Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.

Frailty and Nutrition: What We Have Learned from Research and Clinical Practice on the Mini Nutritional Assessment.

In this short communication, we review the relationship between frailty and malnutrition risk in the elderly. Frailty is a term used for elderly at increased risk of adverse outcomes, including disability, falls, hospitalization, need for long-term care, and mortality. The Mini Nutritional Assessment (MNA) was designed and validated in a series of studies to assess nutritional status of elderly, as integral part of the comprehensive geriatric assessment, with a 2-steps screening process; when the MNA-SF classify a person at risk, the full MNA should be completed. The MNA and MNA-SF are sensitive, specific, and accurate in identifying nutrition risk. Increased risk of malnutrition, a common condition in the elderly, is closely associated with many potential contributors of frailty. The maintenance of optimal physical and cognitive performances depends on the early screening of critical conditions to develop preventive targeted interventions; the MNA supports such preventive action.

Health and nutrition promotion program for patients with dementia (NutriAlz): cluster randomized trial.

OBJECTIVE: To assess the effectiveness of health and nutrition program (NutriAlz) versus usual care on functional level in elderly people with dementia living at home, as well as on clinical practice related to nutrition and on the caregiver's burden. DESIGN: Cluster randomized multi-centre study with one-year follow-up. SETTING: 11 Alzheimer outpatients and day care centres (Barcelona, Spain). PARTICIPANTS: Nine hundred and forty six home-living Alzheimer patients with identified caregiver were consecutively recruited (intervention group: 6 centres, 448 patients vs control group: 5 centres, 498 patients). INTERVENTION: The intervention was a teaching and training intervention on health and nutrition program, NutriAlz, directed both to physician and main caregiver, as well as persons affected by Alzheimer's disease or other dementias, including a standardised protocol for feeding and nutrition. MAIN OUTCOME MEASURES: The main outcome measure was the reduction in the loss of autonomy (Activities of daily living (ADL/IADL) scales) assessed at 6 and 12 months. Secondary outcomes measures were Improvement in nutritional status (Mini Nutritional Assessment (MNA), BMI, and weight changes), and caregiver burden (Zarit scale). RESULTS: The one-year assessment was completed for 293 patients (65.4%) in the intervention group and 363 patients (72.9%) in the control group (usual care). The annual rate of ADL change was -0.83 vs -0.62 (p=0.984), and the caregiver's subjective burden 0.59 vs 2.36 (p=0.681) in intervention and control group, respectively. MNA, however, showed an improvement (+0.46 vs -0.66, p=0.028), suggesting an effective nutritional behaviour. CONCLUSION: The NutriAlz program had no effect on functional decline in Alzheimer disease patients living at home over one year, but reduced the risk for malnutrition, as recommendations concerning diet and exercise were provided.

Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status.

OBJECTIVE: To validate a revision of the Mini Nutritional Assessment short-form (MNA(R)-SF) against the full MNA, a standard tool for nutritional evaluation. METHODS: A literature search identified studies that used the MNA for nutritional screening in geriatric patients. The contacted authors submitted original datasets that were merged into a single database. Various combinations of the questions on the current MNA-SF were tested using this database through combination analysis and ROC based derivation of classification thresholds. RESULTS: Twenty-seven datasets (n=6257 participants) were initially processed from which twelve were used in the current analysis on a sample of 2032 study participants (mean age 82.3y) with complete information on all MNA items. The original MNA-SF was a combination of six questions from the full MNA. A revised MNA-SF included calf circumference (CC) substituted for BMI performed equally well. A revised three-category scoring classification for this revised MNA-SF, using BMI and/or CC, had good sensitivity compared to the full MNA. CONCLUSION: The newly revised MNA-SF is a valid nutritional screening tool applicable to geriatric health care professionals with the option of using CC when BMI cannot be calculated. This revised MNA-SF increases the applicability of this rapid screening tool in clinical practice through the inclusion of a "malnourished" category.

Health and nutritional promotion program for patients with dementia (NutriAlz Study): design and baseline data.

