Assessing the older person - MNA® Elderly
Assessing the older person - MNA® Elderly
Assessing the older person - MNA® Elderly
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The Journal of Nutrition, Health & Aging©Volume 7, Number 1, 2003THE JOURNAL OF NUTRITION, HEALTH & AGING©ASSESSING THE OLDER PERSON: IS THE MNA A MORE APPROPRIATENUTRITIONAL ASSESSMENT TOOL THAN THE SGA?L. BARONE, M. MILOSAVLJEVIC, B. GAZIBARICHCorrespondence: Lilliana Barone BSc Master Nut Diet (Sydney University) Clinical Dietitian, Wollongong Hospital Nutrition Department, P.O Box 178, Wollongong, New SouthWales, Australia 2500. e-mail address : baronel@iahs.nsw.gov.auAbstract: OBJECTIVES: A study was undertaken to determine which nutritional assessment tool would bebetter in assessing changes in nutritional status over time in hospitalised <strong>older</strong> patients. The two tools used were<strong>the</strong> Mini Nutritional Assessment (MNA) and <strong>the</strong> Subjective Global Assessment (SGA). DESIGN: Single blind,prospective study conducted over a 60-day period. SETTING: Five regional hospitals within Sou<strong>the</strong>rn NewSouth Wales, Australia. SUBJECTS: There were 43 patients at <strong>the</strong> commencement of <strong>the</strong> study, <strong>the</strong>n 28 patientsat day 30 and 20 patients at day 60. METHODS: All patients over 65 years of age admitted to <strong>the</strong> five hospitalsduring May 2001 were eligible. The only exclusions were those patients admitted to palliative care or with severedementia. Two dietitians saw each patient. Each dietitian assessed <strong>the</strong> patient using his or her assigned nutritionalassessment tool ei<strong>the</strong>r <strong>the</strong> SGA or <strong>the</strong> MNA. All dietitians were randomly assigned <strong>the</strong> tool at <strong>the</strong>commencement of <strong>the</strong> study. They were familiarised with <strong>the</strong> use of <strong>the</strong> tool by participating in a workshop priorto <strong>the</strong> start of <strong>the</strong> study. RESULT: The MNA was able to detect greater numbers of malnourished subjects whencompared to <strong>the</strong> SGA. This finding was consistent across Day 0, 30 and 60 and statistically significant (p
The Journal of Nutrition, Health & Aging©Volume 7, Number 1, 2003ASSESSING THE OLDER PERSONnutritional status of individuals aged 65 years and over?2. Is <strong>the</strong>re a difference in <strong>the</strong> detection of malnutrition atDay 30 and Day 60 after admission, between <strong>the</strong> SGA andMNA?MethodsSubjectsThe study included patients 65 years of age and overadmitted to five hospitals within <strong>the</strong> IAHS. All new admissionsto <strong>the</strong>se sites over a one-month period (between May and June2001) were eligible for <strong>the</strong> study; with <strong>the</strong> exception ofpalliative care patients and patients with severe dementia.DesignThis was a prospective single blind study conducted over a60-day period. A paired sample was used. Two observations(<strong>the</strong> SGA and MNA) were done on each participant at baseline(Day 0), Day 30 and Day 60 after admission. Those patientsthat were discharged during this period were followed up athome or place of residence. Results and o<strong>the</strong>r relevant datasuch as social status, and admitting diagnosis (if available)were recorded on a simple patient data form by each observerfor every subject.Tools for AssessmentThe SGA is a subjective global assessment tool designed forhospitalised patients (11,12) and <strong>the</strong> MNA is specificallydeveloped for <strong>the</strong> assessment of <strong>the</strong> nutritional status of <strong>the</strong><strong>older</strong> <strong>person</strong> (16,17).Modification of <strong>the</strong> MNA toolThe MNA was developed in France with collaboration from<strong>the</strong> Clinical Nutrition Program, University of New MexicoUSA and <strong>the</strong> Nestle Research Centre, Lausanne Switzerland(18). After consultation with <strong>the</strong> author (19), <strong>the</strong> MNA