REVIEW
CURRENTOPINION Mini Nutritional Assessment
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1363-1950 � 2011 Wolters Kluwer
Purpose of review To summarize recent evidences and advances on the implementation and the use of the Mini Nutritional Assessment (MNA).
Recent findings Despite being introduced and validated for clinical use about 20 years ago, the MNA has recently received new attention in order to more widely disseminate among healthcare professionals the practice of a systematic nutritional screening and assessment of the old patient. Particularly, the structure has been implemented to face the difficulties in having the patients contributing to the assessment and to reduce further the time required to complete the evaluation. Recent data also confirm that in older populations prevalence of malnutrition by this tool is associated with the level of dependence. The rationale of nutritional assessment is to identify patients candidate to nutritional support. However, the sensitivity of the MNA is still debated because it has been associated with a high-risk ‘overdiagnosis’ and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.
Summary The MNA is a simple and highly sensitive tool for nutritional screening and assessment. The large mass of data collected and the diffusion among healthcare professionals clearly support its use. However, the cost- effectiveness of interventions based on its scoring deserves investigation.
Keywords elderly, malnutrition, Mini Nutritional Assessement, Mini Nutritional Assessment Short Form, nutritional screening tools, risk of malnutrition
INTRODUCTION
The Mini Nutritional Assessment (MNA) is the most widespread tool for nutritional screening and assess- ment due to the ease of use and the feasibility in any clinical care setting. Despite being introduced and validated for clinical use about 20 years ago, this tool has recently received new attention and has been the object of reappraisals in order to disseminate more widely the practice of a systematic nutritional screening of the old patient. In this scenario, the aim of this review is to summarize recent evidences and advances on the implementation and the use of this instrument.
Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
Correspondence to Emanuele Cereda, MD, PhD, Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy. Tel: +39 0382 501615; fax: +39 0382 502801; e-mail: e.cereda@smatteo.pv.it
Curr Opin Clin Nutr Metab Care 2012, 15:29–41
DOI:10.1097/MCO.0b013e32834d7647
THE NEED TO SCREEN THE ELDERLY PATIENT
Looking at the demographic time trends, the ratio of people aged over 65 years is considerably growing, rising up in the past decade from 18 to 20% of total population (from 2 to 3% for those >85 years old) with a mean lifetime increase of 2 years in both sexes [1].
illiams & Wilkins. Unau
Health | Lippincott Williams & Wilk
Nutritional disorders are of specific relevance for the elderly. Aging is intrinsically associated with a progressive reduction in muscle mass and more widely with a loss of metabolically active com- ponents of the body which in turn result not only in loss of functionality but also in worse outcome [2
&
,3 &
,4 &&
]. This increased vulnerability to stressors has led experts in to seek for a clinical definition of ‘frailty syndrome’, a condition that is believed to be a continuum situated between normal aging and end-stage disability. In regard to this, no consensus was achieved but an agreement to consider frailty a predisability stage was found [5,6]. The MNA has been proposed as a useful
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mailto:e.cereda@smatteo.pv.it
C
KEY POINTS
� ‘As easy as MNA’ is now considered the business card of the MNA.
� Despite being introduced and validated for clinical use about 20 years ago, time-course improvements in its structure have allowed implementing and disseminating the practice of a systematic nutritional screening of the old patient.
� The MNA is a sensitive tool for nutritional screening and assessement but the risk of ‘overdiagnosing’ nutritional derangements has been the object of debate and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.
Ageing: biology and nutrition
alternative tool to identify frail patients [5] and, interestingly, previous research has shown that in institutionalized patients at risk of malnutrition most of the association between nutritional and functional status (by MNA and Barthel index, respectively) is explained by some of the key features of frailty such as weight loss and sarcopenia [7].
The proneness of aging people to nutritional derangements is likely to be multifactorial and a list of causative factors has been elegantly resumed in the ‘9 Ds’ and the practical acronym ‘MEALS ON WHEELS’ (Table 1) [8,9].
