Current Opinion in Clinical Nutrition & Metabolic Care:
AGEING: BIOLOGY AND NUTRITION: Edited by Ronni Chernoff and Tommy Cederholm
Mini Nutritional Assessment
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: email@example.com
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.
The Mini Nutritional Assessment (MNA) is the most widespread tool for nutritional screening and assessment 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.
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 .
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 components 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 alternative tool to identify frail patients  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 .
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 theoretically result in early diagnosis of risk conditions 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 . 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 nutritional 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 . Despite the good agreement with the physician's judgement, which still remains the gold standard of nutritional assessment, the initial researchers 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-step evaluation process. Although the full MNA can be completed 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. 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 physician's clinical rating was again taken as reference standard. However, scoring the patients to a maximum 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 the community-dwelling elderly and less efficient than the full version for nursing home residents .
The issue of short time burden has been always considered a mainstay for the design of nutritional screening procedures. In regard to this, the introduction of MNA-SF has provided significant advances in the dissemination of nutritional screening as an integral part of routine care. However, researchers 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-International Group has implemented the MNA-SF  in order to allow the identification of three nutritional 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 potentially time-consuming and less accessible evaluation of BMI. Accordingly, calf circumference was demonstrated a good substitute of BMI. Particularly, 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 . Indeed, these results are promising 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-validation 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 multidimensional approach, the prevalence picture of nutritional conditions provided by the MNA appears in some measure able to reflect the nutritional 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.
In this context, it raises attention towards the recent retrospective pooled analysis of previously published datasets performed by the MNA International 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  and Vellas et al. date back to 2006 and include all published articles until early 2006. Particularly, in the review by Guigoz  an interesting estimation of the prevalence of malnutrition and risk of malnutrition across the studies according to the different settings was provided. The systematic evaluation of literature was then continued until early 2008 by Bauer et al. 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 additionally assessed after searching through PubMed and using the MNA Literature Database of the Nestlè Nutrition Institute (available at: http://www.mna-elderly.com). A detailed description of the articles providing 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 provide 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 attention was focused on the following settings: acute care (hospital); subacute/rehabilitation care; institutions (nursing home, long-term care and sheltered housing); outpatients/home-care; community. Accordingly, prevalence of malnutrition and its risk were
Table 4-a Prevalence...Image Tools
1. acute care (69 studies, n = 17 775 elderly), 23.4% (range 0–68%) and 49.4% (range 8–93%);
2. subacute/rehabilitation care (9 studies, n = 3724 elderly), 31.0% (range 6–46%) and 54.0% (range 46–67%);
3. institutions (73 studies, n = 20 410 elderly), 27.2% (range 0–61%) and 52.1% (range 0–82%);
4. outpatients/home-care (45 studies, n = 12 386 elderly), 7.7% (range 0–38%) and 39.6% (range 7–75%);
5. community-dwelling elderly (53 studies, n = 50 957 elderly) 4.2% (range 0–26%) and 27.4% (range 0–76%); including three studies focusing on rural communities from developing countries and reporting significantly higher prevalence of malnutrition and its risk [57▪,68▪,102].
As observed by Guigoz , 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 , the MNA seems to describe the potential patient's ‘journey’ across the different 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 significantly 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 . 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 was the provenience, and institutionalization is a forced choice. In this ‘journey’ the nutritional status of the patient is likely to worsen. However, institutions 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 provenience 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 malnutrition. In regard to this, the use of screening procedures 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 International 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  and clearly defined thresholds. Thus, it appears appropriate for decision-making and guiding nutritional intervention. To stimulate and increase the diffusion of systematic nutritional assessment among clinicians, apart from the aforementioned historical improvements, the tool has been validated in several ethnicities and ethnic-specific anthropometric cut-points have been set up. Along with this, the MNA has been translated in several languages and a free downloadable iPhone application is now available for a bedside use in any setting (download available at: http://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 interviewing. However, the accuracy and the reliability of results have been the object of discussion particularly when nursing home residents or hospital inpatients are assessed due to the frequent coexistence of cognitive and linguistic disabilities or the lack of consciousness. This issue has been recently addressed by Kaiser et al.[87▪▪], who have demonstrated 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 completion, which has brought this tool to be challenged 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 number of ‘don’t know’ answers (MNA-SF) , making its scoring independent of BMI measurement and validating it for the grading of nutritional status  have made the tool very suitable for any setting and systematic screening and assessment. Also the question 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 hospital), 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. identify patients malnourished or at risk of malnutrition;
2. identify patients at risk of developing nutrition-related complications; and
3. identify patients who can benefit from nutritional 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, whereas a high specificity is required for diagnosis and this tool has been associated with a high risk of ‘overdiagnosis’ (low specificity) . This aspect may have important implications from an economical 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 outcomes. Reimbursability of nutritional interventions by sip feeding is still a critical point and the situation is heterogeneous among different countries. However, the importance of early intervention should be emphasized, because the efficacy of treatment in the presence of mild nutritional deterioration is likely to be higher and could theoretically allow the prevention of several complications and cost burden .
‘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 application, has allowed a significant improvement of its structure and of nutritional screening and assessment processes. However, the strength of being highly sensitive in the identification of patients at risk of malnutrition and of nutrition-related complications 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 outcome only of the malnourished elderly in hospital .
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.
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.
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).
