Jordana LevinePurpose of the Tool & Explanation to Patients The Mini Nutritional Assessment (MNA) is a screening tool for independent and clinicallyrelevant elderly populations. The MNA contains geriatric-specific assessment questions related tonutritional and health conditions, independence, quality of life, cognition, mobility and subjective health.The MNA is recommended for routine geriatric assessments. It is a tool that identifies geriatric patientsage 65 and above who are at risk of malnutrition. The MNA is easily completed within 10-15 minutes.The MNA consists of 18 questions derived from four parameters of assessment as listed above:anthropometric, general, dietary, and subjective. The full MNA has two components-six screeningquestions in part 1 and 12 assessment questions in part 2. When a quick screening is all thats needed, justthe first six questions, also known as the MNA short form (MNA-SF) can be completed in less than fiveminutes. The changes to the MNA-SF facilitate its use across care settings and make it much more userfriendly (Bauer et al., 2008). In community-dwelling elderly persons, the MNA detects risk of malnutrition and life-stylecharacteristics associated with nutritional risk while albumin levels and the BMI are still in the normalrange (Tsai &Ku 2007). In outpatients and in hospitalized patients, the MNA is predictive of outcome andcost of care. In home care patients and nursing home residents, the MNA is related to living conditions,meal patterns, and chronic medical conditions and allows targeted intervention. The MNA has been usedsuccessfully in follow-up evaluation of outcome, nutritional intervention, nutritional education programs,and physical intervention programs in elderly persons. The MNA-SF allows quick screening to determinea persons risk of malnutrition (2007). Early detection of malnutrition is important to allow targeted nutritional intervention and shouldbe a key component of the geriatric assessment. The MNA, as a two-step procedure (screening with theMNA-SF followed by assessment, if needed, by the full MNA), is reliable and can be easily administeredby general practitioners and by health professionals at hospital or nursing home admission for earlydetection of risks of malnutrition. The MNA has the following characteristics: The MNA is a two step
Jordana Levineprocedure: the MNA-SF to screen for malnutrition and risk of malnutrition; assessment of nutritionalstatus with the full MNA. The MNA is an 18-item questionnaire comprising anthropometricmeasurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaireregarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), aglobal assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia ordepression), and a self-assessment (self-perception of health and nutrition) (Guigoz, Vellas, & Garry,1994). The MNA-SF comprises 6 items from the 18. The MNA correlates highly with clinical assessmentand objective indicators of nutritional status (albumin level, BMI, energy intake, and vitamin status). Ahigh MNA score indicates satisfactory nutritional status and no need for additional intervention (1994). Alow MNA score can predict hospital-say outcomes in older patients and can be used to follow up changesin nutritional status (1994). Guided by the MNA score, the clinician may refer the patient with a lowerMNA score to a Registered Dietitian or qualified nutrition specialist for a full nutrition assessment. Thisqualified nutrition specialist uses the problem areas identified on the MNA and other nutrition assessmentdata, to make the specific nutrition diagnosis, which then drives specific nutrition interventions andfollow-up monitoring.History or Development of the Tool In the early 1990s, the Mini Nutritional Assessment was developed for nutrition screening in theelderly. Since then, it became the most established and widespread screening tool for older persons andhas been translated into 15 different languages. The MNA shows prognostic relevance with regard tofunctionality, morbidity, and mortality of the elderly in different settings (Bauer et al., 2008). Development and validation of the MNA was intended to become part of a routine geriatricassessment. In addition, it was intended to develop as a screening tool as an interview to support face-to-face contact of the interviewer with the elderly person who is being screened. The MNA was developedusing measurements and questions that can be attributed to 5 different categories (Bauer et al., 2008).