Indeed, the work of international societies and ad-hoc study groups is a timely and rationalized effort to improve the patient’s outcome. Diseases have changed from acute to chronic ones. Similarly, medicine has turned to a preventive approach from a curative one. Accordingly, increased knowledge and awareness, as well as improved practice should
opyright © Lippincott Williams & Wilkins. Unautho
Table 1. Summary of factors potentially involved in nutriti
The ‘9 Ds’ [8] The acron
Dementia Medicatio
Depression Emotional
Disease (acute and chronic) Anorexia
Dysphagia Late life p
Dysgeusia Swallowin
Diarrhoea Oral facto
Drugs No money
Dentition Wanderin
Dysfunction (functional disability) Hyperthyr
Enteric pro
Eating pro
Low salt, l
Stones, so
30 www.co-clinicalnutrition.com
theoretically result in early diagnosis of risk con- ditions that, being more likely to be reversible, allow planning of effective interventions.
THE STRUCTURE AND ITS IMPLEMENTATION OVER TIME
It is highly recommended that a screening tool fits best to the population object of evaluation [10]. Due to the potentially multifactorial origin of nutritional risk in the elderly it appears that the MNA properly addresses this requirement. Structured in 18 questions grouped in four rubrics (anthropometry, general status, dietary habits, and self-perceived health and nutrition states), the MNA provides a multidimensional assessment of the patient (Table 2) [11,12].
It was initially developed as a one-step evaluation procedure, using as principal reference criteria the physician-rated nutritional status and a full nutri- tional assessment including anthropometric measures, biochemical parameters, dietary intake and functional variables such as cognition (by Mini-Mental State Examination) and activities of daily living (general and instrumental). After its completion, the final score (a maximum of 30 points) allows grading the nutritional status according to clearly defined thresholds: scores above 24, good status; scores 23.5–17, risk of malnutrition; scores below 17, malnutrition. The main features targeted during this phase of design and validation were the reliability, the simplicity, the speed of execution and the acceptability by the patient [11]. Despite the good agreement with the physician’s judgement, which still remains the gold standard of nutritional assessment, the initial researchers
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onal derangements
ym ‘MEALS ON WHEELS’ [9]
n effects
problems (especially depression)
nervosa or alcoholism
aranoia
g disorders
rs such as poorly fitting dentures, caries
g and other dementia related behaviours
oidism or hypothyroidism or hyperparathyroidism or hypoadrenalism
blems
blems (such as inability to feed self)
ow-cholesterol diet
cial problems (such as isolation, inability to obtain preferred foods)
Volume 15 � Number 1 � January 2012
Table 2. MNA scoring system
Rubrics and questions Score range
Rubric I. Anthropometric assessment (maximum 8 points)
Body weight and height, and related calculation of BMIa 0–3 points
Arm circumference 0–1 points
Calf circumference 0–1 points
3-Month weight lossa 0–3 points
Rubric II. General status assessment (maximum 9 points)
Independence of living 0–1 points
Recent acute events (disease or psychological distress)a 0–2 points
Presence of pressure or skin ulcers 0–1 points
Number of medications taken on 0–1 points
Cognition/depressiona 0–2 points
Mobilitya 0–2 points
Rubric III. Dietary assessment (maximum 9 points)
Eating problems (appetite, swallowing, chewing)a 0–2 points
Number of full meals 0–2 points
Markers of protein intake 0–1 points
Intake of vegetables and fruit 0–1 points
Intake of liquids 0–1 points
Self-sufficiency in eating 0–2 points
Rubric IV. Self-perceived health and nutrition states (maximum 4 points)
Self-perception of nutritional status 0–2 points
Self-perception of health status 0–2 points
MNA, Mini Nutritional Assessment. Data from [12]. aQuestions included in the first version of the MNA–SF.
Mini Nutritional Assessment Cereda
and the scientific community worked hard to bring further improvements and in the following years the tool was the object of different reappraisals. The key passages of this process are summarized in Table 3.
