The document discusses the Mini Nutritional Assessment (MNA), a screening tool used to assess nutritional status in elderly populations. The MNA contains 18 questions in two parts - the first part screens for malnutrition risk and the second part fully assesses nutritional status if needed. It identifies individuals at risk of malnutrition and allows for targeted intervention. Studies show the MNA has good reliability and validity in detecting malnutrition across various elderly care settings before other indicators appear. It is widely used internationally but may need adjustment for non-Western cultures. The MNA is considered an effective screening tool for nutritional assessment in older adults.

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Mini Nutritional Assessment
NTR5503K

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Purpose of the Tool & Explanation to Patients
The Mini Nutritional Assessment (MNA) is a screening tool for independent and clinically
relevant elderly populations. The MNA contains geriatric-specific assessment questions related to
nutritional 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 patients
age 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 screening
questions in part 1 and 12 assessment questions in part 2. When a quick screening is all that's needed, just
the first six questions, also known as the MNA short form (MNA-SF) can be completed in less than five
minutes. The changes to the MNA-SF facilitate its use across care settings and make it much more user
friendly (Bauer et al., 2008).
In community-dwelling elderly persons, the MNA detects risk of malnutrition and life-style
characteristics associated with nutritional risk while albumin levels and the BMI are still in the normal
range (Tsai &Ku 2007). In outpatients and in hospitalized patients, the MNA is predictive of outcome and
cost 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 used
successfully 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 determine
a person's risk of malnutrition (2007).
Early detection of malnutrition is important to allow targeted nutritional intervention and should
be a key component of the geriatric assessment. The MNA, as a two-step procedure (screening with the
MNA-SF followed by assessment, if needed, by the full MNA), is reliable and can be easily administered
by general practitioners and by health professionals at hospital or nursing home admission for early
detection of risks of malnutrition. The MNA has the following characteristics: The MNA is a two step

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procedure: the MNA-SF to screen for malnutrition and risk of malnutrition; assessment of nutritional
status with the full MNA. The MNA is an 18-item questionnaire comprising anthropometric
measurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaire
regarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), a
global assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or
depression), 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 assessment
and objective indicators of nutritional status (albumin level, BMI, energy intake, and vitamin status). A
high MNA score indicates satisfactory nutritional status and no need for additional intervention (1994). A
low MNA score can predict hospital-say outcomes in older patients and can be used to follow up changes
in nutritional status (1994). Guided by the MNA score, the clinician may refer the patient with a lower
MNA score to a Registered Dietitian or qualified nutrition specialist for a full nutrition assessment. This
qualified nutrition specialist uses the problem areas identified on the MNA and other nutrition assessment
data, to make the specific nutrition diagnosis, which then drives specific nutrition interventions and
follow-up monitoring.
History or Development of the Tool
In the early 1990s, the Mini Nutritional Assessment was developed for nutrition screening in the
elderly. Since then, it became the most established and widespread screening tool for older persons and
has been translated into 15 different languages. The MNA shows prognostic relevance with regard to
functionality, 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 geriatric
assessment. 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 developed
using measurements and questions that can be attributed to 5 different categories (Bauer et al., 2008).

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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 count
Safety of Use
The MNA is regarded as especially useful in a setting where it is intended to identify older people
who are at risk and who need preventive nutrition measures. On the other hand, under circumstances
where resources are scarce, this high sensitivity not only for obvious malnutrition but also for being at
risk may highlight more people than today’s health systems can economically manage. The tool can
identify 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 has
been linked with adverse conditions including diminished cognitive function, bad teeth, and poor
eyesight. Among the hospitalized elderly, low MNA scores have been associated with longer
hospitalizations and higher rates of discharge to nursing homes and death. In general, MNA scores of 27
or higher have been associated with "successful aging" and lower rates of osteoporosis and death within
three years (2001). The multidimensionality of causes for malnutrition in the elderly cannot be identified
by an easy and practical screening tool so it would not be safe to assume causal relationships solely based
on assessment results. Although the MNA offers some clues to the etiology of deteriorated nutrition status
in an older person, once again, it should not be regarded as a substitute for a profound assessment and
physical examination that must be done regularly after someone has been categorized as having overt

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malnutrition or as being at risk by the MNA. If there is suspicion of the presence of one or multiple
micronutrient deficiencies, the proper laboratory tests should be performed. The approach for treatment is
individualized.
Plausible or Purported Mechanism
The MNA should be used as a part of a comprehensive assessment that employs other tools
specific 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 as
current mobility or neuropsychological problems and a decrease in body mass index (BMI). A score of 12
to 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 specific
foods and fluids. The patient reports nutritional and health status, and the practitioner determines mid-arm
and mid-calf circumferences. The total score for the full MNA will fall between 0 and 30 points: 24 and
higher indicates a well-nourished patient; 17 to 23.5 indicates a risk of malnutrition; lower than 17
indicates 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 a
tool measures what it's designed to measure-in this case, nutritional status) in the screening of
malnutrition and risk of malnutrition in older adults, including those hospitalized, living in the
community, living with or without memory impairment, and living in various Western countries It can
detect malnutrition before changes in weight or serum protein levels are evident.

