Nutritional Risk Screening Tools for Older Adults with COVID-19: A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Eligibility Criteria
2.2. Databases and Search Strategy
2.3. Screening and Selection of Studies
2.4. Data Extraction
2.5. Evaluation of Studies’ Methodological Quality and Instruments’ Properties
2.6. Narrative Summary of Results
3. Results
3.1. Methodological Quality of Studies
3.2. Participants’ Characteristics
3.3. COVID-19 Diagnosis Method
3.4. Nutritional Screening Instruments Used to Identify Nutritional Risk
3.5. Nutritional Risk in Older Adults with COVID-19
3.6. Association between Comorbidities and Nutritional Risk
3.7. Sensitivity, Specificity, and Criterion Validity of Nutritional Screening Instruments
3.8. Predictive Validity of Screening and Nutritional Assessment Instruments
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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Cohort—Newcastle-Ottawa Scale | |||||||||
---|---|---|---|---|---|---|---|---|---|
Selection | Comparability | Outcome | |||||||
Quality criteria | 1. Representativeness of the exposed cohort | 2. Selection of the non-exposed cohort | 3. Ascertainment of exposure | 4. Demonstration that outcome of interest was not present at start of study | 1. Comparability of cohorts on the basis of the design or analysis | 1. Assessment of outcome | 2. Was follow-up long enough for outcomes to occur? | 3. Adequacy of follow up of cohorts | |
Liu et al., 2020 [46] | * | * | ** | * | * | * | |||
Zhang et al., 2020 [43] | * | * | ** | * | * | * | |||
Cross-sectional—Newcastle–Ottawa Scale | |||||||||
Selection | Comparability | Outcome | |||||||
Quality criteria | 1. Representativeness of the sample | 2. Sample size | 3. Ascertainment of exposure | 4. Non-respondents | 1. The subjects in different outcome groups are comparable, based on the study design or analysis. Confounding factors are controlled. | 1. Assessment of outcome | 2. Statistical test | ||
Li et al., 2020 [44] | * | * | ** | ** | * | ||||
Case series—Murad et al. (2018) | |||||||||
Selection | Ascertainment | Causality | Reporting | ||||||
Quality criteria | 1. Does the patient (s) represent (s) the whole experience of the investigator (center), or is the selection method unclear to the extent that other patients with similar presentation may not have been reported? | 2. Was the exposure adequately ascertained? | 3. Was the outcome adequately ascertained? | 4. Were other alternative causes that may explain the observation ruled out? | 5. Was there a challenge/rechallenge phenomenon? | 6. Was there a dose–response effect? | 7. Was follow-up long enough for outcomes to occur? | 8. Is the case (s) described with sufficient details to allow other investigators to replicate the research or to allow practitioners make inferences related to their own practice? | |
Yuan et al., 2020 [45] | * | * | NA | NA | NA | * | * |
Domain | Item | Liu et al., 2020 [46] | Li et al., 2020 [44] | Yuan et al., 2020 [45] | Zhang et al., 2020 [43] | |
---|---|---|---|---|---|---|
Patient Selection | Signaling questions (yes/no/unclear) | Was a consecutive or random sample of patients enrolled? | No | No | No | Yes |
Was a case–control design avoided? | Yes | Yes | Yes | Yes | ||