After development and validation, the tool was then implemented as a more practical two-stepevalu- ation process. Although the full MNA can be com- pleted in 15–20 min, in cognitively impaired people the assessment may require more time and in some cases answers are difficult to obtain. Moreover, in acute care settings time-consuming procedures may not be performed. A reanalysis of the initial database by Rubenstein et al. [13] allowed a selection of six questions (step 1) to be used as the basic screening procedure [MNA Short Form (MNA-SF)], taking up to 5 min, but that would nevertheless retain the same accuracy of the original tool. To this purpose phys- ician’s clinical rating was again taken as reference standard. However, scoring the patients to a maxi- mum of 14 points, the initial version of MNA-SF allowed identifying only risk of malnutrition (scores <12) so that the completion of full MNA (step 2) is required for confirmation and a diagnosis of malnutrition at risk or overt malnutrition. Moreover, this tool appeared more appropriate for Copyright © Lippincott Williams & Wilkins. Unau 1363-1950 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilk the community-dwelling elderly and less efficient than the full version for nursing home residents [12]. The issue of short time burden has been always considered a mainstay for the design of nutritional screening procedures. In regard to this, the intro- duction of MNA-SF has provided significant advan- ces in the dissemination of nutritional screening as an integral part of routine care. However, research- ers have recently considered that some more could be done to improve the utility and the efficiency of this tool. Performing a laborious and commendable pooled datasets analysis, in 2009 the MNA-Inter- national Group has implemented the MNA-SF [14] in order to allow the identification of three nutri- tional status categories as the case of the full MNA (forms available for free download at: www.mna- elderly.com/mna_forms.html). To this purpose cut- points of the revised MNA-SF were optimized by comparison with those of full MNA obtaining a sensitivity of 89.3% and a specificity of 94.3% for nutritional risk (score <12) and malnutrition (score <8), respectively. Moreover, the group tested the other anthropometric parameters included in the full version (calf and mid-arm circumferences) to allow the completion independent of the thorized reproduction of this article is prohibited. ins www.co-clinicalnutrition.com 31 http://www.mna-elderly.com/mna_forms.html http://www.mna-elderly.com/mna_forms.html C Table 3. Key passages of MNA implementation history Historical steps Year Targeted features MNA development and validation [11] 1994 Reliable scale with clearly defined thresholds; compatibility with assessor’s skills; minimal opportunity of bias in data collection; acceptability by the patient; application in different settings and conditions; low cost MNA-SF development [13] 2001 Minimal examination time; lowest amount of of ‘don’t know’ answers; wider distribution among general practitioners MNA-SF revision [14] 2009 Possibility to grade nutritional status in three categories as with the full MNA without increasing the burden of time; independence from body weight and BMI measurement as well as from any anthropometric parameter; wider distribution in any healthcare setting. MNA, Mini Nutritional Assessment; MNA-SF, Mini Nutritional Assessement Short Form. Ageing: biology and nutrition potentially time-consuming and less accessible evaluation of BMI. Accordingly, calf circumference was demonstrated a good substitute of BMI. Particu- larly, it was found that a cut-point of 11 had a sensitivity of 90.2% and a specificity of 76.2% for nutritional risk, whereas a cut-point of 8 had a sensitivity of 88.3% and a specificity of 88.7% for malnutrition [14]. Indeed, these results are promis- ing and looking at the mass of data available for the full MNA and the first version of the MNA-SF there are only a few things that still need to be done to complete the validation. The first is a cross-vali- dation study that reasonably takes into account its application in different healthcare settings, whereas the second is an evaluation of its prognostic value in relation to different outcomes. It