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Clinical Interventions in Aging Dovepress
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Open Access Full Text Article ORIGINALRESEARCH
Predictive Value of Nutritional Risk Screening
2002 and Mini Nutritional Assessment Short
Form in Mortality in Chinese Hospitalized
Geriatric Patients
This article was published in the following Dove Press journal:
Clinical Interventions in Aging
Xiaoyan Zhang * Background and Aim: The presence of malnutrition in hospitalized geriatric patients is
Xingliang Zhang* associated with an increased risk of mortality. This study aimed to examine the performance
Yunxia Zhu of Nutritional Risk Screening 2002 (NRS2002) and Mini Nutritional Assessment Short Form
Jun Tao (MNA-SF) in predicting mortality for hospitalized geriatric patients in China.
Zhen Zhang Methods: A prospective analysis was performed in 536 hospitalized geriatric patients aged
Yue Zhang ≥65 years. Nutrition status was assessed using the MNA-SF and NRS2002 scales within
Yanyan Wang 24 hrs of admission. Anthropometric measures and biochemical parameters were carried out
YingYing Ke for each patient. Patients were follow-up for up to 2.5 years.
ChenXi Ren Results: At baseline, 161 (30.04%) patients had malnutrition/nutritional risk according to
NRS2002 assessment. According to MNA-SF, 284 (52.99%) patients had malnutrition/
Jun Xu nutritional risk. Malnutrition/nutritional risk patients had lower anthropometric and biochem-
Department of Geriatrics, Shanghai ical parameters (P<0.05). NRS2002 and MNA-SF had a strong correlation with classical
Jiaotong University Affiliated Sixth nutritional markers (P<0.05). NRS2002 versus MNA-SF showed moderate agreement
People’s Hospital, Shanghai 200233, (kappa=0.493, P<0.001). During a median follow-up time of 795 days (range 10–947
People’s Republic of China
days), 118 (22%) participants died. The Kaplan–Meier curve demonstrated that malnutri-
*These authors contributed equally to tion/nutritional risk patients according to NRS2002 or MNA-SF assessment had a higher risk
this work of mortality than the normal nutrition patients (χ2 2
=17.67, P<0.001; χ =28.999, P<0.001,
respectively). From the components of the Cox regression multivariate models, only the
NRS2002 score was an independent risk factor influencing the mortality.
Conclusion: Both NRS2002 and MNA-SF scores could predict mortality in Chinese
hospitalized geriatric patients. But only NRS2002 score was the independent predictor for
mortality.
Keywords: NRS2002, MNA-SF, elderly, nutritional screening, malnutrition
Introduction
The prevalence of malnutrition in hospitalized patients has been reported as
20–60% depending on the screening instruments used for assessment.1,2
Furthermore, the importance of nutrition in hospitalized geriatric patients has
been extensively documented. Malnutrition is more common in geriatric patients
due to aging, comorbidities, cognitive impairment, polypharmacy, and economical
3,4
Correspondence: Xiaoyan Zhang difficulty. The presence of malnutrition in geriatric hospitalized patients is asso-
Email zhangxy971088@hotmail.com ciated with increased risk of complications, prolonged hospital stays, readmission
submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2020:15 441–449 441
DovePress ©2020 Zhang et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
http://doi.org/10.2147/CIA.S244910 php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Zhang et al Dovepress
rate, increased mortality, and increased medical costs.5 and MNA-SFinthesamepopulation are very valuable and
Therefore, early diagnosis of malnutrition or nutritional informative, since they are not biased by differences
risk by evaluating the nutritional status of hospitalized between populations, setting, or age.7
geriatric patients is highly important. The purpose of this study was to evaluate the perfor-
Screeningformalnutritionistherecommendedfirststep mance of NRS2002 and MNA-SF, the main nutritional
in nutritional management.6 Nutritional risk screening screening tools used nowadays, especially in predicting
using validated tools is a simple technique to rapidly iden- mortality in hospitalized geriatric patients in China.
tify geriatric patients at nutritional risk, providing a basis for
promptandadequatenutritionalsupportreferrals,aswellas Methods
anindividualizednutritionalintervention.Therefore,appro- Study Design
priate tools must be applied when assessing the risk of Thestudywasaprospectivelongitudinalanalysis in patients
malnutrition in hospitalized geriatric patients. Within the hospitalized in the Department of Geriatrics at Shanghai
last several decades, 33 different nutritional risk screening Jiaotong University Affiliated Sixth People’sHospital.
