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34. MINI NUTRITIONAL ASSESSMENT:01. Interacción 24/09/12 9:51 Página 1619
Nutr Hosp. 2012;27(5):1619-1625
ISSN 0212-1611 • CODEN NUHOEQ
S.V.R. 318
Original
MNA®Mini Nutritional Assessment as a nutritional screening tool
for hospitalized older adults; rationales and feasibility
1 2 2 1 1 1
I. Calvo , J. Olivar , E. Martínez , A. Rico , J. Díaz and M. Gimena
1 2
Nutrition Unit. La Paz University Hospital. Madrid. Spain. Department of Endocrinology and Nutrition. Infanta Sofía
Hospital. Madrid. Spain.
Abstract USO DEL MINI NUTRITIONAL ASSESSMENT
The high prevalence of malnutrition in the growing COMO HERRAMIENTA DE CRIBAJE
population of older adults makes malnutrition screening NUTRICIONAL EN LA POBLACIÓN MAYOR DE 65
critical, especially in hospitalized elderly patients. AÑOS EN EL ÁMBITO HOSPITALARIO;
The aim of our study was to evaluate the use of the CONVENIENCIA Y FACTIBILIDAD
MNA®Mini Nutritional Assessment in hospitalized older Resumen
adults for rapid evaluation of nutritional risk.
A prospective cohort study was made of 106 patients 65 El envejecimiento de la población y la elevada preva-
years old or older admitted to an internal medicine ward lencia de desnutrición en este colectivo hacen que el cri-
of a tertiary-care teaching hospital to evaluate the use of baje de desnutrición sea fundamental, especialmente en
the short form, or screening phase, of the MNA-SF. In the ancianos ingresados.
first 48 hours of admission, the full MNA questionnaire Realizamos un estudio prospectivo sobre una pobla-
was administered and laboratory tests and a dermato- ción de 106 pacientes mayores de 65 años, ingresados en
logic evaluation were made. The MNA score showed that plantas de Medicina Interna de un hospital terciario, en el
77% of the patients were at risk of malnutrition or were que se ha seguido la aplicación sistemática de Minimal
frankly malnourished. Low blood levels of albumin, Nutritional Assessment (MNA) en las primeras 48 horas
cholesterol and vitamins A and D showed a statistically de ingreso, así como una evaluación hematológica y der-
significant association with malnutrition or risk of matológica. Hemos detectado situación nutricional de
malnutrition. Separate evaluation of the MNA-SF riesgo (RM) o malnutrición (MN) en el 77% de los casos.
showed that it was accurate, sensitive and had predictive Los marcadores biológicos que resultaron asociados esta-
value for the screening process. dísticamente a la MN o RM fueron la hipoalbuminemia,
Routine use of the MNA-SF questionnaire by admis- hipocolesterolemia, así como la hipovitaminosis A y D.
sion nurses to screen patients is recommended. Patients Proponemos el empleo rutinario de la fase de cribaje del
with MNA-SF scores of 11 or lower should be specifically MNA por la enfermera de hospitalización, y la valoración
assessed by the nutritional intervention team. específica por equipo especializado (Unidad de Nutrición)
(Nutr Hosp. 2012;27:1619-1625) en caso de puntuación igual o inferior a 11 .
DOI:10.3305/nh.2012.27.5.5888 (Nutr Hosp. 2012;27:1619-1625)
Key words: Elderly. Nutritional status. Malnutrition. DOI:10.3305/nh.2012.27.5.5888
® Palabras clave: Ancianos. Desnutrición. Mini Nutritional
MNA Mini Nutritional Assessment. The short form of the
MNA-SF. Mass screening. Assessment (MNA). Herramienta de cribaje.
Introduction of chronic disease and the number of hospital admis-
sions in conjunction with the changes in nutritional
Rising life expectancy and diminished mortality in status and body composition that occur during aging.
most developed countries is accompanied by popula- These factors increase the incidence of nutritional
tion aging. Consequently, there is a higher prevalence deficits in older adults. The development of nutritional
deficits is progressive, starting with inadequate
Correspondence: Isabel Calvo. nutrient intake during hospitalization1 and followed by
Hospital Universitario La Paz. signs of changes in biochemical parameters and body
Unidad de Nutrición. Hospital General. composition. Functional dependence and impaired
Paseo de la Castellana, 261. general health or quality of life correlate poorly with
28046 Madrid. Spain. the nutritional status of frail elderly.2 The large vari-
E-mail: icalvo.hulp@salud.madrid.org ability in the prevalence of malnutrition in hospitalized
Recibido: 23-II-2012. older adults is due to the characteristics of the hospital,
1.ª Revisión: 11-V-2012. the population served, the disease of the group studied
Aceptado: 21-V-2012.