BACKGROUND: There is a lack of data on global weight loss prevention programs for patients with dementia or clear evidence about their impact on a functional level, caregiver burden or the use of healthcare and social resources. NutriAlz is a socio-educative and nutritional intervention program to prevent weight loss and loss of function in dementia patients. STUDY DESIGN AND METHODS: A cluster randomized multi-centre study, which will allow the comparison of a group benefiting from the intervention with a control group after a year of monitoring. Patients were recruited from 11 hospitals in the ambulatory diagnostic units and day care centres. The baseline interview include: sociodemographic and socioeconomic variables (age, gender, educational level, marital status); diagnostic, treatments, MMS, a list of comorbid conditions; activities of daily living (ADL, IADL), Zarit Scale, brief-NPI, Cornell scale and nutritional status as measured by the Mini Nutritional Assessment. All participants or their family signed the inform consent form. BASELINE CHARACTERISTICS: Total of 946 patients were included, with a mean (+/- SD) of 79 +/- 7.3 year of age; 68,1 % were women; 44,9% lives with their partner, only 3% lives alone; 79.8% had Alzheimer's dementia, 5.25 +/- 3.0 years since symptoms of dementia and 2.8 +/- 2.11 years since diagnosis. Mean MMSE score was 15.4 +/- 6.2; mean weight was 64.4 +/- 12.5 kg; mean BMI was 27.0 +/- 4.5 (with 3% below 19, 5% between 19-21, 10% between 21-23, and 82% above 23). Mean ADL without difficulties was 3.2 +/- 2.1; mean IADL without difficulties was 0.7 +/- 1.6; mean number of symptoms in the NPI was 4.4 +/- 2.59, with severity score of 7.9 +/- 5.9 and distress score of 11.3 +/- 9.0; mean Zarit scale was 27.4 +/- 15.5; mean MNA was 23.2 +/- 3.5 with 5 % as malnourished, 32 % at risk of malnutrition, and 63 % with adequate nutritional status.

Systemic inflammatory markers in older persons: the effect of oral nutritional supplementation with prebiotics.

OBJECTIVE: To evaluate the effect of oral nutritional supplementation with and without oligosaccharides on gut bacteriology, in particular the bifidogenic flora, and on immunology and inflammatory parameters in older persons at risk of malnutrition. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: Division of Geriatric Medicine, St. Louis University, Missouri, United States. PARTICIPANTS: Seventy-four community dwelling elderly and/or nursing home subjects (age superior 70 y; 84 +/- 7 years) either undernourished or at risk of undernutrition. INTERVENTION: Daily liquid supplements, with (1.3 g/250 ml) and without oligosaccharides (OS) for 12 weeks. MEASUREMENTS: Nutritional evaluation, serum immunoglobulins, lymphocyte subsets, various cytokines and the endotoxin soluble receptor CD14 (sCD14) in serum, and cytokines specific mRNA in peripheral blood mononuclear cells at baseline and 12 weeks, and fecal bacteriologicy. RESULTS: Specific mRNA extracted from blood leucocytes showed a different level of pro-inflammatory gene activation: TNF-alpha mRNA and IL-6 mRNA diminished in the OS group after 12 weeks, while no changes were detected in the control group (P=0.05 and P=0.04 respectively). Serum levels of sCD14, a product shed by activated macrophages, decreased only in the OS group without reaching statistical significance (P=0.08). No significant differences were detected in the fecal gut flora or in the nutritional parameters. CONCLUSIONS: This study shows that the administration of supplements in older persons at risk of malnutrition may benefit from the addition of prebiotics that can improve the low noise inflammatory process frequently observed in this population.

The Mini Nutritional Assessment (MNA) review of the literature--What does it tell us?