Jordana Levine 1. Anthropometric measurements: weight loss, weight, height, mid-arm circumference, calf circumference 2. General Assessment: lifestyle, medication, acute disease, mobility, neuropsychological problems, and skin lesions 3. Dietary assessment: number of meals, food and fluid intake, appetite, and feeding mode 4. Subjective assessment: self-perception of nutrition status and comparison of own health status to others 5. Biochemical markers: serum levels of albumin, pre-albumin, cholesterol, lymphocyte countSafety of Use The MNA is regarded as especially useful in a setting where it is intended to identify older peoplewho are at risk and who need preventive nutrition measures. On the other hand, under circumstanceswhere resources are scarce, this high sensitivity not only for obvious malnutrition but also for being atrisk may highlight more people than today’s health systems can economically manage. The tool canidentify those at risk for malnutrition before biochemical or weight changes appear (Rubenstein et al.,2001). This is important because progressive malnutrition often goes undiagnosed, and malnutrition hasbeen linked with adverse conditions including diminished cognitive function, bad teeth, and pooreyesight. Among the hospitalized elderly, low MNA scores have been associated with longerhospitalizations and higher rates of discharge to nursing homes and death. In general, MNA scores of 27or higher have been associated with "successful aging" and lower rates of osteoporosis and death withinthree years (2001). The multidimensionality of causes for malnutrition in the elderly cannot be identifiedby an easy and practical screening tool so it would not be safe to assume causal relationships solely basedon assessment results. Although the MNA offers some clues to the etiology of deteriorated nutrition statusin an older person, once again, it should not be regarded as a substitute for a profound assessment andphysical examination that must be done regularly after someone has been categorized as having overt
Jordana Levinemalnutrition or as being at risk by the MNA. If there is suspicion of the presence of one or multiplemicronutrient deficiencies, the proper laboratory tests should be performed. The approach for treatment isindividualized.Plausible or Purported Mechanism The MNA should be used as a part of a comprehensive assessment that employs other toolsspecific to geriatrics. As mentioned above, there are 2 parts to the MNA. Part 1 is designed to detect"psychological stress or acute disease" or a decline in eating or weight in the past three months, as well ascurrent mobility or neuropsychological problems and a decrease in body mass index (BMI). A score of 12to 14 signifies normal nutritional status and no need for further assessment. Score of 1 or lower indicates"possible malnutrition," and the interviewer proceeds to part 2 (Bauer et al., 2008).Part 2 determines the presence of polypharmacy or pressure ulcers, the number of full meals eaten daily,the mode of feeding, whether the person lives independently, and the amount and frequency of specificfoods and fluids. The patient reports nutritional and health status, and the practitioner determines mid-armand mid-calf circumferences. The total score for the full MNA will fall between 0 and 30 points: 24 andhigher indicates a well-nourished patient; 17 to 23.5 indicates a risk of malnutrition; lower than 17indicates malnutrition (Bauer et al., 2008).Synopsis of peer-reviewed literature & Appropriate Patient Selection Criteria The MNA has demonstrated moderate reliability and construct validity (the degree to which atool measures what its designed to measure-in this case, nutritional status) in the screening ofmalnutrition and risk of malnutrition in older adults, including those hospitalized, living in thecommunity, living with or without memory impairment, and living in various Western countries It candetect malnutrition before changes in weight or serum protein levels are evident.
Jordana LevineIn the developmental process, 3 consecutive studies were performed among both frail and healthy elderlypopulations in various settings. These included a developmental study, a validation study, and anadditional validation study. In the developmental study, 155 elderly individuals, both healthy and frail were included. Meanage was 78.3 years, 66% were female. Enrolled participants were examined by a comprehensive nutritionassessment. Participants were additionally rated independently by 2 trained physicians as either normal,malnourished, or uncertain. The MNA was then validated using the conventional nutrition assessment andthe physicians’ rating as a reference. Data analysis yielded profound correlation of the MNA test resultswith the conventional nutritional assessment and the older persons’ clinical status. The study participantswere categorized into well nourished, at risk for malnutrition, and overt malnutrition. The MNA’scategorization did not change when biochemical markers were excluded, leaving the MNA with 4categories (anthropometry, general, dietary, and subjective assessment (Bauer et al., 2008). The decisionto exclude blood samples was considered a major step forward in the development process, therebykeeping low cost of the MNA for the assessed individual. Calculation of sensitivity and specificity for theMNA without laboratory tests in this population was 96% and 98% respectively (2008). The validation study was performed in 120 frail elderly persons whose mean age was 79.1 years,of which 70.6 were female. MNA, biochemical parameters, anthropometrical measurements, andfunctional assessment (ADL, hand-grip strength) were carried out. The clinical status was evaluatedindependently by 2 physicians and was again taken as a reference for the MNA. Then it was shown bydiscriminant analysis that the MNA was in agreement with the physicians’ rating at a very highpercentage (89%). By crows-classification of the participants from the developmental and the validationstudy, between 70% and 75% were correctly classified by the MNA as normal or malnourished.However, in 25%-30%, allocation to either group could not be achieved. Presumably, this was the case inparticipants who had not yet developed overt malnutrition but were at risk for this condition (Bauer et al.,2008).