could not be excluded that the group is already working on these research issues. THE PICTURE OF NUTRITIONAL STATUS ACCORDING TO THE MINI NUTRITIONAL ASSESSMENT The MNA has been widely used in clinical research and a consistent mass of data is now available. Several investigators all over the world have tested its application and, in regard to this, attention has been primarily focused on the healthcare setting (community, home care/outpatients, acute hospital care, subacute and rehabilitation care, institutions) and the type of patients assessed (e.g. cognitively impaired and/or the frail elderly). Given the multi- dimensional approach, the prevalence picture of nutritional conditions provided by the MNA appears in some measure able to reflect the nutri- tional features (e.g. BMI, weight loss, dietary habits) and the dependence level of the patients assessed across different settings [12,15]. This consideration is a further confirmation of its utility as a tool for grading nutritional derangements. opyright © Lippincott Williams & Wilkins. Unautho 32 www.co-clinicalnutrition.com In this context, it raises attention towards the recent retrospective pooled analysis of previously published datasets performed by the MNA Inter- national Group [16 && ] and Soini et al. [17 && ] in order to provide a perspective of malnutrition frequency in different standards of care. Extensive reviews of literature on the use of the MNA have been previously performed. The first of these by Guigoz [12] and Vellas et al. [18] date back to 2006 and include all published articles until early 2006. Particularly, in the review by Guigoz [12] an interesting estimation of the prevalence of malnu- trition and risk of malnutrition across the studies according to the different settings was provided. The systematic evaluation of literature was then con- tinued until early 2008 by Bauer et al. [15] but no updated estimation on the prevalence was given. In the present review, literature (English full-text) on the MNA published until June 2011 has been addi- tionally assessed after searching through PubMed and using the MNA Literature Database of the Nestlè Nutrition Institute (available at: www.mna-elderly. com). A detailed description of the articles provid- ing unpublished prevalence data is listed in Table 4 [7,17 && ,19–26,27 & ,28–56,57 & ,58–67,68 & ,69– 121]. Therefore, data extracted were analysed together with those already reviewed in order to pro- vide an updated picture of malnutrition prevalence. Only those observational studies providing setting- specific data on elderly patients according to three categories of nutritional status (either by full or revised short-form MNA) were considered. The atten- tion was focused on the following settings: acute care (hospital); subacute/rehabilitation care; institutions (nursing home, long-term care and sheltered hous- ing); outpatients/home-care; community. Accord- ingly, prevalence of malnutrition and its risk were (1) a riz cute care (69 studies, n¼17 775 elderly), 23.4% (range 0–68%) and 49.4% (range 8–93%); ed reproduction of this article is prohibited. Volume 15 � Number 1 � January 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 4. Prevalence of malnutrition and risk of malnutrition according to the MNA (literature review from early 2008 through mid-2011) Author Pub year Country Setting Population (N) Malnutrition (%) Malnutrition at risk (%) Alhamdan and Alsaif [19] 2011 Saudi Arabia Hospital 100 36.5 50.6 Bahat et al. [20] 2011 Turkey Nursing home 254 22.8 9.8 Battaglia et al. [21] 2011 Italy Outpatients (stable COPD) 460 3.7 27 Borges et al. [22] 2011 Brazil Outpatients 16 0 43.7 Boström et al. [23] 2011 Canada Long-term care 120 31 58 Brain et al. [24] 2011 France Outpatients (breast cancer undergoing chemotherapy) 40 0 6 De La Montana and Miguez [25] 2011 Spain Community 728 12.5 57.5 Ferreira et al. [26] 2011 Brazil Community 1170 2.4 25.6 Gioulbasanis et al. [27&] 2011 Greece Hospital (lung cancer patients) 115 25.2 51.3 Gioulbasanis et al. [28] 2011 Greece Hospital (lung cancer patients) 171 26 46.2 Kaburagi et al. [29] 2011 Japan Community 130 2.3 19.2 Khater and Abouelezz [30] 2011 Egypt Nursing home 120 10.8 40.8 Leandro-Merhi et al. [31] 2011 Brazil Hospital 109 8.3 30.3 Nip et