tool wasmodified as follows to make it more culturally specific to <strong>the</strong><strong>older</strong> Australian population.i) Question F Body Mass Index (BMI) (weight inkg)/(height in m) 2Score BMI Original MNA BMI Modified MNA0 Less than 19 Less than 221 19 to less than 21 22 to less than 24.52 21 to less than 23 24.5 to less than 273 23 or greater 27 or greaterThe French anthropometric standards are lower than thoseused for <strong>the</strong> USA and Australia, <strong>the</strong>refore <strong>the</strong> BMI range wasmodified to reflect <strong>the</strong> ranges recommended by <strong>the</strong> DietaryGuidelines for Older Australians. For healthy <strong>older</strong> adults mostassessment standards suggest a range of 22 - 27 (20), <strong>the</strong>reforeQuestion F in <strong>the</strong> screening component was adjusted asillustrated above.ii) Question K Selected consumption markers forprotein intakeThe original MNA had two or more servings of legumes oreggs per week. After consultation with <strong>the</strong> author, this wasmodified to one - two servings per week to better match <strong>the</strong>Australian dietary practices. Legumes are traditionallyconsumed in greater quantities in Mediterranean diets. Onaverage 18g legumes are consumed per day in Mediterraneandiets compared with 6g per day in <strong>the</strong> Australia (21,22).iii) Question Q Mid-arm circumference (MAC) in cmScore MAC Original MNA MAC Modified MNA0.0 MAC less than 21 MAC less than 26.6(male)25.1(female)0.5 MAC 21 to 22 MAC 26.6 to 30.4 (male)25.1 to 29.7 (female)1.0 MAC 22 or greater MAC 30.4 or greater(male)39.7 or greater (female)Adjustments to MAC measurements were made based on <strong>the</strong>American percentile norms for measurements of MAC in <strong>older</strong>white subjects (23), which also included gender differences.ProcedureFor <strong>the</strong> purpose of <strong>the</strong> study, participating hospitals weregrouped into three sites. A total of six dietitian’s (two fromeach site) acted as investigators. The investigators worked inpairs, each being randomly assigned a nutrition assessment tool– ei<strong>the</strong>r <strong>the</strong> SGA or MNA.All investigators had been trained in <strong>the</strong> use of <strong>the</strong> SGA andwere currently using this tool in <strong>the</strong>ir normal clinical practice.To minimise user bias and familiarise <strong>the</strong>mselves with <strong>the</strong>MNA tool, all dietitians involved in <strong>the</strong> study used <strong>the</strong> MNAover a trial period of one week prior to <strong>the</strong> commencement of<strong>the</strong> study. To maximise inter-rater reliability a workshop wasconducted prior to this trial where <strong>the</strong> dietitians were trained in<strong>the</strong> use of <strong>the</strong> MNA.ImplementationThe SGA and MNA were each conducted on all new (andappropriate) admissions, over a 30-day period. The firstassessment on admission was Day 0 (baseline). The sameinvestigators used <strong>the</strong> same assessment tool to reassess eachsubject at Day 30 and again at Day 60. “Patient data forms”were completed for each subject at Day 0, 30 and 60, andforwarded on to ano<strong>the</strong>r dietitian, independent of <strong>the</strong> study forcollation. If a subject was identified as nutritionallycompromised <strong>the</strong> site dietitian provided nutrition carethroughout <strong>the</strong>ir admission as per standard dietetic practicewithin <strong>the</strong> Nutrition Department. Follow-up of <strong>the</strong> subjects atDay 30 and 60 were arranged closer to <strong>the</strong> time due. Wheresubjects were willing, an outpatient clinic appointment wasmade, however, <strong>the</strong> majority of follow-ups were home visits.14