tools have been invented to detect malnutrition patients in Atotal of 536 consecutive patients between April 2017 and
worldwide hospitals, home care institutions, and commu- April 2018 were recruited in this study. The study inclusion
nity settings.7
Althoughtherearemanywidelyusednutritionalscreen- criteria were being ≥65 years of age, not having received
ing tools, well-known examples are Mini Nutritional nutritional therapy at the time of assessment. The exclusion
Assessment (MNA) and Nutritional Risk Screening 2002 criteria were age <65 years, presence of ending carcinoma-
(NRS2002).TheMNAwasdevelopedtocertainsubgroups, tous cachexia (referent to the clinical history), inability to
especially for elderly individuals before changes in weight communicate. The study was approved by the Ethics
or albumin occur.8 Short-form of MNA (MNA-SF) was Committee of the Shanghai Jiaotong University Affiliated
designed later to provide a simple and more practical Sixth People’s Hospital (approval number, 2016-141-(1)).
screening tool given the original MNA was time- Written informed consent was obtained from all participants
consuming.9 Another reason for the development of MNA- and adhered to the tenets of the Declaration of Helsinki.
SF is the original MNA had low specificity, as well as Data Collection
subjects had difficulties in completing the full assessment
withoutthehelpofacaregiver.MNA-SFhasbeenvalidated Participants’ demographic information, lifestyle variables,
as a screening tool and shown as high sensitivity (97%) and and personal disease history were collected using ques-
specificity compared to the MNA full test. The MNA-SF tionnaires and confirmed through examination of medical
onlyincorporates 6 of the original 18 items that were on the records. The variables included age, sex, history of dia-
MNA and takes approximately 5 mins to perform. betes, hypertension, cerebral infarction, chronic obstruc-
NRS2002 was developed for hospitalized patients and tive pulmonary disease, coronary heart disease, dementia,
recommended by the European Society for Clinical and neoplasms.
Nutrition and Metabolism.10 NRS2002 was thought to be
effective allowing for quicker identification, especially in Anthropometric Measurements
case of acute illness; however, its initial design was not for Anthropometric parameters included height, weight, mid-
use in the elderly population. The use of an inappropriate armcircumference (MAC),waistcircumference (WC), and
screening tool negatively influences patients care and risks calf circumference (CC). Height and weight were measured
misdiagnosis or missed diagnosis of nutrition-related while the participants were barefoot and in light clothing
problems. using the height and weight scale to the nearest 0.1 cm and
There is a need for universal nutrition screening tools as 0.1kg,respectively.Bodymassindex(BMI)wascalculated
a“goldstandard”foruseinhospitalizedgeriatricpatients.11 as weight in kilograms divided by height in meters squared.
Since the different tools were used in different settings by MACwasmeasuredwithamillimeter tape at the midpoint
different studies, it is very hard to compare between studies of the arm, between the olecranon and acromion. WC was
andconcludewhichtoolisthe“adequatetool”toscreenthe measured at the middle point between the rib cage and iliac
nutritional status of hospitalized elderly patients. To assess crests. CC was measured with the elderly individual in
which tool performs the best, studies comparing NRS2002 standing position, at the greatest circumference of the
442 submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2020:15
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Dovepress Zhang et al
lower right leg, recorded in centimeters (cm), accurate to Handgrip Strength (HGS)
one decimal place. All measurements were performed in HGSwasmeasuredwith the subject in the seated position,
duplicate, and the means were calculated for analysis. knee and hip flexion at 90 degrees, and two feet naturally
Nutritional Risk Assessment placed on the ground; the shoulders remained adducted,
the upper arm is flat with the chest, the forearm is neutral,
NRS2002 was used to determine malnutrition and nutri- and the elbow is bent to 90 degrees. The maximum HGS
tional risk. Nutritional status was determined by three of the dominant hand (WCS-100 electronic vibrometer,
variables: recent weight loss, low food intake, and BMI China) was measured three times with 1 min of rest
during the week before admission. The diseases were between each repetition. HGS has defined the maximum
analyzed as an indicator of metabolic stress and increased value of three repetitions.
nutritional requirements. Both categories give 0 to 3
points. An adjustment factor was used in individuals Follow-Up for Adverse Outcomes
aged ≥70 years. The total NRS2002 score indicates
whether the patient is at nutritional risk or malnutrition All the participants were followed in the geriatric outpatient
(score ≥3) or normal nutritional status. clinic of Shanghai Jiaotong University Affiliated Sixth
MNA-SF contains six questions selected from MNA. People’s Hospital. The deadline for the follow-up was
These questions include BMI, recent weight loss, appetite October 30, 2019. All deaths occurring between study entry
or eating problems, mobility impairment, acute illness/ anddeadlinewereincluded.Duetotheparticipantsaccepting
psychological stress, and dementia or depression. Each healthcare at Shanghai Jiaotong University Affiliated Sixth
question is rated from 0 to 2 or 3 and the total score of People’s Hospital, there were no missing follow-ups.