Did the study avoid inappropriate exclusions? | Yes | Yes | No | Yes | ||
Risk of bias: High/low/unclear | Could the selection of patients have introduced bias? | High | High | High | Low | |
Concerns regarding applicability: High/low/unclear | Are there concerns that the included patients do not match the review question? | Low | Low | Low | Low | |
Index Test | Signaling questions (yes/no/unclear) | Were the index test results interpreted without knowledge of the results of the reference standard? | Unclear | - | - | - |
If a threshold was used, was it pre-specified? | Yes | Yes | Yes | Yes | ||
Risk of bias: High/low/unclear | Could the conduct or interpretation of the index test have introduced bias? | Low | Low | Low | Low | |
Concerns regarding applicability: High/low/unclear | Are there concerns that the index test, its conduct, or interpretation differ from the review question? | Low | Low | Low | Low | |
Reference Standard | Signaling questions (yes/no/unclear) | Is the reference standard likely to correctly classify the target condition? | Yes | Yes | - | - |
Were the reference standard results interpreted without knowledge of the results of the index test? | Unclear | Unclear | - | - | ||
Risk of bias: High/low/unclear | Could the reference standard, its conduct, or its interpretation have introduced bias? | Low | Low | - | - | |
Concerns regarding applicability: High/low/unclear | Are there concerns that the target condition as defined by the reference standard does not match the review question? | Low | Low | - | - | |
Flow and Timing | Signaling questions (yes/no/unclear) | Was there an appropriate interval between index test (s) and reference standard? | Yes | Yes | - | - |
Did all patients receive a reference standard? | Yes | Yes | - | - | ||
Did all patients receive the same reference standard? | Yes | Yes | - | - | ||
Were all patients included in the analysis? | Yes | Yes | - | - | ||
Risk of bias: High/low/unclear | Could the patient flow have introduced bias? | Low | Low | - | - |
Author | Country | Design | n | Age Group (Years) | Sex | Nutritional Screening Tool | Nutritional Risk |
---|---|---|---|---|---|---|---|
Liu et al., 2020 [46] | China | Retrospective cohort | 141 | 65 to 87 | Women: 73. Men: 68 | NRS-2002-NR: score ≥ 3 (out of a maximum of 6); MNA-sf-NR: score < 12 (out of a maximum of 14); MUST-NR: score ≥ 2 (out of a maximum of 6); NRI-SNR: score < 83.5 and no NR > 100. | NRS-2002: 120 (85.1%); MNA-sf: 109 (77.3%); MUST: 58 (41.1%); NRI: 101 (60.4%). |
Li et al., 2020 [44] | China | Cross-sectional | 182 | Average age of 68.5 years old | Women: 117. Man: 65. | MNA: No NR/malnutrition ≥ 24; risk of malnutrition: 17–23.5; malnutrition < 17. | No nutritional risk/malnutrition: 36 (19.8%); risk of malnutrition: 50 (27.5%); malnutrition: 96 (52.7%). |
Yuan et al., 2020 [45] | China | Case series | 61 | 65 to 71 | Women: 4. Man: 2. | GNRI: High NR: score < 82—cut-off point used to diagnose nutritional risk in the study; moderate NR: score from 82 to <92; low NR: score from 92 to ≤98; no risk: score > 98. | 4 (100%). |
Zhang et al., 2020 [43] | China | Retrospective cohort | 136 | Average age 69 years | Women: 50 (37%) Man: 86 (63%) | mNUTRIC score. High NR ≥ 5. Low NR < 5. | High NR: 83 (61.0%). Low NR: 53 (39.0%). |
