Using and Scoring SCREEN

Table of Contents:

General Questions
What is nutrition risk? How is this different from malnutrition risk?
What is the difference between nutrition screening and assessment?
What is SCREEN©?
I am a community-dwelling older adult. Can I take SCREEN© myself?
What are the differences between SCREEN-14, SCREEN-8, and SCREEN-3?

Language and Translations
In what languages is SCREEN© available?

Validity
What group has SCREEN© been validated for?
Where can I read more information on the validity and reliability of SCREEN©?

Administration and Training
Do I need to obtain a license to use SCREEN©?
Is any training for SCREEN© available?
Who can administer SCREEN©?
What methods can be used to administer SCREEN©?
Can I administer SCREEN© to older adults with cognitive impairment?
In what context(s) should SCREEN© be administered?
How often should SCREEN© be administered?

Score
How do I score SCREEN©?
How do I interpret the SCREEN© score?
How do I communicate the SCREEN© results to the older adult?

General Questions:

What is nutrition risk? How is this different from malnutrition risk?

Definitions of malnutrition risk and nutrition risk are elusive, despite recent consensus on the definition of malnutrition (Cederholm et al., Clin Nutr 2016). Malnutrition is considered a clinical disorder and malnutrition risk is the term used to define those in a clinical setting who present with indicators that suggest malnutrition is present (e.g., very low food intake, weight loss, functional loss). Most of the screening tools developed to date were focused, at least initially, on identifying malnutrition risk in a hospital setting. Nutrition risk, on the other hand, is more upstream and represents the determinants and risk factors that place an individual at risk for poor food intake and if not interrupted, can lead to malnutrition. The following diagram further clarifies this concept. Other screening tools, which rely on a few key indicators of malnutrition, are probably best described as malnutrition risk tools vs. nutrition risk tools and identify moderate or severe malnutrition in its full state.

What is the difference between nutrition screening and assessment?

NUTRITION SCREENING is completed for large groups to identify potential nutritional problems or ‘risk’. Individuals do not need to have specialized skills in nutrition care to complete nutrition screening. All older adults who participate in screening are provided with general nutrition information. Older adults found to have nutrition risk are referred for further assessment and/or community services.

NUTRITION ASSESSMENT is completed for smaller numbers of older adults to assess or clarify previously identified nutrition problems and diagnose malnutrition and where changes need to be made to improve nutritional status. A nutrition assessment requires the skills of a registered dietitian, or a specially trained health professional, since the process involves clinical skills and judgement. A nutrition assessment helps to further identify the sources or causes of poor food intake and malnutrition, and thus potential treatment. Treatment can involve individual nutrition counselling as well as oral nutritional supplements, or in some cases, artificial feeding. Older adults may also be referred for medical assessment or to community services.

What is SCREEN©?

SCREEN© (Seniors in the Community: Risk Evaluation for Eating and Nutrition) is a nutrition screening tool that assesses common risk factors of older adults living in the community. SCREEN© identifies nutrition problems early on or “upstream”. Early identification of nutrition risk means that interventions have an opportunity to work and help prevent, or delay, malnutrition. It can be used to identify older adults who need nutrition education, community resources, or a comprehensive assessment to determine the extent of their nutrition problems and to diagnose malnutrition. For research, it can be used to determine the association between nutrition factors and health outcomes. It can also serve as a tool for examining the resource needs of the community itself, as well as for evaluating the success of a nutrition education program implemented in the community.

I am a community-dwelling older adult. Can I take SCREEN© myself?

If you are an older adult who is interested in learning more about how you are doing with choosing foods that help you stay healthy and active, complete SCREEN-14. This short questionnaire will show you what you are doing well and where you can improve. If you are interested in receiving strategies that you can use to improve your eating habits, please bring your completed SCREEN-14 results to your primary healthcare provider.

What are the differences between SCREEN-14, SCREEN-8, and SCREEN-3?

The SCREEN© tools were rebranded in 2020 to SCREEN-14, SCREEN-8, and SCREEN-3. The updated names reflect the number of questions that older adults are asked during the screening process. In previous literature, they were described as: SCREEN-II; SCREEN-II-Abbreviated, SCREEN-II-AB or SCREEN-II 8 item; and SCREEN-III, respectively.

Refer to the “Guidance” section under the Toolkit tab. There is a document entitled “Comparing the Different Versions of SCREEN©”.

Refer to the “History” section under the Toolkit tab. This section describes the development of SCREEN© and how the tool has changed over time.

Language and Translations:

In what languages is SCREEN© available?

SCREEN-14, SCREEN-8 and SCREEN-3 are available in English and French. Visit the “Screen Tools” tab to download the tools.

The wording of the question stems was updated to be consistent with the 2019 Canada’s Food Guide. For example, ice cream is no longer listed as an example of a milk-based food. The original version, SCREEN-II, is available in several other languages. Please contact Professor Keller if you would like to find out more about these other translations (hkeller@uwaterloo.ca).

Validity:

What group has SCREEN© been validated for?

