Evaluation of the Mini Nutritional Assessment<br />Jessica Wescott<br />NTR 5502: Nutritional Assessment<br />NYCC<br />De...
Nutritional Assessment Project
Nutritional Assessment Project
Nutritional Assessment Project
Nutritional Assessment Project
Nutritional Assessment Project
Nutritional Assessment Project
Nutritional Assessment Project
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Nutritional Assessment Project

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  • Hi, Jessica. Your paper was well written. I was just curious as to the cost of this tool, because I am under the assumption that the patients cannot administer it themselves. Thanks, Stacy
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  • Jessica, well done, your paper was well researched. What made you choose this topic? Would you use it in your practice if you had a number of elderly patients? Are there any circumstances under which you would not want to use this screening tool? Under what circumstances would other tools be preferable i.e. blood analysis?
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Nutritional Assessment Project

  1. 1. Evaluation of the Mini Nutritional Assessment<br />Jessica Wescott<br />NTR 5502: Nutritional Assessment<br />NYCC<br />Detecting malnutrition in the elderly is important because protein-energy has been shown to be in as much as 50% of the elderly population. It has been shown that protein-energy malnourished elderly have worse clinical outcomes and have higher mortality rates (Bleda, Bolibar, Pares, & Salva, 2002). Therefore, the Mini-Nutritional Assessment (MNA) was developed as a nutrition screening assessment tool to identify elderly 65 years of age or older who are malnourished or at a risk of malnutrition (Mini Nutritional Assessment, 2011). According to the Mini Nutritional Assessment website (2011), the test can be used in a variety of settings, including hospitals, nursing homes, geriatric clinics, geriatric feeding programs, health fairs, assisted living sites, home care settings, dental clinics, dialysis centers and physician offices and can be used as often as every three months as a screening tool. According to the developers of the test (Nestle), the MNA will identify an at-risk person before weight loss occurs or serum protein levels fall, allowing for intervention to occur earlier and hence be more likely to be successful. The test not only identifies the people who are at risk for malnutrition, but also identifies the specific cause of malnutrition. This allows the health care professional to target the intervention for that patient more specifically (Mini Nutritional Assessment, 2011). <br />The MNA was developed by the Nestle and leading international geriatricians. It was developed as a tool to both screen and assess for malnutrition in the elderly that would eliminate the need for more invasive tests, such as blood sampling (A guide to completing the Mini Nutritional Assessment MNA, 2011). The test consists of 18 questions and takes about 15 minutes to complete. The 18 questions can be divided into 4 categories, which are anthropometric, global assessment, dietetic assessment and subjective evaluation. The anthropometric assessment includes BMI, which is calculated from weight and height, weight loss and arm and calf circumferences. The general assessment comes from 6 questions that relate to lifestyle, medication, mobility and signs of depression or dementia. The dietary assessment involves 8 questions that look at the number of meals, food and fluid intake and autonomy of feeding. The subjective assessment is based on self perception of health and nutrition. There has also been recent development of a short form mini nutritional assessment that takes less than 4 minutes to complete. The short form is for screening and involves the first 5 questions of the original form and either calculating the patient’s BMI or measuring their calf circumference (Mini Nutritional Assessment, 2011). <br />Before having a patient complete that MNA, they may question what the purpose of the MNA is. A good way to explain the MNA to a patient is that it is a quick and easy way to assess if an elderly person is getting proper nutrition. I would then tell the patient that if the results show that they are not receiving the proper nutrition, then steps can be taken to correct this before the patient gets sick. <br />The MNA involves only questions and a few body measurements in order to determine the nutritional status of an elderly patient. After doing research involving the MNA, Adhami (2007) concluded it was a “simple, non-invasive and cost effective tool for assessing nutritional status of rehabilitation/geriatric hospital inpatients.” Compared to other ways to asses nutritional status, such as blood sampling, the MNA is safe because it not invasive. <br />According to the official site for the MNA, this test was initially validated in three studies that were conducted in France and the United States from 1991-1993 