Tool | Criteria | Score | Applications |
---|---|---|---|
NRI | NRI = (1.519 × serum albumin (g/L) + 41.7 × (present weight/usual weight) | No NR > 100. Mild risk: 97.5–100. Moderate risk: 83.5–97.5. High risk < 83.5. | Recommended settings: hospital, and home care. |
GNRI | GNRI = (14.89 × albumin (g/dL)) + (41.7 × (body weight/ideal body weight)) | Low NR 92–≤98. Moderate NR: 82–<92. High NR <82. | Recommended settings: hospital. |
MUST | Three domains: BMI, weight loss, and consequences of disease severity. Each parameter can be rated as 0, 1, or 2. BMI domain: BMI (kg/m2) > 20 (0), 18.5–20.0 (1), <18.5 (2). Unintentional weight loss in past 3–6 months (%): <5 (0), 5–10 (1), >10 (2). Disease severity domain: drastic reduction of food consumption or inability to eat on more than five days (2). | Low NR: 0. Medium NR: 1. High NR ≥ 2. | Recommended settings: hospital, home care, and community. |
NRS-2002 | Two domains: disease severity score and nutritional score. Disease severity score domain: patients with diabetes, cancer, COPD (1 point); patients with severe pneumonia (2 points); intensive care patients (APACHE > 10) (3 points). Nutritional score domain: Weight loss greater than 5% in the last three months or food intake between 50% and 75% of nutritional needs (1 point); weight loss greater than 5% in the last two months, food intake between 25% and 60% of nutritional needs, or BMI 18.5–20.5 with impaired general health (2 points); weight loss greater than 5% in one month, >15% in three months, or food intake between 0% and 25% of nutritional needs (3 points). Score adjusted for age: if ≥70 years, one additional point. | NR: score ≥ 3. | Recommended settings: hospital, home care, and community. |
NUTRIC score | Six domains: age, APACHE, SOFA, number of comorbidities, days from hospital to ICU admission, and IL-6. Age: <50 (0); 50–74 (1); ≥75 (2). APACHE II: <15 (0); 15–19 (1); 20–28 (2); ≥28 (3). SOFA: <6 (0); 6–9 (1); ≥10 (2). Number of comorbidities: 0–1 (0); ≥2 (1). Days from hospital to ICU admission: 0–<1 (0); ≥(1). IL-6: 0-<400 (0); ≥400 (1). | Score with IL-6: Low NR: 0–5. High NR: 6–10. Score without IL-6: Low NR: 0–4. High NR: 5–9. | Recommended settings: critically ill patients (ICU). |
MNA-sf | Six domains: decrease in food intake, weight loss, mobility, disease severity, neuropsychological problems (depression, dementia), and BMI. Decrease in food intake: severe (0); moderate (1); none (2). Involuntary weight loss during the last three months? >3 kg (0); does not know (1); 1–3 kg (2); none (3). Mobility: bedridden (0); able to get out of bed/chair but does not go out (1); goes out (2). Disease severity: acute disease or psychological stress in the past 3 months (0); no acute disease or psychological stress in the past 3 months (2). Neuropsychological problems: severe depression or dementia (0); mild dementia (1); none (2). BMI (kg/m2): <19 (0); <21 (1); <23 (2); ≥23 (3). | Normal: 12–14. Risk of malnutrition: 8–11. Malnutrition: 0–7. | Recommended settings: hospital, home care, and community. |