To review the literature on the MNA to Spring 2006, we searched MEDLINE, Web of Science and Scopus, and did a manual search in J Nutr Health Aging, Clin Nutr, Eur J Clin Nutr and free online available publications. VALIDATION AND VALIDITY: The MNA was validated against two principal criteria, clinical status and comprehensive nutrition assessment using principal component and discriminant analysis. The MNA shortform (MNA-SF) was developed and validated to allow a 2-step screening process. The MNA and MNA-SF are sensitive, specific, and accurate in identifying nutrition risk. NUTRITIONAL SCREENING: The prevalence of malnutrition in community-dwelling elderly (21 studies, n = 14149 elderly) is 2 +/- 0.1% (mean +/- SE, range 0- 8%) and risk of malnutrition is 24 +/- 0.4% (range 8-76%). A similar pattern is seen in out-patient and home care elderly (25 studies, n = 3119 elderly) with prevalence of undernutrition 9 +/- 0.5% (mean +/- SE, range 0-30%) and risk of malnutrition 45 +/- 0.9% (range 8-65%). A high prevalence of undernutrition has been reported in hospitalized and institutionalized elderly patients: prevalence of malnutrition is 23 +/- 0.5% (mean +/- SE, range 1- 74%) in hospitals (35 studies, n = 8596) and 21 +/- 0.5% (mean +/- SE, range 5-71%) in institutions (32 studies, n = 6821 elderly). An even higher prevalence of risk of malnutrition was observed in the same populations, with 46 +/- 0.5% (range 8-63%) and 51 +/- 0.6% (range 27-70%), respectively. In cognitively impaired elderly subjects (10 studies, n = 2051 elderly subjects), detection using the MNA, prevalence of malnutrition was 15 +/- 0.8% (mean +/- SE, range 0-62%), and 44 +/- 1.1% (range 19-87%) of risk of malnutrition. CHARACTERISTICS: The large variability is due to differences in level of dependence and health status among the elderly. In hospital settings, a low MNA score is associated with an increase in mortality, prolonged length of stay and greater likelihood of discharge to nursing homes. Malnutrition is associated with functional and cognitive impairment and difficulties eating. The MNA(R) detects risk of malnutrition before severe change in weight or serum proteins occurs. NUTRITIONAL INTERVENTION: Intervention studies demonstrate that timely intervention can stop weight loss in elderly at risk of malnutrition or undernourished and is associated with improvements in MNA scores. The MNA can also be used as a follow up assessment tool. CONCLUSION: The MNA is a screening and assessment tool with a reliable scale and clearly defined thresholds, usable by health care professionals. It should be included in the geriatric assessment and is proposed in the minimum data set for nutritional interventions.

Overview of the MNA--Its history and challenges.

The Mini Nutritional Assessment (MNA) is a simple tool, useful in clinical practice to measure nutritional status in elderly persons. From its validation in 1994, the MNA has been used in hundreds of studies and translated into more then 20 languages. It is a well-validated tool, with high sensitivity, specificity, and reliability. An MNA score > or = 24 identifies patients with a good nutritional status. Scores between 17 and 23.5 identify patients at risk for malnutrition. These patients have not yet started to lose weight and do not show low plasma albumin levels but have lower protein-calorie intakes than recommended. For them, a multidisciplinary geriatric intervention is needed, which takes into account all aspects that might interfere with proper alimentation and, when necessary, proposes therapeutic interventions for diet or supplementation. If the MNA score is less than 17, the patient has protein-calorie malnutrition. It is important at this stage to quantify the severity of the malnutrition (by measuring biochemical parameters like plasma albumin or prealbumin levels, establishing a 3- day record of food intake, and measuring anthropometric features like weight, BMI, arm circumference and skin folds). Nutritional intervention is clearly needed and should be based on achievable objectives established after a detailed comprehensive geriatric assessment. The MNA has been shown to be useful for nutritional intervention follow-up as well. The MNA can help clinicians design an intervention by noting where the patient loses points when performing the MNA. Moreover, when a nutritional intervention is successful, the MNA score increases. The MNA is recommended by many national and international clinical and scientific organizations. It can be used by a variety of professionals, including physicians, dietitians, nurses or research assistants. A short screening version (MNA-SF) has been developed, which, if positive, indicates the need to complete the full MNA. It takes less than 4 minutes to administer the MNA-SF and between 10 and 15 minutes for the full MNA.

Nutritional status using the Mini Nutritional Assessment questionnaire and its relationship with bone quality in a population of institutionalized elderly women.