MNA-SF is 14. Patients with 12–14 points are at the
normal nutritional status and patients with scores ≤11 are Statistical Analysis
at nutritional risk/malnutrition. A multidisciplinary nutri- For continuous variables, results were presented as mean ±
tion research team evaluated the nutritional status of each standarddeviationormedian(25thpercentileto75thpercen-
patient. All patients underwent nutritional status assess- tile), and the differences between groups were evaluated with
ment in the first 24 h of hospital stay. Moreover, the the Student’s t-test or Mann–Whitney U-test. Categorical
research team members were not aware of the laboratory variables were presented as frequency percentage, and inter-
test results at the time of assessment. group comparisons were analyzed using the chi-square test.
Theassociation between NRS2002 and MNA-SFscores and
Laboratory Measurements other nutritional parameters were evaluated with Pearson or
Fasting blood samples were collected from each patient. Spearman correlation analysis. The agreement between the
Hemoglobin (Hb) level was measured using a standard two screening tools was compared using the kappa coeffi-
cyanmethemoglobin method. Total lymphocyte count cient. The results were interpreted as follows: <0, no agree-
(TLC) was assayed automatically by a blood cell analyzer ment; ≤0.20, poor agreement; 0.20–0.40, weak agreement;
(Beckman Coulter LH750). Serum iron (Iron) levels were 0.40–0.60moderateagreement;0.61–0.80,substantialagree-
measured by performing a colorimetric endpoint assay ment; and 0.81 to 1.00, almost perfect agreement. Kaplan–
with commercial kits from Roche China (Shanghai, Meier analysis with the Log rank test was used to compare
China). Serum albumin (ALB), prealbumin (PAB), the difference between the normal and malnutrition/nutri-
Retinol-binding protein (RBP), and creatinine (Cr) levels tional risk groups according to the NRS2002 and MNA-SF.
were assessed using turbidimetric immunoassay (Hitachi, The results of the mortality were illustrated by survival
Tokyo, Japan). Serum transferrin was detected by nephe- curves. All variables with a P<0.05 in the univariate analysis
lometry on Behring BNⅡ automatic specific protein deter- were included in the multivariate Cox regression analyses.
mination system and its supporting reagents (Siemens, MultivariableCoxregressionmodelswithhazardratios(HR)
Erlangen, Germany). Serum folic acid and vitamin B12 and 95% CI were conducted to examine the association of
levels were measured using a chemiluminescent immu- NRS2002 and MNA-SF with mortality. All statistical ana-
noassay. Serum C-reactive protein (CRP) was measured lyses were performed using SPSS 21.0 (SPSS Inc., Chicago,
by particle-enhanced immunonephelometric assay (Dade IL). A two-sided P-value <0.05 was considered statistically
Behring Inc., Newark, NJ, USA). significant.
Clinical Interventions in Aging 2020:15 submit your manuscript | www.dovepress.com 443
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Zhang et al Dovepress
Hb, RBP, Iron, transferrin, but higher age and CRP levels
Results
Baseline Characteristics of the Patients when compared to normal nutritional status (P<0.05).
with and Without Malnutrition/ There was no significant difference between malnutrition/
Nutritional Risk nutritional risk and normal groups in TLC, Cr, folic acid,
and vitamin B12 (P>0.05). Distribution of the basic char-
A total of 536 individuals met the eligibility criteria and acteristics at baseline between normal and malnutrition/
completed a nutrition assessment within 24 h of admission. nutritional risk according to NRS2002 and MNA-SF were
The average age was 86.84±4.23 years, including 406 men summarized in Table 1.