and involved more than 600 subjects. These studies showed looked at the accuracy and effectiveness of the MNA. Accuracy was defined as the specificity (Can it identify those who do not have the condition?), sensitivity (can it identify patients with the condition?) and the positive/negative predictability of the test. The effectiveness of the test was defined as “related to likelihood of positive outcomes if intervention is provided,” (Mini Nutritional Assessment, 2011). The results from the MNA were then compared to the clinical status of the patient. The clinical status of the patient was determined by a nutrition assessment preformed independently by 2 physicians trained in nutrition and based on the subject’s clinical record without knowledge of the MNA results. The results showed a strong correlation between the MNA and biochemical nutritional parameters (p ‹ .0001 for albumin). The results from these initial studies showed a 96% sensitivity, 98% specificity and 97% predictive value for the MNA. The MNA could classify 70-75% of the elderly as normal or undernourished without the use of biochemical indices. The test was also able to identify 20-25% of the elderly as at-risk before changes in weight or albumin levels occurred. For these at-risk individuals, usually an increase in caloric intake is all that is needed to correct their nutritional intervention. It was also found that the MNA was predictive of mortality and hospital costs (Mini Nutritional Assessment, 2011). According to the Mini Nutritional Assessment’s official website (2011), there are currently more than 400 published studies that support the sensitivity, specificity and reliability of the MNA in different setting and countries. The site also claims that in “medical practice and clinical research, the MNA is by far the most widely used and validated tool for nutritional screening and assessment of the elderly” (Mini Nutritional Assessment, 2011). <br />The studies used as testimonials on the official MNA website were from the early 1990s, when the MNA was first developed. There are numerous studies that are from within the last decade that look at the MNA. In 2009, the British Journal of Nutrition published an article that compared the MNA to another tool used to assess nutritional status in the elderly called the Geriatric Nutritional Risk Index (GNRI). This study took 241 institutionalized elderly, 94 males and 147 females that had a mean age of 80 ± 8.3 years. Each patient’s BMI, height, weight, mid-upper arm and calf circumference was measured within a 2 month period. Subjects were excluded if they had well known liver, renal or neoplastic disorders. Then, each subject was assessed using the MNA and the GNRI. For the MNA, the scores are as follows; adequately nourished, MNA ≥ 24; at risk of malnutrition, MNA =17-23·5; protein–energy malnutrition, MNA < 17. For the GNRI, categorization was as follows; severe/moderate risk < 92; low risk = 92–98; no risk > 98. Subjects were then followed for 6 months for the occurrence of death, infections and bedsores. The risk of overall and single complications (death, infections, bedsores) was similar (P >0.05) in both patients with scores from the GNR< 92 and MNA<17 categories. Multivariate logistic regression revealed the GNRI as an independent predictor of complications (Cerada et al., 2009). Cerada et al. (2009) concluded in “overall-outcome prediction, a good sensitivity was found only for GNRI , 98 (0·86 (95 % CI 0·67, 0·96)). The combination of a GNRI > 98 with an MNA > 24 seemed to exclude adverse outcomes. The GNRI showed poor agreement with the MNA in nutritional assessment, but appeared to better predict outcome. In home-care resident elderly, outcome prediction should be performed by combining the suggestions from both these tools.”<br />In another study, Drescher et al. (2010) compared the MNA and the Nutritional Risk Screening 2002 (NRS) to protein malnutrition in patients. Subjects were 104 geriatric patients that had been admitted to an acute geriatric ward, 81 were females and 23 were males. The subjects had a median age of 84 years. Blood samples were taken from each patient within 24 hours of admission and evaluated for serum albumin, prealbumin, retinol-binding protein, blood lymphocytes, creatine and C-reactive protein. Proteins were measured on the Beckman-Coulter nephelometry system. Patient’s calf and upper arm circumference were measured and the MNA and NRS were assessed within the first 3 days after admission. The MNA found that 23 patients were malnourished, 50 were at risk for malnutrition and 31 had a normal nutritional status. The NRS showed the 35 were at moderate to severe risk of malnutrition and 69 were at low risk (Drescher et al., 2010). Drescher et al. (2010) found that “serum prealbumin and retinol-binding protein concentrations were inversely associated with the severity of malnutrition as indicated by the NRS (P=0.06 and <0.01, respectively).” The study also found that the MNA was not associated with the serum protein values. After the results were adjusted for C-reactive protein and creatine clearance, only retinol-binding protein concentrations were consistently associated with both the NRS and MNA scores. The study concluded that the NRS seemed to be the better test compared to the MNA and serum proteins in identifying elderly patients at risk for malnutrition during an acute illness (Drescher et al., 2010).