MNA | 18 domains: decrease in food intake, weight loss, mobility, disease severity, neuropsychological problems (depression, dementia), and BMI (For these domains, same criteria as in the MNA-sf.). Other domains: lives independently, medication, pressure sores or skin ulcers, number of full meals daily, markers for protein intake, fruit or vegetable consumption, fluid intake, mode of feeding, self-view of nutritional status, self-assessment of health status, mid-arm circumference in cm, and calf circumference in cm. | Normal: 24–30. At risk of malnutrition: 17–23.5. Malnutrition < 17. | Recommended settings: hospital, home care, and community. |
Author | Screening Tool | Reference Standard | TP | FP | FN | TN | Sensitivity (95%CI) | Specificity (95% CI) | PPV (%) | NPV (%) | Other Analysis |
---|---|---|---|---|---|---|---|---|---|---|---|
Liu et al., 2020 [46] | NRS-2002 | BMI | 7 | 113 | 0 | 21 | 100 (59 to 100) | 16 (10 to 23) | 5.8 | 100 | - |
Liu et al., 2020 [46] | NRS-2002 | MUST | 57 | 63 | 1 | 20 | 98 (91 to 100) | 24(15 to 35) | 47.5 | 95.2 | - |
Liu et al., 2020 [46] | NRS-2002 | MNA-sf | 102 | 18 | 7 | 14 | 94 (87 to 97) | 44 (26 to 62) | 85.0 | 66.7 | - |
Liu et al., 2020 [46] | NRS-2002 | NRI | 98 | 22 | 3 | 18 | 97 (92 to 99) | 45 (29 to 62) | 81.7 | 85.7 | - |
Liu et al., 2020 [46] | MUST | BMI | 7 | 51 | 0 | 83 | 100 (59 to 100) | 62 (53 to 70) | 12.1 | 100 | - |
Liu et al., 2020 [46] | MUST | NRS-2002 | 57 | 1 | 63 | 20 | 47 (38 to 57) | 95 (76 to 100) | 98.3 | 24.1 | - |
Liu et al., 2020 [46] | MUST | MNA-sf | 57 | 52 | 1 | 31 | 98 (91 to 100) | 37 (27 to 49) | 52.3 | 96.9 | - |
Liu et al., 2020 [46] | MUST | NRI | 53 | 5 | 48 | 35 | 52 (42 to 63) | 88 (73 to 96) | 91.4 | 42.2 | - |
Liu et al., 2020 [46] | MNA-sf | BMI | 7 | 102 | 0 | 32 | 100 (59 to 100) | 24 (17 to 32) | 6.4 | 100 | - |
Liu et al., 2020 [46] | MNA-sf | NRI | 86 | 23 | 15 | 17 | 85 (77 to 91) | 42 (27 to 59) | 78.9 | 53.1 | - |
Liu et al., 2020 [46] | MNA-sf | NRS-2002 | 102 | 3 | 22 | 18 | 82 (74 to 99) | 86 (64 to 97) | 97.1 | 45.0 | - |
Liu et al., 2020 [46] | MNA-sf | MUST | 57 | 1 | 52 | 31 | 52 (43 to 62) | 97 (84 to 100) | 98.3 | 37.4 | - |
Liu et al., 2020 [46] | NRI | BMI | 7 | 94 | 0 | 40 | 100 (59 to 100) | 30 (22 to 38) | 6.9 | 100 | - |
Liu et al., 2020 [46] | NRI | MNA-sf | 86 | 15 | 23 | 17 | 79 (70 to 86) | 53 (35 to 71) | 85.2 | 42.5 | - |
Liu et al., 2020 [46] | NRI | NRS-2002 | 98 | 3 | 22 | 18 | 82 (74 to 88) | 86 (64 to 97) | 97.0 | 45.0 | - |
Liu et al., 2020 [46] | NRI | MUST | 53 | 48 | 35 | 5 | 60 (49 to 61) | 9 (3 to 21) | 52.5 | 12.5 | - |
Li et al., 2020 [44] | MNA | BMI | - | - | - | - | - | - | - | - | BMI (kg/m2)—no malnutrition: 25.6 ± 3.0; risk of malnutrition: 23.3 ± 3.4 kg/m2; malnutrition: 21.1 ± 3.6 kg/m2. F or X2 value: 4.106, p = 0.035. |
Li et al., 2020 [44] | MNA | Calf circumference (cm) | - | - | - | - | - | - | - | - | Calf circumference (cm)—no malnutrition: 33.4 ± 5.6; risk of malnutrition: 31.2 ± 4.8; malnutrition: 28.7 ± 5.7, F or X2 value: 2.518, p = 0.047. |
Li et al., 2020 [44] | MNA | Albumin (g/L) | - | - | - | - | - | - | - | - | Albumin (g/L)—no malnutrition: 38.5 ± 4.2; risk of malnutrition: 30.1 ± 6.4; malnutrition: 25.7 ± 5.3, F or X2 value: 10.217, p < 0.001. |