The Journal of Nutrition, Health & Aging©Volume 7, Number 1, 2003THE JOURNAL OF NUTRITION, HEALTH & AGING©ResultsOverall 43 subjects were assessed at baseline using eachtool. Table 1 describes <strong>the</strong> subjects’ characteristics at <strong>the</strong> threetime points. There was no statistical difference in <strong>the</strong> variablesat each of <strong>the</strong> three time points measured.Figure 2Nutritional status as determined by <strong>the</strong> SGAand MNA at Day 30Table 1Demographic characteristics of subjectsVariables Measured Baseline Day 30 Day 60Number of Subjects 43 28 20Age (years) mean 78.6 78.2 80(range) (68-94) (68-92) (70-92)Sex % female 60 50 55% male 40 50 45BMI (kg/m2) mean 24.5 23.8 24.2Female 24.8 23.9 24.4Male 24.0 23.7 24.0Social Status % alone 35 50 50% partner/carer 60 50 50% hostel 5 0 0% nursing home 0 0 0Figure 3Nutritional status as determined by <strong>the</strong> SGAand MNA at Day 60Reasons for <strong>the</strong> dropout included subjects withdrawal from<strong>the</strong> study, subjects uncontactable for follow up, subjects onholiday over <strong>the</strong> follow up period, difficulty with time/resourceconstraints for dietitians to follow up some subjects whorequired home visits.Graphs (Figure 1,2 and 3) illustrate <strong>the</strong> nutritional status asdetected by <strong>the</strong> SGA and MNA over <strong>the</strong> 60-day time period.There was not a significant difference between <strong>the</strong> numbersidentified as undernourished (i.e. at risk and malnourished)with each tool. The significance however, lies in <strong>the</strong> degree ofmalnutrition detected, with <strong>the</strong> MNA identifying a greaterproportion of malnourished subjects consistently across <strong>the</strong>time intervals, compared to <strong>the</strong> SGA.Figure 1Nutritional status as determined by <strong>the</strong> SGAand MNA at Day 0DiscussionThe literature cites rates of malnutrition amongsthospitalized <strong>older</strong> <strong>person</strong>s as ranging from 20 to 60% (16,24).Similar to <strong>the</strong> rates identified in this study. The rates ofmalnutrition and those at risk of malnutrition identified in thisstudy using <strong>the</strong> modified MNA reflect similar rates to thosefound in o<strong>the</strong>r MNA studies (25).The major finding from this study is that <strong>the</strong> modified MNAdetected greater numbers of malnourished subjects whencompared to <strong>the</strong> SGA. This finding was consistent across <strong>the</strong>three time intervals measured and was statistically significant(see table 2).15
The Journal of Nutrition, Health & Aging©Volume 7, Number 1, 2003ASSESSING THE OLDER PERSONTable 2Percentage of Subjects Detected as Malnourished using <strong>the</strong>SGA and MNA assessment toolsAssessment Tool/Time period SGA MNA *P value(category c) (less than 17)Day 0 ( n=43) 5 21 0.005Day 30 ( n=28) 4 18 0.005Day 60 ( n=20) 0 20 0.05* Analysed using <strong>the</strong> Wilcoxon-Sign Ranked Test.This finding supports <strong>the</strong> claim by o<strong>the</strong>r authors that <strong>the</strong>SGA cannot be used to monitor changes in nutritional statusbecause of its subjectivity and non-quantitative data analysis(17), whereas <strong>the</strong> quantitative nature of <strong>the</strong> MNA allows foreasier monitoring of nutritional changes over time. O<strong>the</strong>rstudies using <strong>the</strong> SGA for nutritional assessment of <strong>the</strong> <strong>older</strong><strong>person</strong> have found discrepancies in <strong>the</strong> detection ofmalnutrition (14). This may be explained in part by <strong>the</strong> lowerinter-rater agreement found with <strong>the</strong> SGA when used with <strong>older</strong>patients (13,14). The MNA however, has been found to havegood inter-rater reproducibility (15).One of <strong>the</strong> advantages of <strong>the</strong> MNA for dietitians is that itdoes not rely on additional measurements that may be difficultfor dietitians to access- such as blood tests. It is a tool that issensitive enough to detect <strong>the</strong> small changes in nutritionalstatus that may occur over time with nutritional support.Fur<strong>the</strong>r work is needed to determine <strong>the</strong> extent to which <strong>the</strong>MNA can be used as a detector of nutritional change