al. [32] 2011 UK Hospital (stroke patients) 100 7 66 O’Leary et al. [33] 2011 Australia Rehabilitation hospital 52 5.8 53.8 Ribeiro et al. [34] 2011 Brazil Community 236 1.3 25 Santomauro et al. [35] 2011 Italy Nursing home 463 22.5 58.3 Soderhamn et al. [36] 2011 Norway Hospital 158 17 43.8 Tsai and Chang [37] 2011 Taiwan Hospital (haemodialysis patients) 152 32.2 24.3 Tsai et al. [38] 2011 Taiwan Hospital (liver cancer patients) 300 1.7 47.3 Tsai et al. [39] 2011 Taiwan Hospital (psychiatric patients) 120 5.8 23.3 Velasco et al. [40] 2011 Spain Hospital 400 14.5 44 Vikstedt et al. [41] 2011 Finland Service house residents 375 21 65 Wyka et al. [42] 2011 Poland Community 238 0 16 Yang et al. [43] 2011 USA Home care 198 12 51 Aaldriks et al. [44] 2010 Netherlands Outpatients (undergoing chemotherapy for cancer) 202 5 30 Amirkalali et al. [45] 2010 Iran Outpatients 179 3.4 41.3 Amirkalali et al. [46] 2010 Iran Community 221 3.2 43.4 Bahat et al. [47] 2010 Turkey Nursing home 157 8.9 22.9 Buffa et al. [48] 2010 Italy Home care (Alzheimer’s disease patients) 83 5 27 Buffa et al. [49] 2010 Italy Community 200 1.2 35.9 Cabre et al. [50] 2010 Spain Hospital (pneumonia) 134 27.5 54.7 Cereda et al. [51] 2010 Italy Long-term care 266 18.8 49.6 Chang et al. [52] 2010 Taiwan Hospital 1008 29.3 50.2 Charton et al. [53] 2010 Australia Rehabilitation hospital 2076 33 51.1 Chen et al. [54] 2010 Taiwan Community 156 0 17.9 De Oliveira and Leandro-Merhi [55] 2010 Brazil Hospital 240 29.1 37.1 Drescher et al. [56] 2010 Switzerland Hospital 104 22.1 48 Ferdous et al. [57&] 2010 Bangladesh Community 457 26 62 Hafsteinsdóttir et al. [58] 2010 Netherlands Hospital (neurology and neurosurgery) 196 7 34 Hsieh et al. [59] 2010 Taiwan Community (solitary elderly) 120 5 39.2 Community (nonsolitary elderly) 240 0 6.7 Mini Nutritional Assessment Cereda 1363-1950 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-clinicalnutrition.com 33 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 4 (Continued) Author Pub year Country Setting Population (N) Malnutrition (%) Malnutrition at risk (%) Kim et al. [60] 2010 Korea Hospital (cancer patients undergoing chemotherapy) 65 19 60 Mesas et al. [61] 2010 Brazil Community 267 1.9 19.6 Niedźwiedzka and Wądołowska [62] 2010 Poland Community 390 1 22 Saka et al. [63] 2010 Turkey Outpatients 413 13 31 Tsai et al. [64] 2010 Taiwan Long-term care 208 22.6 56.7 Tsai et al. [65] 2010 Taiwan Outpatients (haemodialysis) 192 5 36 Tsai et al. [66] 2010 Taiwan Community 301 0.7 12 Vanderwee et al. [67] 2010 Belgium Hospital 2329 33 43 Vedantam et al. [68&] 2010 India Community 227 13.7 37 Vischer et al. [69] 2010 Switzerland Outpatients (diabetic) 146 13.9 75 Volkert et al. [70] 2010 Germany Hospital 205 30.2 69.8 Wang et al. [71] 2010 China Outpatients (Parkinson’s disease) 117 1.7 19.7 Amer et al. [72] 2009 Egypt Nursing home 100 9 45 Bernabeu-Wittel et al. [73] 2009 Spain Hospital 812 10.3 52.6 Buffa et al. [74] 2009 Italy Community 170 1.2 35.9 Cansado et al. [75] 2009 Portugal Hospital 531 32.4 60.8 Cereda et al. [76] 2009 Italy Long-term care 241 12.8 39 Correa et al. [77] 2009 Brazil Home care 34 38.2 61.8 Elkan et al. [78] 2009 Sweden Outpatients (rheumatoid arthritis) 80 1.3 32.5 Essed et al. [79] 2009 Netherlands Nursing home 86 2.4 15.1 Ghasemi et al. [80] 2009 Iran Institutions 1100 35.9 60.9 Gillioz et al. [81] 2009 France Home care (Alzheimer’s disease patients) 126 12.6 55.9 Grieger et al. [82] 2009 Australia Long-term care 74 16 37 Guerra and Amaral [83] 2009 Portugal Retirement home and social day care 55 3.6 23.6 Han et al. [84] 2009 China Community 162 8 36.4 Hengstermann et al. [85] 2009 Germany Hospital 189 14.5 69.6 Johansson et al. [86] 2009 Sweden Community 258 0.4 16 Kaiser et al. [87&&] 2009 Germany Nursing home (according to the nursing staff) 138 8.7 54.3 Lei et al. [88] 2009 China Hospital 184 19.6 53.2 O’Dwyer et al. [89] 2009 Ireland Home care (meals-on-wheels patients) 63 9.5 27 Oliveira et al. [90] 2009 Brazil Hospital 240 29.1 37.1 Orsitto et al. [91] 2009 Italy Hospital 623 18 58 Salva et al. [92] 2009 Spain Outpatients (dementia; 80% Alzheimer’s disease) 946 5 32 Serra-Prat et al. [93] 2009 Spain Long-term care 25 12 44 Smoliner et al. [94] 2009 Germany Nursing home 114 22.8 57.9 Soini et