adults: a
demonstrated model. Nutrition and Dietetics, 71 (Suppl. S1), 45-45.

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