1619
34. MINI NUTRITIONAL ASSESSMENT:01. Interacción 03/09/12 10:12 Página 1620
3,4
and the nutritional method used. No single parameter tions related to number of meals, food and fluid intake,
meets all the requirements of a good marker of nutri- and mode of feeding), and subjective assessment
tional status. A Dutch group studied body mass index (personal view of health and nutritional status). The
(BMI) compared to weight loss > 10% in 6 months as a sum of the MNA scores of both phases distinguishes
predictor of malnutrition, and found that only 21% of between elderly patients with adequate nutrition, MNA
5
patients with weight loss > 10% had BMI < 18.5. Most score ≥ 24; risk of malnutrition, MNA score 17.5-23.5;
14
authors agree that a comprehensive assessment of clin- and protein-calorie malnutrition, MNA < 17.
6,7
ical and laboratory markers is needed . In the first 24-48 hours of admission, a dermatologic
Hospital malnutrition, according to the series examination was made of the skin (hyperkeratosis,
studied and markers used, affects 10-80% of hospital- bleeding, edema, and pigmentation), hair (alopecia,
8
ized patients. The most accepted figures indicate that capillary fragility), nails (color and thickness), and
9
30 to 50% of hospitalized patients are malnourished. mucous membranes (hydration and color).
The prevalence of malnutrition in older adults depends Blood samples were obtained for the white blood
on where they live. Malnutrition affects more than 50% cell count and albumin, cholesterol, folic acid, phos-
10
of older adults who are institutionalized and 15% of phorus, magnesium, zinc and vitamins A, C, D, E and
11
those living at home. B12 measurements.
The World Health Organization declared in 1992 the All patients were asked to give their informed
elderly population as one of the most nutritionally vulner- consent to participate in the study. The study was
able groups, due to changes that take place in anatomic approved by the Institutional Review Board of the La
12
and physiologic characteristics during the aging process. Paz University Hospital.
Early detection of malnutrition in older adults is a priority
for optimizing healthcare and has a significant effect on
13
morbidity and mortality in this population. Statistical analysis
We designed a study to assess the prevalence of
malnutrition and its impact on blood chemistries and The data were analyzed using the SPSS 9 statistical
the skin of patients older than 65 years admitted to the program. Qualitative data were described as absolute
internal medicine department of a tertiary public frequencies and percentages and quantitative data as
hospital. Our main objective was to evaluate the use of the mean, median, and standard deviation depending
a simple nutritional screening tool in the nursing on the distribution of data.
assessment of patients on admission to ensure early Qualitative variables were compared using the chi-
detection of patients requiring specialized nutritional square test (Pearson’s test or Fisher’s test). Quantita-
intervention. tive variables were analyzed using the Student t test to
compare the distribution of two groups and the
ANOVA test to compare the distribution of three
Material and methods groups. The correlation between quantitative variables
was analyzed by calculating the Spearman correlation
A prospective, cross-sectional study was made of coefficient. All statistical tests were two-sided and
patients admitted to three different internal medicine significance was set at p < 0.05.
units of La Paz University Hospital (Madrid, Spain)
during two months (February and March). Patients
with chronic kidney failure, liver disease, or tumoral Results
disease were excluded as a group with higher nutri-
tional risk. One hundred and six patients were included in the
The data were collected in the first 24-48 hours of study in February and March of 2007: 58 men (54.7%)
admission of the patient. The same investigator (IC) and 48 women (45.3%), mean age 79.4 years, and body
did all the interviews to minimize interobserver bias. mass index (BMI) 27.1. In this group, 96 patients
®
The complete MNA Mini Nutritional Assessment (90.6%) lived at home (alone or with a family member
(Nestlé Nutrition Institute) (Annex 1), consisting of a or caregiver) and 10 (9.4%) in nursing homes.
screening phase (MNA-SF, or short form) and assess- According to the complete MNA score, 22% of
ment phase, was administered to all patients. The patients were malnourished, 55% were at risk of
screening phase (used as a short form to identify malnutrition, and 24% were adequately nourished.