over time.Questions such as, “At what time interval should a patient havea repeat nutritional assessment performed to most accuratelydetect altered nutritional status?” need to be investigated.Vellas (17) suggests that monthly weight measurements and arepeat MNA at 3 months is an important follow up fornutritionally compromised <strong>older</strong> patients. A nutritionintervention study conducted in Nursing Homes in France (25)demonstrated changes in MNA score at day 60 following oralsupplementation.It is also interesting to note that <strong>the</strong> average BMI of thisstudy population was 24.5 (within <strong>the</strong> normal standard range of22-27). The MNA (at a score between 17 and 23.5) hasdemonstrated an ability to assess declining i.e. “at risk”nutritional status before severe changes in weight (or albuminlevels) occurs (15).Future Directions for Clinical PracticeThe ability of <strong>the</strong> modified MNA to more accurately identifymalnourished <strong>older</strong> patients compared to <strong>the</strong> SGA asdemonstrated by <strong>the</strong>se study findings has importantimplications for dietetic practice and care of this group.Nutrition intervention is said to be easier and more effectivewhen implemented in those identified as at risk of malnutritionthan in those who are severely malnourished (26). Fur<strong>the</strong>rinvestigation is warranted to determine if changes in currentdietetic practices, such as more aggressive intervention innutritional support, are necessary.The screening component (MNA-SF) (27) could be easilyadministered by nursing/medical staff on admission to hospital,with those identified as at risk of malnutrition (MNA screeningscore 11 points or below) being referred to <strong>the</strong> dietitian forfur<strong>the</strong>r assessment and appropriate nutrition intervention. Thiswould increase staff awareness of <strong>the</strong> prevalence ofmalnutrition amongst <strong>older</strong> patients and would also allowdietitians to spend more of <strong>the</strong>ir clinical time in nutritionassessment, intervention and follow up of <strong>the</strong>se patients.ConclusionIn this study, <strong>the</strong> modified MNA has proved to be a moreappropriate nutrition assessment tool than <strong>the</strong> SGA inhospitalised <strong>older</strong> patients. It is better able to identifymalnourished patients. This could potentially impact on dieteticpractice, as more aggressive nutritive <strong>the</strong>rapy may be necessaryto improve nutritional outcomes within this patient group.Acknowledgments: We would like to thank <strong>the</strong> following dietitians for <strong>the</strong>ir invaluableassistance in <strong>the</strong> reviewing of <strong>the</strong> manuscript and <strong>the</strong>ir involvement in <strong>the</strong> data collection.Without <strong>the</strong>ir assistance and cooperation this work could not have been done. Kate Burge,Jodie Crouch, Jennifer Haughton, Jacqueline Hampton, Kelly Lambert, Craig Patch andJane Wishart.References1. Edington, J., Kon P., Martyn,C.N.,Prevalence of malnutrition in patients in generalpractice, Clin. Nutr., 1996;15:60-63.2. SENECA, Investigators. Longitudinal changes in iron and protein status of <strong>older</strong><strong>person</strong> Europeans, Eur. J. Clin. Nutr. 1996;50(suppl:2):S16-S24.3. Cederholm, T., et al., Nutritional status and performance capacity in internal medicalpatients. Clin. Nutr., 1993,12:8-14.4. Morley, J.E., Silver, A.J., Nutritional issues in nursing home care, Ann. Intern.Med.,1995;123:850-859.5. Mowe,M., Bohmer, T., Kindt, E., Reduced nutritional status in an <strong>older</strong> <strong>person</strong>population (>70 y) is probable before disease and possibly contributes to <strong>the</strong>development of disease,Am. J. Clin. Nutr., 1993;58:317-324.6. Kaye,G,L.,In: Outcomes management. Linking research to practice. Joint publicationof ADA and Ross Products division of Abbott Laboratories 1996.7. Reilly, J.J., et al., Economic impact of malnutrition: a model system for