Malnutrition, a risk factor for osteoporotic fractures, is frequent in elderly people and, is underdiagnosed and undertreated. There are only few studies on the nutritional status of elderly people in Europe. The Mini Nutritional Assessment (MNA) is a non invasive and validated questionnaire to evaluate nutritional status in elderly people, classified in three groups: 1 degree score < 17: malnourished, 2 degrees score >17 and < 24: at risk of malnutrition, 3 degrees score >24: well-nourished, with a maximum of 30 points. Quantitative ultrasound of bone (QUS) is a method for assessing quality of bone which can be easily performed in nursing homes. Therefore, these two tests allowed to study the relationships between nutritional status and ultrasonic parameters of bone in 78 institutionalized women aged 86 +/- 6 years, living in 11 nursing homes around Lausanne (Switzerland). All were assessed by the MNA, had a measurement of the tricipital skin fold and of the grip strength. Functional status was evaluated by the scale "Activity of Daily Living" (ADL), and serum albumin level was measured when permitted. All had QUS of the calcaneus (with an Achilles, GE Lunar). The measured parameters are the Broadband Ultrasound Attenuation (BUA), attenuation of a band of ultrasonic frequencies through the medium, expressed in dB/MHz, and the Speed of Sound (SOS), speed of the ultrasounds through the medium, expressed in m/s. A third parameter, the stiffness index (SI), expressed as a percentage of the values obtained by the manufacturer in a young population and derived from BUA and SOS, was calculated automatically : SI = (0.67xBUA) + (0.28xSOS) - 420, expressed in percent compared to a young adult population (%YA). Fifteen percent of the women were undernourished and 58% were at risk of malnutrition. As expected, compared with the well-nourished minority, undernourished subjects had significant lower body mass index (BMI), tricipital skin fold (TSF), ADL score and albumin level (p < 0,01). The subjects "at risk of malnutrition" had significant lower BMI, ADL score (p < 0.01), tricipital skin fold and serum albumin (p < 0.05). Ultrasound parameters were low independently of the nutritional status. MNA score correlated significantly with tricipital skin fold (r = 0.508, p < 0.01), ADL (r = 0.538, p < 0.01) and albumin serum level (r = 0.409, p = 0.01). There was a trend for a correlation between the MNA and the ultrasound parameter BUA (r = 0.207, p = 0.07), whereas no correlation was found with SOS and SI. A multivariate analysis showed that tricipital skin fold and ADL explained 61% of the variance of the MNA. In conclusion, using simple and non invasive methods, this study showed that malnutrition and osteoporosis are frequent in institutionalized elderly persons in our country, and the ultrasound parameters are influenced by many others factors in addition to nutrition, especially at this age and in elderly residents of nursing homes.

Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF).

BACKGROUND: The Mini-Nutritional Assessment (MNA) is a validated assessment instrument for nutritional problems, but its length limits its usefulness for screening. We sought to develop a screening version of this instrument, the MNA-SF, that retains good diagnostic accuracy. METHODS: We reanalyzed data from France that were used to develop the original MNA and combined these with data collected in Spain and New MEXICO: Of the 881 subjects with complete MNA data, 151 were from France, 400 were from Spain, and 330 were from New MEXICO: Independent ratings of clinical nutritional status were available for 142 of the French subjects. Overall, 73.8% were community dwelling, and mean age was 76.4 years. Items were chosen for the MNA-SF on the basis of item correlation with the total MNA score and with clinical nutritional status, internal consistency, reliability, completeness, and ease of administration. RESULTS: After testing multiple versions, we identified an optimal six-item MNA-SF total score ranging from 0 to 14. The cut-point score for MNA-SF was calculated using clinical nutritional status as the gold standard (n = 142) and using the total MNA score (n = 881). The MNA-SF was strongly correlated with the total MNA score (r = .945). Using an MNA-SF score of > or = 11 as normal, sensitivity was 97.9%, specificity was 100%, and diagnostic accuracy was 98.7% for predicting undernutrition. CONCLUSIONS: The MNA-SF can identify persons with undernutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions.

Relationships between nutritional markers and the mini-nutritional assessment in 155 older persons.