al. [17&&] 2009 Finland Service housing 1475 13.4 64.6 Tsai et al. [95] 2009 Taiwan Community 501 0.5 13.6 Tsai et al. [96] 2009 Taiwan Hospital (neuropsychiatric patients) 105 7.6 21.9 Tsai et al. [97] 2009 Taiwan Long-term care 208 22.1 61.1 Tsai and Shih [98] 2009 Taiwan Long-term care (poststroke) rehabilitation 74 13.5 63.5 Ageing: biology and nutrition 34 www.co-clinicalnutrition.com Volume 15 � Number 1 � January 2012 Table 4 (Continued) Author Pub year Country Setting Population (N) Malnutrition (%) Malnutrition at risk (%) Vidal et al. [99] 2009 France Community 123 2.4 17.1 Wengstrom et al. [100] 2009 Sweden Hospital (hip fracture) 32 43.7 53.1 Adams et al. [101] 2008 Australia Hospital 100 33 61 Aliabadi et al. [102] 2008 Iran Community 1962 12 45.3 Amici et al. [103] 2008 Italy Hospital 180 19 67 Cabrè et al. [104] 2008 Spain Hospital (pneumonia) 117 30.9 53.1 Carlsson et al. [105] 2008 Sweden Residential care facilities 173 17 59 Cereda et al. [7] 2008 Italy Long-term care 163 20.3 51.1 Chevalier et al. [106] 2008 France Outpatients (rehabilitation) 182 6 13 Cuervo et al. [107] 2008 Spain Community 22007 4.3 25.3 De Marchi et al. [108] 2008 Brazil Community 471 1.3 20.6 Ferreira et al. [109] 2008 Brazil Long-term care 89 28.1 50.6 Gil-Montoya et al. [110] 2008 Spain Community 2860 3.5 31.5 Hengestermann et al. [111] 2008 Germany Hospital 189 14.5 69.6 Iizaka et al. [112] 2008 Japan Community 130 0 12.6 Kulnik and Elmadfa [113] 2008 Austria Nursing home 245 37.8 48.3 Miller et al. [114] 2008 Australia Outpatients (amputee) 94 1.1 17 Odencrants et al. [115] 2008 Sweden Hospital (COPD patients) 50 48 48 Odlund Olin et al. [116] 2008 Sweden Service flat residents 122 27 63 Pérez-Llamas et al. [117] 2008 Italy Nursing home 86 0 0 Soto et al. [118] 2008 France Alzheimer’s acute care unit 492 35 55 Tsai et al. [119] 2008 Taiwan Community 2800 2 13.1 Tsai and Ku [120] 2008 Taiwan Long-term care (normal cognition) 169 21.9 59.2 Long-term care (cognition impaired) 139 33.8 53.9 Wikby et al. [121] 2008 Sweden Residential care facilities 127 16 53 Mini Nutritional Assessment Cereda (2) s Co 136 ubacute/rehabilitation care (9 studies, n¼3724 elderly), 31.0% (range 6–46%) and 54.0% (range 46–67%); (3) in stitutions (73 studies, n¼20 410 elderly), 27.2% (range 0–61%) and 52.1% (range 0–82%); (4) o utpatients/home-care (45 studies, n¼12 386 elderly), 7.7% (range 0–38%) and 39.6% (range 7–75%); (5) c ommunity-dwelling elderly (53 studies, n¼ 50 957 elderly) 4.2% (range 0–26%) and 27.4% (range 0–76%); including three studies focus- ing on rural communities from developing countries and reporting significantly higher prevalence of malnutrition and its risk [57 & , 68 & ,102]. As observed by Guigoz [12], these estimates appear significantly associated with the expected level of dependence (Fig. 1). Along with this, as previously reported for the Geriatric Nutritional Risk Index (GNRI) tool [10], the MNA seems to describe the potential patient’s ‘journey’ across the different pyright © Lippincott Williams & Wilkins. Unau 3-1950 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilk healthcare settings. Community-dwelling elderly are generally characterized by less need for help in daily living when compared to outpatients and patients at home-care services. This need signifi- cantly increases in those admitted to hospitals. Acute diseases are likely to be responsible for iporexia, weight loss and progressive reduction in BMI and skeletal muscle mass due to increased catabolism and inflammation. Sarcopenia and low body weight lead also to severe disability, whereas psychological distress deriving from acute events, as well as overt depression may also contribute to the worsening of global health and its self-perception. In addition, also the poor nutritional routines and attitudes among healthcare professionals may be involved in the process of nutritional deterioration [122]. Accordingly, it does not surprise that patients discharged from acute care are characterized by prolonged recovery. This is reflected by the necessity to be admitted to postacute care or to be included in rehabilitation programmes. In many other cases, elderly patients do not ever come back home, if this thorized reproduction of this article is prohibited. ins