<br />A study done by Tsai et al. (2009) compared the use of the BMI versus the calf circumference in the predictive reliability of the short-form MNA. Although this paper is about the MNA, the short-form MNA is similar to the MNA, except there are fewer questions. Therefore, I think that looking at a study that evaluates the short form MNA can add insight into the reliability of the MNA. The study looked at 301 community living subjects, 109 care center living subjects and 68 nursing home living elderly. The subjects were 68 years or older. The subjects were evaluated with three versions of the short-form MNA. One version was the original, one was the Taiwan version 1, which adopted population specific BMI cutpoints, and the third version was Taiwan version 2, which substituted calf circumference for BMI. The results were analyzed with an SPSS for Windows 12.0 software package (Tsai et al., 2009). Tsai et al. (2009) found “BMI cutpoints improved the predictive ability of the short-form MNA, whereas replacement of BMI with calf circumference further improved the predictive ability of the scale (kappa values of the binary classification tests were 0.596, 0.742, and 0.843 for community-living; 0.560, 0.683, and 0.839 for care center–living; and 0.346, 0.454, and 0.522 for nursing home–living elderly for the original, T1, and T2 MNA short-form versions, respectively).” The results from the study suggest that modifying the measurement tool according to cultural or anthropometric feature of the specific population is necessary. It was also concluded from the study that calf circumference is an acceptable alternative to BMI measurement in the short-form MNA (Tsai et al., 2009). <br />According to the official website for the Mini Nutritional Assessment (2011), there are over 400 published articles on the MNA. It would be impossible to discuss all of the 400 articles in this paper. Therefore, this paper attempts to look at a sampling of research that shows results both in favor and against the MNA in order to for the reader to be able to make an informed decision about the MNA. There have been numerous studies that concluded the MNA is an accurate tool for assessing the nutritional status of the elderly. The newly developed short form MNA has also been shown to be a successful tool in a quick assessment, taking less than 4 minutes to complete, to determine nutritional status. However, there are other studies that are more recent that have shown there are other nutritional assessment tools, including the GNRI and the NRS 2002 that may be better than the MNA at accessing nutritional status. It can be concluded that the MNA has been found to be an accurate tool for assessing nutritional status in geriatrics, but that it is not the only assessment tool and may not be the best one available. <br />References<br />Adhami, S. (2007). The Mini Nutritional Assessment Tool: A step in the right direction. Sydney South <br />West Area Health Service. Retrieved from http://www.archi.net.au/e-library/delivery/medical/mini-nutrition <br />Bleda, M. J., Bolibar, I., Pares, R. & Salva, A. (2002). The reliability of the mini nutritional assessment in <br />institutionalized elderly people. The Journal Of Nutrition, Health & Aging. 6, 134-137. <br />Cereda, E., Pusani, C., Limonta, D. & Vanotti, A. (2009). The ability of the Geriatric Nutritional Risk Index <br />to assess the nutritional status and predict the outcome of home-care resident elderly: a comparison with the Mini Nutritional Assessment. British Journal of Nutrition. 102, 563–57.<br />Drescher, T., Singler, K., Ulrich, A., Koller, M., Keller, U., Christ-Crain, M.,  & Kressig, R. W. (2010). <br />Comparison of two malnutrition risk screening methods (MNA and NRS 2002) and their association with markers of protein malnutrition in geriatric hospitalized patients. European Journal of Clinical Nutrition. 64, 887-893. <br />A guide to completing the Mini Nutritional Assessment MNA. (2011). Retrieved from <br />http://www.scribd.com/doc/28750968/Guide-for-Mini-Nutritional-Assessment<br />Mini Nutritional Assessment. Nestle Nutrtion Institute. (2011). Retrieved from http://www.mna-<br />elderly.com/default.html <br />Tsai, A. C., Chang, T., Wang, Y. & Liao, C. (2010). Population-Specific Short-Form Mini Nutritional <br />Assessment with Body Mass Index or Calf Circumference Can Predict Risk of Malnutrition in Community-Living or Institutionalized Elderly People in Taiwan. Journal of the American Dietetic Association. 110 (9), 1328-1334.<br />  <br />

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