and 130 women. The most frequent cause of hospitalization
was cardiac disease (n=168), followed by cerebrovascular Variables Associated with the NRS2002
disease (n=96), hypertension (n=91), pulmonary infection and MNA-SF Scores
(n=90), diabetes (n=53), dementia (n=20), and cancer Table 2 shows the Pearson or Spearman correlation
(n=18). Due to the comorbidity of geriatric patients, all the coefficients of NRS2002 and MNA-SF scores with
patients had several diseases when admission. We only serum nutrition-related biomarkers and anthropometric
ranked according to the first diagnosis. parameters. Anthropometric parameters (MAC, WC,
At baseline, 284 (52.99%) patients were malnutrition/ CC) and serum nutrition-related biomarkers (ALB,
malnutritional risk and 252 (47.01%) patients were well- PAB, Hb, RBP, Cr, Transferrin, TLC) correlated posi-
nutritional according to MNA-SF assessment. According tively with malnutrition scores of MNA-SF and corre-
to NRS2002 assessment, 161 (30.04%) patients were mal- lated inversely with the scores of NRS2002 (P<0.05). It
nutrition/nutritional risk and 375 (69.96%) patients were was found a significant negative correlation of MNA-SF
normal nutritional status. Patients who were classified as scores with age and CRP (P<0.05). While NRS2002
malnutrition/nutritional risk using either NRS2002 or scores with age and CRP have a positive correlation
MNA-SF had lower BMI, MAC, CC, HGS, ALB, PAB, (P<0.05).
Table 1 Comparison of Basic Baseline Anthropometric and Biochemical Characteristics of Subjects According to NRS2002 and MNA-
SF Assessment
Variables NRS P MNA-SF P
Malnutrition/Nutritional Risk Normal Malnutrition/ Normal
Nutritional Risk
Case(%) 161(30.04) 375(69.96) / 284(52.99) 252(47.01) /
Age(year) 87.64±4.33 86.49±4.15 0.004 87.81±4.33 85.75±3.85 <0.001
Sex(M/F) 117/44 289/86 0.164 205/79 201/51 0.167
2
BMI(kg/m ) 22.64±3.53 24.08±3.69 0.002 22.48±3.98 24.72±3.17 <0.001
MAC(cm) 22.79±3.27 26.62±6.57 0.011 23.90±7.23 27.17±7.15 0.010
WC(cm) 84.80±11.95 88.77±18.37 0.111 86.44±14.87 88.98±18.75 0.228
CC(cm) 28.52±4.41 31.18±4.14 <0.001 28.92±4.56 31.84±3.72 <0.001
HGS(kg) 17.12±6.36 20.41±17.66 0.006 17.47±7.28 21.23±7.11 <0.001
TLC(cells/m3) 1.20(0.90–1.70) 1.40(1.10–1.80) 0.393 1.30(1.00–1.70) 1.40(1.10–1.80) 0.195
ALB (g/dl) 37.27±5.04 39.61±4.04 <0.001 37.48±4.69 40.55±3.61 <0.001
PAB(mg/L) 189.77±64.63 205.34±49.51 0.008 191.79±56.96 210.73±50.85 <0.001
Hb (g/dL) 110.31±19.96 120.76±17.66 <0.001 112.81±19.72 123.12±16.49 <0.001
RBP(mg/L) 40.46±9.86 43.31±8.62 0.002 41.20±9.34 43.86±8.63 0.001
Cr (μmol/L) 75.50(60.75–96.25) 84.00(69.00–100.00) 0.474 79.00(61.25–99.75) 84.00(70.00–99.00) 0.323
Iron(μmol/L) 8.43±4.77 13.51±5.58 <0.001 10.07±4.76 14.72±5.63 <0.001
Transferrin(μmol/L) 1.62±0.59 2.02±0.36 0.008 1.79±0.50 2.07±0.32 0.016
Folic acid(μg/L) 7.57(5.06–13.44) 7.79(5.16–12.24) 0.742 7.09(4.76–11.28) 8.51(5.60–12.69) 0.110
Vitamin B12(ng/L) 737.00(435.43–1092.50) 656.15(483.38–944.03) 0.370 649.00(438.00–970.60) 662.90(485.85–919.30) 0.990
CRP (mg/L) 9.77(4.54–16.03) 3.63(1.01–6.25) 0.007 9.00(3.42–17.16) 2.08(0.67–7.26) <0.001
Abbreviations:BMI, bodymassindex;MAC,mid-armcircumference;WC,waistcircumference; CC,calf circumference;HGS,handgripstrength; TCL, totallymphocyte count;
ALB, albumin; PAB, prealbumin; Hb, hemoglobin; RBP, retinol-binding protein; Cr, creatine; CRP, C reactive protein.
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