2
patients at risk of malnutrition) consists of six items: a MNA score correlated negatively with age (r = -0218,
food intake item, two anthropometric parameters P = 0.025). Consequently, patient stratification by age
(recent weight loss and body mass index, or BMI), and group showed an inverse relationship between MNA
three general parameters (mobility, physical and score and age (table I). No association was found
emotional stress, and neuropsychological). The assess- between malnutrition and gender (74% of men and
ment phase had twelve items: anthropometric (calf and 79% of women were malnourished or at risk of malnu-
upper arm circumference), general (six questions on trition). MNA nutritional status categories showed a
lifestyle, medication and mobility), dietary (eight ques- significant association with the place of residence,
1620 Nutr Hosp. 2012;27(5):1619-1625 I. Calvo et al.
34. MINI NUTRITIONAL ASSESSMENT:01. Interacción 03/09/12 10:12 Página 1621
Annex 1
malnutrition being significantly higher among patients The comparison of the MNF-SF and the complete
living in nursing homes (table II). MNA scores, screening phase and assessment phase, is
2
BMI correlated linear with the MNA score (r = summarized in table IV. Using an MNA-SF score of 11
0.203, p = 0.037), but BMI £23 as a cutoff point identi- or lower as a cutoff value suggestive of malnutrition,
fied only 17 patients (16%) as malnourished or at risk the MNA-SF score had sensitivity, specificity, positive
of malnutrition (table III). predictive value, and negative predictive value for
MNA (short form) as a screening Nutr Hosp. 2012;27(5):1619-1625 1621
in the hospital
34. MINI NUTRITIONAL ASSESSMENT:01. Interacción 03/09/12 10:12 Página 1622
Table I
Nutritional status (MNA score) in relation to age in 106 hospitalized patients over 65 years old
Malnutrition Risk of malnutrition Absence of malnutrition
MNA < 17 MNA 17-23.5 MNA ≥ 24
≤ 74 years 2 (8.7%) 13 (65%) 8 (35%)
75-84 years 15 (23%) 33 (52%) 16 (25%)
> 84 years 6 (32%) 12 (63%) 1 (5%)
Chi-square,p < 0.012.
Table II
Nutritional status (MNA score) in relation to place of residence in 106 hospitalized patients over 65 years old
Malnutrition Risk of malnutrition Absence of malnutrition
MNA < 17 MNA 17-23.5 MNA ≥ 24
Resides at home 17 (18%) 54 (56%) 25 (26%)
Nursing home 6 (60%) 4 (40%) –
Chi-square,p < 0.002.
Table III
Nutritional status (MNA score) in relation to BMI in 106 hospitalized patients over 65 years old
Malnutrition Risk of malnutrition Absence of malnutrition
MNA < 17 MNA 17-23.5 MNA ≥ 24
BMI ≤ 20 2 (67%) 1 (33%) –
BMI 21-23 5 (29%) 9 (53%) 3 (18%)
BMI > 23 16 (22%) 48 (56%) 22 (27%)
BMI: Body Mass Index.
Chi-square,p < 0.052.
Table IV
MNA screening score versus MNA total assessment score
Malnutrition Risk of malnutrition Absence of malnutrition
MNA < 17 MNA 17-23.5 MNA ≥ 24
≤ 11 points 23 54 9
Possible malnutrition
≥ 12 points –416
Absence of malnutrition
Total 23 58 25
defining malnutrition risk or malnutrition of 95%, Discussion
64%, and 80%, respectively.
The biochemical and hematologic findings of our In our study of 106 patients older than 65 years
study population are given in table V. Low levels of admitted to an internal medicine department of a
albumin, serum cholesterol, and vitamin A and D showed tertiary hospital, 75% were malnourished or at risk of
a statistically significant association with malnutrition malnutrition according to the MNA score. This
status assessed by MNA score. Other analytical parame- presumably means that malnutrition has a significant
15
ters had a linear, nonsignificant relation. Zinc deficiency impact on morbidity and mortality, as well as costs,
was more frequent in patients with malnutrition or risk of not only in terms of economically quantifiable parame-
malnutrition that in patients with adequate nutritional ters but also in terms of the functionality of older
status (19 vs.4 patients, p < 0.018). adults.16 In view of the findings of this and earlier
We found no association between the dermatolog- studies,17 hospitalized older adult patients should
ical variables evaluated and MNA score in our study receive optimal nutritional care, which often is not the
population. case. Our findings suggest that nutritional screening in
1622 Nutr Hosp. 2012;27(5):1619-1625 I. Calvo et al.
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