OBJECTIVE: To investigate the relationships between nutritional status measured by a comprehensive nutritional assessment including anthropometric measurements, nutritional biological markers, evaluation of dietary intake, and the Mini-Nutritional Assessment (MNA) nutrition screening tool. DESIGN: A prospective study. PARTICIPANTS: One hundred fifty-five older subjects (53 men and 102 women; mean age = 78 years; range = 56-97 years). These participants were hospitalized in a geriatric evaluation unit (n = 105) or free living in the community (n = 50). MEASUREMENT: Weight, height, knee height, midarm and calf circumferences, triceps and subscapular skinfolds, albumin, transthyretin (prealbumin), transferrin, ceruloplasmin, C-reactive protein, alpha1-acid glycoprotein, cholesterol, vitamins A, D, E, B1, B2, B6, B12, folate, copper, zinc, a 3 day food record combined with a food-frequency questionnaire; the MNA nutritional screening. RESULTS: The MNA scores have been found to be significantly correlated to nutritional intake (P < .05 for energy, carbohydrates, fiber, calcium, vitamin D, iron, vitamin B6, and vitamin C), anthropometric and biological nutritional parameters (P < .001 for albumin, transthyretin, transferrin, cholesterol, retinol, alpha-tocopherol, 25-OH cholecalciferol zinc). An MNA score between 17 and 23.5 can identify those persons with mild malnutrition in which nutrition intervention may be effective. CONCLUSIONS: The MNA is a practical, noninvasive, and cost-effective instrument allowing for rapid nutritional evaluation and effective intervention in frail older persons.

Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial.

OBJECTIVES: To validate a nutritional intervention programme for elderly people living in nursing homes. DESIGN: In a prospective, randomized, controlled study of 88 residents, we determined nutritional status at day 0 and day 60 using a record of dietary intake, anthropometry, hand-grip strength and mini-nutritional assessment. Dietary intake, grip strength and body weight were also recorded at day 30. We divided subjects into four groups according to their mini-nutritional assessment score. Those with a score 24 received no oral supplementation. Those at risk of malnutrition (with a score of 17-23.5) were randomized to oral supplementation. Those with a score <17 received oral supplementation. We recorded the amount of oral supplements consumed daily. RESULTS: Compliance with oral supplementation was good, and daily intake averaged about 400 kcal. The total energy intake on day 60 was significantly higher in both of the groups that received supplements. Following supplementation, most subjects at risk of malnutrition improved their mini-nutritional assessment score and increased their weight (by 1.4 +/- 0.5 kg). Neither the mini-nutritional assessment score nor weight improved in subjects at risk of malnutrition who did not receive supplements. Supplementation in the malnourished group resulted in a mean mini-nutritional assessment score increase (from 13.9 +/- 2.6 to 17.1 +/- 3.9) and a mean weight gain of 1.5 +/- 0.4 kg. CONCLUSION: Oral nutritional supplements are well accepted and result in increased daily protein and energy intake, body weight and nutritional status in most malnourished patients and in those at risk of malnutrition.

The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients.

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals, and nursing homes. It has been translated into several languages and validated in many clinics around the world. The MNA test is composed of simple measurements and brief questions that can be completed in about 10 min. Discriminant analysis was used to compare the findings of the MNA with the nutritional status determined by physicians, using the standard extensive nutritional assessment including complete anthropometric, clinical biochemistry, and dietary parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate nutritional status, MNA > or = 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%, specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of mortality and hospital cost. Most important it is possible to identify people at risk for malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels occur. These individuals are more likely to have a decrease in caloric intake that can be easily corrected by nutritional intervention.

Anorexia of aging, leptin, and the Mini Nutritional Assessment.

In this chapter we have reviewed the evidence for physiological anorexia of aging and stressed that its pathophysiology involves both central and peripheral mechanisms. Early satiation in the older person appears to involve signals predominantly arising in the stomach. The increased feeling of satiety in older persons is mainly related to changes in the central feeding drive, in particular a decrease in the opioid rewarding properties for fatty foods. Increased cytokines, secondary to inflammatory conditions which are common in old age, may further increase the anorexia seen in older persons. Leptin, the fat hormone, is an excellent indicator of fat mass in women, in whom leptin concentrations correlate with the MNA. In men, testosterone inhibits leptin, and the fall in testosterone with age results in an increase in leptin concentrations. In males the MNA is not related to leptin concentrations. Finally, we have examined the interrelation of two nutritional screening indices, MNA and SCALES. The two indices were well correlated and were both predictive of poor basic function. We conclude that the MNA is an excellent predictor of nutritional status. These findings suggest that malnutrition is a major predictor of frailty or the "failure to thrive" syndrome in older persons. Depression is a major cause of poor nutritional status in older persons.