Li et al., 2020 [44] | MNA | TLC | - | - | - | - | - | - | - | - | TLC—no malnutrition: 1.7 ± 0.52; risk of malnutrition: 1.2 ± 0.43, malnutrition: 0.9 ± 0.38, F or X2 value: 11.237, p < 0.001. |
Li et al., 2020 [44] | MNA | TSFT (mm) | - | - | - | - | - | - | - | - | TSFT (mm)—no malnutrition: 16.8 ± 7.2; risk of malnutrition: 15.7 ± 6.9; malnutrition: 14.9 ± 7.3, F or X2 value: 1.632, p = 0.126. |
Li et al., 2020 [44] | MNA | MAC (cm) | - | - | - | - | - | - | - | - | MAC (cm)—no malnutrition: 28.7 ± 2.8; risk of malnutrition: 27.6 ± 3.3; malnutrition: 26.5 ± 3.2, F or X2 value: 2.679, p = 0.379. |
Yuan et al., 2020 [45] | GNRI | TLC | - | - | - | - | - | - | - | - | Of the four patients at nutritional risk, one had low TLC levels and three had normal levels. |
Zhang et al., 2020 [43] | NUTRIC score | Albumin (g/L) | - | - | - | - | - | - | - | - | High NR group (n = 83): 29 g/L (25–32). Low NR group (n = 53): 30 g/L (28–32), p = 0.107. |
Zhang et al., 2020 [43] | NUTRIC score | Prealbumin (g/L) | - | - | - | - | - | - | - | - | High NR group (n = 83): 82 g/L (80–122). Low NR group (n = 53): 95 (80–128) g/L, p = 0.281. |
Zhang et al., 2020 [43] | NUTRIC score | TLC | - | - | - | - | - | - | - | - | High NR group (n = 83): 0.5 × 109/L (0.3–0.7). Low NR group (n = 53): 0.6 × 109/L (0.4–0.9), p = 0.007. |
Zhang et al., 2020 [43] | NUTRIC score | Creatinine (mmol/L) | - | - | - | - | - | - | - | - | High NR group (n = 83): 90 (65–144) mmol/L. Low NR group (n = 53): 67 (54–85) mmol/L, p < 0.001. |
Author | NST | Length of Stay (LOS) | Appetite Change | Weight Change | Hospital Expenses | Complications | Mortality |
---|---|---|---|---|---|---|---|
Liu et al., 2020 [46] | NRS-2002 | Nutritional risk predicted longer LOS; OR (95% CI): 0.102 (0.042–0.250), p = 0.000; AUC for LOS > 30 days (95% CI): 0.724 (0.640–0.808), p = 0.000. Rating: Weak. | Nutritional risk predicted change in appetite; OR (95% CI) for no change: 11.179 (3.881–32.169), p = 0.000; AUC for poor appetite (95% CI): 0.670 (0.586–0.747), p = 0.014. Rating: Poor. | Nutritional risk predicted weight change; OR (95% CI): 0.128 (0.047–0.350), p = 0.000; AUC for weight change >2.6 kg (95% CI): 0.613 (0.528–0.694), p = 0.000. Rating: Poor. | Nutritional risk predicted higher hospital expenses (CNY); OR (95% CI): 0.131 (0.054–0.313), p = 0.000; AUC for hospital expenses > CNY 56,163 (95% CI): 0.667 (0.583–0.744), p = 0.000. Rating: Poor. | Nutritional risk predicted greater disease severity; OR (95% CI): 0.095 (0.031–0.292), p = 0.000. | - |
Liu et al., 2020 [46] | MNA-sf | Nutritional risk predicted longer LOS; OR (95% CI): 0.401 (0.198–0.813), p = 0.011; AUC for LOS > 30 days (95% CI): 0.602 (0.304–0.492), p = 0.032. Rating: Poor. | Nutritional risk predicted change in appetite; OR (95% CI) for no change: 40.731 (13.681–121.389), p = 0.000; AUC for poor appetite (95% CI): 0.868 (0.801–0.919), p = 0.000. Rating: Good. | Nutritional risk predicted weight change; OR (95% CI): 0.085 (0.035–0.206), p = 0.000; AUC for weight change >2.6 kg (95% CI): 0.895 (0.832–0.940), p = 0.000. Rating: Good. | Nutritional risk predicted higher hospital expenses (CNY); OR (95% CI): 0.436 (0.216–0.880), p = 0.021; AUC for hospital expenses > CNY 56,163 (95% CI): 0.597 (0.511–0.679), p = 0.063. Rating: Failure. | Nutritional risk predicted greater disease severity; OR (95% CI): 0.632 (0.289–1.382), p = 0.250. Rating: Poor. | - |