Community-dwelling older adults (aged 55 years and older) were the original sample used for the validation of SCREEN©. An older adult is considered community-dwelling if they are responsible for getting at least two meals a day on their own. Therefore, SCREEN© can be used in situations where a meal is offered at a maximum of once per day, such as in retirement apartments or supportive living residences.

Screen was validated against the criterion of a dietitian’s nutritional assessment which included diet, anthropometrics, function and clinical risk identification such as swallowing problems. A dietitian’s assessment for malnutrition is considered the ‘gold standard’ for determination of nutrition risk tool validity.

Where can I read more information on the validity and reliability of SCREEN©?

Refer to the “Guidance” section under the Toolkit tab. There is a document entitled “How to Implement SCREEN© with Confidence” that shows the sensitivity, specificity, test-retest reliability and inter-rater reliability of each version of SCREEN©.

Visit the “Publications” section under the Toolkit tab. This section has publications describing prevalence, validation, and reliability testing of SCREEN©.

Administration and Training:

Do I need to obtain a license to use SCREEN©?

On the 10th anniversary of SCREEN-II (2014), the need to obtain a copyright license for SCREEN© was waived. Provision of the SCREEN© tools on the “Older Adult Nutrition SCREENing” website is with the understanding that providers using SCREEN variations will use the tools in the way they are intended, and will not alter or eliminate questions when determining nutrition risk.

Users have the unlimited right to use SCREEN© for health care, community services programs, and research. Users cannot charge others for the use of the SCREEN© tools. Users are asked to refer others to the “Older Adult Nutrition SCREENing” website to attain a copy of the tool; this website can be cited in publications and other websites for this purpose. This will ensure that users have access to the most up-to-date version and guidance on the use of SCREEN© in their practice or research.

If you wish to embed SCREEN© into an electronic platform, please contact Professor Keller at: hkeller@uwaterloo.ca.  

Is any training for SCREEN© available?

Refer to the “Training” section under the Toolkit tab. This section provides a training package for prospective SCREEN© administrators.

Who can administer SCREEN©?

SCREEN© is an easily administered questionnaire. Community-dwelling older adults can complete SCREEN© independently or with the help of a trained administrator.

Anyone can be trained to be a SCREEN© administrator, including health professionals, volunteers, older adults, and students. An administrator clarifies any questions, adds up the score, assists the older adult with interpretation of their score, provides them with educational resources, and helps them obtain referrals, if needed.

What methods can be used to administer SCREEN©?

SCREEN© can be administered in person (for more frail older adults) or over the telephone.

Can I administer SCREEN© to older adults with cognitive impairment?

If you are concerned that the older adult is not a reliable informant (i.e., they have some cognitive deficit or memory problems) SCREEN© can be completed by someone who can corroborate their eating habits.  SCREEN© items rely on the older adult’s memory and their perceptions to assess their nutrition risk. A validation study for this group is planned, including the person living with memory changes and their family/friend care partners.

In what context(s) should SCREEN© be administered?

SCREEN© can be used in any community setting that has an older adult and/or an administrator. Recreation centres, seniors’ programs, health clinics, public health units, wellness programs, health teams and family physicians’ offices are examples of sites where screening can and should occur.

How often should SCREEN© be administered?

The frequency of screening depends on the number of older adults in the site/community and the available resources for screening. For a family practice or health clinic it is recommended that screening be repeated yearly in older adults ; this way, you are able to monitor progress in “at risk” older adults and identify nutrition changes in those who are not initially “at risk”.

Score:

How do I score SCREEN©?

Each question has multiple, weighted response options. Add up the total score of the responses (e.g. the subscript beside the response) either manually or using a calculator. It is best to do the addition a second time to ensure it is correct.

How do I interpret the SCREEN© score?

THE LOWER THE SCORE, THE GREATER THE NUTRITION RISK.

  • SCREEN-14:
    • Scores can range from 0 to 64.
    • A score of less than 50 is considered high nutrition risk.
  • SCREEN-8:
    • Scores can range from 0 to 48.
    • A score of less than 38 is considered high nutrition risk.
  • SCREEN-3:
    • Scores can range from 0 to 24.
    • A score of less than 22 indicates potential nutrition risk. It is recommended to continue with the 5 additional items of SCREEN-8 to confirm.

Individual item scores of less than or equal to 2 indicate that this question is putting the individual at nutrition risk. Individual item scores can be used to understand where the risk is coming from (e.g., chewing, eating alone, etc.) and to target specific interventions.

Other risk cut-points were also identified in the validation studies of SCREEN© (e.g., less than 54 indicates risk). These higher cut-points, however, may identify too many at-risk individuals and the lower cut-points provided above are recommended for clinical care.

If users are concerned about too many referrals to programs or to a registered dietitian service, they can adjust the score further downwards (e.g., using a score less than 46 with SCREEN-14). Some individuals will be missed, but a lower cut-point will ensure that those with the most need are receiving resources, which can sometimes be limited.

How do I communicate the SCREEN© results to the older adult?

Refer to the “Training” section under the Toolkit tab. This section provides a examples of how to communicate results to older adults.