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In the developmental process, 3 consecutive studies were performed among both frail and healthy elderly
populations in various settings. These included a developmental study, a validation study, and an
additional validation study.
In the developmental study, 155 elderly individuals, both healthy and frail were included. Mean
age was 78.3 years, 66% were female. Enrolled participants were examined by a comprehensive nutrition
assessment. 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 and
the physicians’ rating as a reference. Data analysis yielded profound correlation of the MNA test results
with the conventional nutritional assessment and the older persons’ clinical status. The study participants
were categorized into well nourished, at risk for malnutrition, and overt malnutrition. The MNA’s
categorization did not change when biochemical markers were excluded, leaving the MNA with 4
categories (anthropometry, general, dietary, and subjective assessment (Bauer et al., 2008). The decision
to exclude blood samples was considered a major step forward in the development process, thereby
keeping low cost of the MNA for the assessed individual. Calculation of sensitivity and specificity for the
MNA 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, and
functional assessment (ADL, hand-grip strength) were carried out. The clinical status was evaluated
independently by 2 physicians and was again taken as a reference for the MNA. Then it was shown by
discriminant analysis that the MNA was in agreement with the physicians’ rating at a very high
percentage (89%). By crows-classification of the participants from the developmental and the validation
study, 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 in
participants who had not yet developed overt malnutrition but were at risk for this condition (Bauer et al.,
2008).

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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 validation
study. Ten percent of the participants were over the age 85. Each participant was assessed using MNA as
it was established in the validation study. A conventional nutrition assessment including measurement of
energy intake, anthropometrics, and biochemical markers were complete for comparative reasons. The
prevalence of malnutrition according to MNA was low in this population. The mean MNA score was 26.6
and 26.4 for men and women, respectively. Only 2 participants scored below 17. However, 18% of the
evaluated participants scored between 17 and 23.5 (“at risk”), whereas body mass index and serum
albumin level were within the normal ranges in these participants. This discrepancy was interpreted as a
sign that the MNA was capable of detecting a borderline nutrition status with lower energy intakes when
conventional biochemical parameters were still inconspicuous (Bauer et al., 2008). This observation
would be of special importance as this at risk condition was considered to be especially suitable for the
intervention.
The MNA also shows prognostic significance with regard to morbidity, mortality, and adverse
outcomes in elderly people. Guigoz et al. analyzed the mortality rate in their population that served to
develop the MNA 1 year after their initial assessment (1994). According to this analysis, 48% of the
participants categorized as malnourished 1 year before had died in the meantime. At-risk participants
showed 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 was
nearly twice the percentage attributed to those being categorized as well-nourished (Bauer et al., 2008). In
patients admitted to a subacute care facility, 25% of those diagnosed as being malnourished by the MNA
had 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 of
malnutrition and the risk of developing malnutrition, although its predictive value increased when
biochemical markers were added or assessment by a physician was done to corroborate the findings. The

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sensitivity of the MNA-its ability to identify people who are malnourished-has been reported as 70% or
higher in nine studies. The MNA-SF's sensitivity ranges from 86% to 100% (Bauer et al., 2008).
That being said, the tool has limitations. Firstly, it was designed to evaluate nutrition status
rapidly, not to measure changes over time. For example, it may be used to assess changes in nutritional
status after intervention, but more research is needed. Secondly, the MNA was developed more than 20
years ago, and uses BMI and anthropometric reference ranges that were standard at that time. Thirdly, the
MNA was developed on the basis of Western diets and anthropometry and hasn't been validated for use in
non-Western cultures. It's important to consider cultural background and individual diet when using the
MNA.
Conclusion
The MNA, specifically the MNA- short form is an excellent tool for mandatory nutrition
screening of elderly participants in government-funded nutrition programs (congregate meals sites, meals
on wheels, etc.). Early detection of those at risk of malnutrition can lead to early intervention which is
more cost effective. In addition, using a validated screen to identify high-risk patients for malnutrition
may 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-term
care facilities, nursing homes, and hospitals (Tsai & Ku, 2007).
At present, it seems as though the MNA is regarded as one of the most established nutrition
screening tool in the elderly. Although it may not serve as the gold standard, I believe it must be
recognized as a relevant reference in this field. Its use seems to be most effective for the screening of
community living elderly, of residents in subacute care, and of those in nursing homes. The MNA should
be 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 at
hospital admission may be temporarily worsened by acute disease. Therefore, the MNA should be

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postponed under such circumstances until the elderly person’s condition has stabilized. It seems to be the
opinion that the application of a yearly MNA is acceptable. The use of the MNA as a follow-up tool
requires further studies as there weren’t that many done to date. Future initiatives may try to adjust the
MNA even more appropriately with regard to those who cannot cooperate in completing it and may allow
facilitating its use even further.
The MNA has gained world-wide acceptance, exists in 15 languages, and confirms high
prevalence of malnutrition in the elderly population in different care settings. Studies have been
completed 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 recommending
this tool for nutritional screening in older people.

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References
Bauer, 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.