Liu et al., 2020 [46] | MUST | Nutritional risk did not predict longer LOS; OR (95% CI): 0.722 (0.391–1.334), p = 0.298; non-significant AUC for LOS > 30 days (95% CI): 0.506 (0.421–0.591), p = 0.887. | Nutritional risk predicted change in appetite; OR (95%CI) for no change: 2.866 (1.449–5.669), p = 0.002; AUC for poor appetite (95% CI): 0.614 (0.528–0.694), p = 0.009. Rating: Poor. | Nutritional risk predicted weight change; OR (95% CI): 0.009 (0.003–0.026), p = 0.000; AUC for weight change >2.6 kg (95% CI): 0.887 (0.823–0.934), p = 0.000. Rating: Good. | Nutritional risk did not predict higher hospital expenses (CNY); OR (95% CI): 0.599 (0.323–1.109), p = 0.103; non-significant AUC for hospital expenses > CNY 56,163 (95% CI): 0.516 (0.430–0.601), p = 0.735. | Nutritional risk did not predict greater disease severity OR (95% CI): 1.367 (0.688–2.718), p = 0.372. | - |
Liu et al., 2020 [46] | NRI | Nutritional risk predicted longer LOS; OR (95% CI): 0.261 (0.133–0.513), p = 0.000; AUC for LOS > 30 days (95% CI): 0.664 (−0.579 to 0.741), p = 0.000. Rating: Poor. | Nutritional risk predicted change in appetite; OR (95% CI) for no change: 2.768 (1.363–5.618). p = 0.005; AUC for poor appetite (95% CI): 0.629 (0.544–0.709), p = 0.014. Rating: Poor. | Nutritional risk predicted weight change; OR (95% CI): 0.182 (0.087–0.378), p = 0.000; AUC for weight change >2.6 kg (95% CI): 0.697 (0.614–0.772), p = 0.000. Rating: Poor. | Nutritional risk predicted higher hospital expenses (CNY); OR (95% CI): 0.199 (0.100–0.397), p = 0.000; AUC for hospital expenses > CNY 56,163 (95% CI): 0.621 (0.535–0.701), p = 0.019. Rating: Poor. | Nutritional risk predicted greater disease severity; OR (95% CI): 0.367 (0.173–0.776), p = 0.009. | - |
Zhang et al., 2020 [43] | mNUTRIC score | Nutritional risk correlated with complications during ICU stay: ARDS (p < 0.001), shock (p < 0.001), acute myocardial injury (p = 0.002), and secondary infection (p = 0.002). Rating: Good. No correlation with acute liver dysfunction (p = 0.820), acute kidney injury (p = 0.172), embolization/thrombosis (p = 0.281), or pneumothorax (p = 0.856). | Nutritional risk correlated with death in the ICU after 28 days (p < 0.001). Rating: Good. |
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Silva, D.F.O.; Lima, S.C.V.C.; Sena-Evangelista, K.C.M.; Marchioni, D.M.; Cobucci, R.N.; Andrade, F.B.d. Nutritional Risk Screening Tools for Older Adults with COVID-19: A Systematic Review. Nutrients 2020, 12, 2956. https://doi.org/10.3390/nu12102956
Silva DFO, Lima SCVC, Sena-Evangelista KCM, Marchioni DM, Cobucci RN, Andrade FBd. Nutritional Risk Screening Tools for Older Adults with COVID-19: A Systematic Review. Nutrients. 2020; 12(10):2956. https://doi.org/10.3390/nu12102956
Chicago/Turabian StyleSilva, David Franciole Oliveira, Severina Carla Vieira Cunha Lima, Karine Cavalcanti Mauricio Sena-Evangelista, Dirce Maria Marchioni, Ricardo Ney Cobucci, and Fábia Barbosa de Andrade. 2020. "Nutritional Risk Screening Tools for Older Adults with COVID-19: A Systematic Review" Nutrients 12, no. 10: 2956. https://doi.org/10.3390/nu12102956