Jordana Levine Three hundred forty seven healthy free-living elderly subjects (mean age 76.8 years, 60% female)from the longitudinal New Mexico Aging Process Study were enrolled in the consecutive validationstudy. Ten percent of the participants were over the age 85. Each participant was assessed using MNA asit was established in the validation study. A conventional nutrition assessment including measurement ofenergy intake, anthropometrics, and biochemical markers were complete for comparative reasons. Theprevalence of malnutrition according to MNA was low in this population. The mean MNA score was 26.6and 26.4 for men and women, respectively. Only 2 participants scored below 17. However, 18% of theevaluated participants scored between 17 and 23.5 (“at risk”), whereas body mass index and serumalbumin level were within the normal ranges in these participants. This discrepancy was interpreted as asign that the MNA was capable of detecting a borderline nutrition status with lower energy intakes whenconventional biochemical parameters were still inconspicuous (Bauer et al., 2008). This observationwould be of special importance as this at risk condition was considered to be especially suitable for theintervention. The MNA also shows prognostic significance with regard to morbidity, mortality, and adverseoutcomes in elderly people. Guigoz et al. analyzed the mortality rate in their population that served todevelop the MNA 1 year after their initial assessment (1994). According to this analysis, 48% of theparticipants categorized as malnourished 1 year before had died in the meantime. At-risk participantsshowed a 24% mortality rate, whereas none of the participants categorized as well nourished had died.Saletti et al reported a 3 year mortality of 50% in malnourished elderly receiving home care, which wasnearly twice the percentage attributed to those being categorized as well-nourished (Bauer et al., 2008). Inpatients admitted to a subacute care facility, 25% of those diagnosed as being malnourished by the MNAhad to be readmitted to the hospital during their stay in this facility (Guigoz, Vellas & Garry, 1994). A number of studies have demonstrated that the MNA is a moderate-to-good predictor ofmalnutrition and the risk of developing malnutrition, although its predictive value increased whenbiochemical markers were added or assessment by a physician was done to corroborate the findings. The
Jordana Levinesensitivity of the MNA-its ability to identify people who are malnourished-has been reported as 70% orhigher in nine studies. The MNA-SFs sensitivity ranges from 86% to 100% (Bauer et al., 2008). That being said, the tool has limitations. Firstly, it was designed to evaluate nutrition statusrapidly, not to measure changes over time. For example, it may be used to assess changes in nutritionalstatus after intervention, but more research is needed. Secondly, the MNA was developed more than 20years ago, and uses BMI and anthropometric reference ranges that were standard at that time. Thirdly, theMNA was developed on the basis of Western diets and anthropometry and hasnt been validated for use innon-Western cultures. Its important to consider cultural background and individual diet when using theMNA.Conclusion The MNA, specifically the MNA- short form is an excellent tool for mandatory nutritionscreening of elderly participants in government-funded nutrition programs (congregate meals sites, mealson wheels, etc.). Early detection of those at risk of malnutrition can lead to early intervention which ismore cost effective. In addition, using a validated screen to identify high-risk patients for malnutritionmay help document the need for adequate program funding. Based on literature reviews from 2006,patients mean age range from 69-85 years old. They are selected from community dwelling, long-termcare facilities, nursing homes, and hospitals (Tsai & Ku, 2007). At present, it seems as though the MNA is regarded as one of the most established nutritionscreening tool in the elderly. Although it may not serve as the gold standard, I believe it must berecognized as a relevant reference in this field. Its use seems to be most effective for the screening ofcommunity living elderly, of residents in subacute care, and of those in nursing homes. The MNA shouldbe done early after the admission of an elderly person to an institution like a nursing home or hospital.Nevertheless, it should be taken into account that the mental and physical state of an elderly person athospital admission may be temporarily worsened by acute disease. Therefore, the MNA should be
Jordana Levinepostponed under such circumstances until the elderly person’s condition has stabilized. It seems to be theopinion that the application of a yearly MNA is acceptable. The use of the MNA as a follow-up toolrequires further studies as there weren’t that many done to date. Future initiatives may try to adjust theMNA even more appropriately with regard to those who cannot cooperate in completing it and may allowfacilitating its use even further. The MNA has gained world-wide acceptance, exists in 15 languages, and confirms highprevalence of malnutrition in the elderly population in different care settings. Studies have beencompleted to reconfirm the strong correlation with commonly used nutritional parameters in the elderly.Due to the validity and user friendly characteristics, I would feel comfortable using and recommendingthis tool for nutritional screening in older people.
Jordana LevineReferencesBauer, J. M., Kaiser, M. J., Anthony, P., Guigoz, Y., Sieber, C. C. (2008). The Mini Nutritional Assessment – Its history, today’s practice, and future perspectives. Nutrition in Clinical Practice, 23(4), 388-396.Guigoz, Y., Vellas, B., Garry, P. J. (1994). Mini Nutritional Assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology, 2(2), 15-59.Rubenstein, L. Z., Harker, J. O., Salva, A., Guigoz, Y., Vellas, B. (2001). Screening for undernutrition in geriatric practice: developing the short-form Mini Nutritional Assessment. Journal of Gerontology and Biological Sciences and Medical Sciences, 56, M366-M372.Tsai, A. C., Ku, P. Y. (2007). Population-specific Mini Nutritional Assessment effectively predicts the nutritional state and follow-up mortality of institutionalized elderly Taiwanese regardless of cognitive status. British Journal of Nutrition, 6, 1-7.