hospitalisedpatients, J. Parenter. Enteral. Nutr.,1988;12:371-3768. Beck, A.M., Ovesen,L.,Osler,M., The ‘Mini Nutritional Assessment’ (MNA) and <strong>the</strong>‘Determine Your Nutritional Health’ Checklist (NSI Checklist) as predictors ofmorbidity and mortality in an <strong>older</strong> <strong>person</strong> Danish population, British Journal ofNutrition.., 1999;81:31-36.9. Beck, E.,etal.,Implementation of malnutrition screening and assessment by dietitians:malnutrition exists in acute and rehabilitation settings, Australian Journal Nutritionand Dietetics., 2001;58(2):92-97.10. Ferguson, M., Bauer, J., Banks, M., Capra, S.,Malnutrition screening and assessmentresource manual. Brisbane: FBBC Nutrition Research Group; 1996.11. Detsky,A.S., et al., Evaluating <strong>the</strong> accuracy of nutritional assessment techniquesapplied to hospitalized patients: methodology and comparisons, Journal of Parenteraland Enteral Nutrition .,1984;8(2):153-9.12. Detsky, A.S., et al., What is Subjective Global Assessment of Nutritional Status?Journal of Parenteral and Enteral Nutrition.,1987;11(1):8-13.13. Deurksen, D.R., et al., The Validity and reproducibility of clinical assessment ofnutritional status in <strong>the</strong> <strong>older</strong> <strong>person</strong>, Nutrition.,2000;16:740-744.14. Ek, A., et al., Interrater variability in subjective global assessment of <strong>older</strong> <strong>person</strong>patients, Scand. J. Caring. Sci., 1996;10:163-168.15. Vellas, B., et al., The Mini Nutritional Assessment (MNA) and its use in grading <strong>the</strong>nutritional status of <strong>older</strong> <strong>person</strong> patients.,Nutrition, 1999;15(2):116-122.16
The Journal of Nutrition, Health & Aging©Volume 7, Number 1, 2003THE JOURNAL OF NUTRITION, HEALTH & AGING©16. Guigoz, Y., Vellas, B., Garry, P., <strong>Assessing</strong> <strong>the</strong> nutritional status of <strong>the</strong> <strong>older</strong> <strong>person</strong>:The Mini Nutritional Assessment as part of <strong>the</strong> geriatric evaluation, NutritionReviews., 1996;54(1):S59-S65.17. Vellas, B., et al., Nutrition Assessment in <strong>the</strong> <strong>older</strong> <strong>person</strong>, Curr. Opin. Clin. Nutr.Metab. Care., 2001;4:5-8.18. Guigoz, Y.,and Vellas, B., The Mini Nutritional Assessment (MNA) for grading <strong>the</strong>nutritional state of <strong>older</strong> <strong>person</strong> patients: Presentation of <strong>the</strong> MNA, history andvalidation. In Mini Nutritional Assessment (MNA): Research and Practice in <strong>the</strong><strong>older</strong> <strong>person</strong>. Nestle Nutrition Workshop Series Clinical & Performance ProgrammeNo. 1 1998. Nestle Nutrition Services:1-2.19. Guigoz., Y., Personal communication. 6 February 2001.20. Bartlett, S., Marian, M., Taren, D., and Muramoto, M., Geriatric Nutrition Handbook1998. Chapman & Hall Nutrition Handbooks 5. International Thomson Publishing.21. Renaud, S.,In. Le Regime Sante 1995. Editions Odile Jacob. Pg 1922. Apparent Consumption of Food stuffs in Australia, 1996-97. (Australian Bureau ofStatistics Catalogue No 4306.0).23. Mitchell, C., and Chernoff, R., Nutritional assessment of <strong>the</strong> <strong>older</strong> <strong>person</strong> in GeriatricNutrition: The Health Professionals Handbook 1991. ASPEN publishers Maryland:chpt 14.24. Saletti, A., etal., Nutritional status according to Mini Nutritional Assessment in aninstitutionalized <strong>older</strong> <strong>person</strong> population in Sweden, Gerontology., 2000;46:139-145.25. Lauque, S., et al..,Protein-energy oral supplementation in malnourished nursinghomeresidents. A controlled trial, Age and Ageing .,2000;29:51-5626. Vellas, B., et al.,Relationships between nutritional markers and <strong>the</strong> Mini NutritionalAssessment in 155 <strong>older</strong> <strong>person</strong>s, Journal American Geriatric Society.,2000;48:1300-1309.27. Rubenstein, L.Z., et al., Screening for undernutrition in geriatric practice.Developing <strong>the</strong> short-form mini-nutritional assessment (MNA-SF),The Journals ofGerontology., 2001;56A(6):M366-72.17