www.co-clinicalnutrition.com 35 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Community Outpatients home-care Acute care Institutions Sub-acute or rehabilitation care 0 10 20 30 40 50 60 70 80 (a) (b) Setting Prevalence (%) Level of dependence Low Mild Moderate-to-high Very high Community Outpatients home-care Acute care Institutions Sub-acute or rehabilitation care 0 10 20 30 40 50 60 70 80 Setting Prevalence (%) Level of dependence Low Mild Moderate-to-high Very high FIGURE 1. Prevalence of malnutrition (plot A) and risk of malnutrition (plot B) according to the full MNA and the level of dependence (weighted mean of the studies retrieved [*]). Ageing: biology and nutrition 36 www.co-clinicalnutrition.com Volume 15 � Number 1 � January 2012 Mini Nutritional Assessment Cereda was the provenience, and institutionalization is a forced choice. In this ‘journey’ the nutritional status of the patient is likely to worsen. However, institu- tions should be considered a setting per se above all due to the heterogeneity of the resident population [12,15], particularly for the prevalence of certain diseases (e.g. dementia) or the setting of prove- nience of the patients. PRACTICAL CONSIDERATION ON THE USE OF THE MINI NUTRITIONAL ASSESSMENT National and international nutrition societies are intensively engaged in the fight against malnu- trition. In regard to this, the use of screening pro- cedures is one of the pillars of prevention or even early recognition. Due to its feasibility and the reduced skills and time required for its completion, the MNA is a true candidate for becoming integral part of routine care assessments and its use is now recommended by the European Society of Clinical Nutrition and Metabolism (ESPEN), the Inter- national Association of Gerontology and Geriatrics (IAGG) and the International Academy Nutrition and Aging (IANA) [123,124 & ]. Unfortunately, it should be said candidate because, despite the great efforts made in the past 30 years, malnutrition still goes underdiagnosed and undertreated. Indeed, the background of the MNA is solid. The tool has been designed specifically for elderly patients. It allows grading nutritional status in an univoque way and in a timely manner having the tool itself a high inter-rater reliability [12] and clearly defined thresholds. Thus, it appears appro- priate for decision-making and guiding nutritional intervention. To stimulate and increase the diffu- sion of systematic nutritional assessment among clinicians, apart from the aforementioned histori- cal improvements, the tool has been validated in several ethnicities and ethnic-specific anthropo- metric cut-points have been set up. Along with this, the MNA has been translated in several languages and a free downloadable iPhone appli- cation is now available for a bedside use in any setting (download available at: www.mna- elderly.com/mna_forms.html). Finally, a main question on the use of the MNA concerns who should apply it. The tool has been designed to be theoretically completed by everyone, including the patients upon appropriate interview- ing. However, the accuracy and the reliability of results have been the object of discussion particu- larly when nursing home residents or hospital inpa- tients are assessed due to the frequent coexistence of cognitive and linguistic disabilities or the lack of consciousness. This issue has been recently Copyright © Lippincott Williams & Wilkins. Unau 1363-1950 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilk addressed by Kaiser et al. [87 && ], who have demon- strated that the objective application by the nursing staff is superior and better correlated with mortality (outcome) compared to one-on-one interviews of the residents. DEBATED ASPECTS OF THE MINI NUTRITIONAL ASSESSMENT Despite highlighting several advantages and strengths of the MNA, some aspects have also been the object of debate. However, as discussed above, two potential limitations have been addressed by recent research. The time required for its com- pletion, which has brought this tool to be chal- lenged by others such as the Malnutrition Universal Screening Tool (MUST) or the Nutritional Risk Score 2002 (NRS-2002), is no longer a problem. Building a shortened version by reducing the num- ber of ‘don’t know’ answers (MNA-SF) [13], making its scoring independent of BMI measurement and validating it for the grading of nutritional status [14] have made the tool very suitable for any setting and systematic screening and assessment. Also the ques- tion of who should complete the tool has been resolved. Accordingly, it has been suggested or even recommended that this should be performed by the nursing staff or the caregiver. However, an essential precondition is the thorough knowledge of the different aspects of the residents’ life [87 && ]. This aspect has been emphasized by a recent study by Cereda et al. [125 & ]. Despite this issue not being clearly discussed, it has been observed that in newly institutionalized elderly (mainly coming from hos- pital), nutritional status by the full MNA was not associated with mortality. It was also noteworthy that the prevalence of impaired nutritional status was up to 90% [125 & ], thus making the detection of differences in the association with outcome between categories of nutritional status difficult. Accordingly, in some cases, the use of other tools (e.g. the GNRI) should be considered. Indeed, the aims of nutritional screening are to: (1) i tho ins dentify patients malnourished or at risk of mal- nutrition; (2) i dentify patients at risk of developing nutrition- related complications; and (3) i dentify patients who can benefit from nutri- tional intervention. In respect to these purposes, some comments should be provided. The MNA is a highly sensitive tool. This applies not only to nutritional status but also to outcome [12,15,126]. However, a high sensitivity is required for screening purposes, rized reproduction of this article is prohibited. www.co-clinicalnutrition.com 37 C Ageing: biology and nutrition whereas a high specificity is required for diagnosis and this tool has been associated with a high risk of ‘overdiagnosis’ (low specificity) [126]. This aspect may have important implications from an econ- omical point of view, because the advantages of a positive screening, and of treatment, need to be investigated through pharmaco-economic studies taking cost-effectiveness among the primary out- comes. Reimbursability of nutritional interventions by sip feeding is still a critical point and the situ- ation is heterogeneous among different countries. However, the importance of early intervention should be emphasized, because the efficacy of treat- ment in the presence of mild nutritional deteriora- tion is likely to be higher and could theoretically allow the prevention of several complications and cost burden [127]. CONCLUSION ‘As easy as MNA’ is now considered the business card of the MNA. Specifically designed and validated for the elderly patient, the MNA has been the object of consistent investigation that, revealing potential limitations on its feasibility and systematic appli- cation, has allowed a significant improvement of its structure and of nutritional screening and assess- ment processes. However, the strength of being highly sensitive in the identification of patients at risk of malnutrition and of nutrition-related compli- cations has been a source of criticism because the risk of ‘overdiagnosing’ could not be counterbalanced by cost-effective early nutritional interventions. Future research should address this lack of evidence by potentially also taking into account the application setting as literature suggests that protein-calorie supplementation is effective in improving the out- come only of the malnourished elderly in hospital [128]. In some cases, however, the use of the MNA should be integrated with that of other tools. It seems likely that the search for a comprehensive and universal tool is never ended but it could not also be denied that the value of the MNA for the moment has no peer. Acknowledgements A special thank to Dr Pedrolli Carlo (Trento Hospital) for the assistance in data review. Conflicts of interest E.C. has received consultancy honoraria and investigator grants from Nutricia Italia for activities outside the present work. There are no conflicts of interest. opyright © Lippincott Williams & Wilkins. Unautho 38 www.co-clinicalnutrition.com REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 93–94). 1. 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