Muscaritoli M, Anker SD, Argilés J, et al. Consensus definition of sarcopenia, cachexia and precachexia: joint document elaborated by Special Interest Groups (SIG) ‘cachexia-anorexia in chronic wasting diseases’ and ‘nutrition in geriatrics’. Clin Nutr 2010; 29:154–159.
This consensus study reports the definition, the assessment and the staging of cachexia as well as the definition of sarcopenia. These issues have been addressed in order to allow early recognition, prevention and time-appropriate treatment of clinically important syndromes negatively impacting on the patient's prognosis.
Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010; 39:412–423.
This consensus study reports the definition of sarcopenia, suggests an algorithm for sarcopenia case finding and provides a list of suggested outcome domains for research. An operational definition of this syndrome would allow defining effective treatment.
Genton L, Karsegard VL, Chevalley T, et al.
Body composition changes over 9 years in healthy elderly subjects and impact of physical activity. Clin Nutr 2011; 30:436–442.
This study provides a picture of the loss of lean tissues occurring with aging. The knowledge of physiological changes would theoretically allow better identifying and early diagnosing pathological conditions leading to sarcopenia and frailty syndromes.
5. Abellan van Kan G, Rolland Y, Bergman H, et al. Frailty assessment of older people in clinical practice expert opinion of a geriatric advisory panel. J Nutr Health Aging 2008; 12:29–37.
6. Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Fraility: toward a clinical definition. J Am Med Dir Assoc 2008; 9:71–72.
7. Cereda E, Valzolgher L, Pedrolli C. Mini Nutritional Assessment is a good predictor of functional status in institutionalised elderly at risk of malnutrition. Clin Nutr 2008; 27:700–705.
8. Robbins LJ. Evaluation of weight loss in the elderly. Geriatrics 1989; 44:31–34.
9. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995; 123:850–859.
10. Cereda E, Pedrolli C. The Geriatric Nutritional Risk Index. Curr Opin Clin Nutr Metab Care 2009; 12:1–7.Erratum in Curr Opin Clin Nutr Metab Care 2009; 12:683.
11. Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 1994; 4 (Suppl 2):15–59.
12. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature: what does it tell us? J Nutr Health Aging 2006; 10:466–485.discussion 485–487.
13. Rubenstein LZ, Harker JO, Salva A, et al. Screening for undernutrition in geriatric practice: developing the short-form Mini-Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001; 56:M366–M372.
14. Kaiser MJ, Bauer JM, Ramsch C, et al. MNA-International GroupValidation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13:782–788.
15. Bauer JM, Kaiser MJ, Anthony P, et al. The Mini Nutritional Assessment: its history, today's practice, and future perspectives. Nutr Clin Pract 2008; 23:388–396.
Kaiser MJ, Bauer JM, Rämsch C, et al. Mini Nutritional Assessment International Group. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc 2010; 58:1734–1738.
On the basis of the collaborative analysis of a multinational pooled database, this study emphasizes that the prevalence of malnutrition and risk of malnutrition is high in every healthcare setting except for the community. Along with this, it provides insight into the prevalence of malnutrition in older populations with various degrees of dependence.
Soini H, Suominen MH, Muurinen S, et al. Malnutrition according to the mini nutritional assessment in older adults in different settings. J Am Geriatr Soc 2011; 59:765–766.
Confirming the multinational data by Kaiser et al.[16▪▪], this study emphasizes that the prevalence of malnutrition is high in every healthcare setting and associates with disability level and prevalent dementia.
18. Vellas B, Villars H, Abellan G, et al. Overview of the MNA: its history and challenges. J Nutr Health Aging 2006; 6:456–465.
19. Alhamdan AA, Alsaif AA. The nutritional, glutathione and oxidant status of elderly subjects admitted to a university hospital. Saudi J Gastroenterol 2011; 17:58–63.
20. Bahat G, Tufan F, Saka B, et al.
Which body mass index (BMI) is better in the elderly for functional status? Arch Gerontol Geriatr (in press).
21. Battaglia S, Spatafora M, Paglino G, et al. Ageing and COPD affect different domains of nutritional status: the ECCE study. Eur Respir J 2011; 37:1340–1345.
22. Borges Tde F, Mendes FA, de Oliveira TR, et al. Overdenture with immediate load: mastication and nutrition. Br J Nutr 2011; 105:990–994.
23. Boström AM, Van Soest D, Kolewaski B, et al. Nutrition status among residents living in a veterans’ long-term care facility in Western Canada: a pilot study. J Am Med Dir Assoc 2011; 12:217–225.
24. Brain EG, Mertens C, Girre V, et al.
Impact of liposomal doxorubicin-based adjuvant chemotherapy on autonomy in women over 70 with hormone-receptor-negative breast carcinoma: a French Geriatric Oncology Group (GERICO) phase II multicentre trial. Crit Rev Oncol Hematol 2011; 80:160–170.
25. De La Montana J, Miguez M. Suitability of the short-form Mini Nutritional Assessment in free-living elderly people in the northwest of Spain. J Nutr Health Aging 2011; 15:187–191.
26. Ferreira LS, do Amaral TF, de Fátima Nunes Marucci M, et al.
Undernutrition as a major risk factor for death among older Brazilian adults in the community-dwelling setting: SABE survey. Nutrition 2011; 27:1017–1022.
Gioulbasanis I, Georgoulias P, Vlachostergios PJ, et al.
Mini Nutritional Assessment (MNA) and biochemical markers of cachexia in metastatic lung cancer patients: interrelations and associations with prognosis. Lung Cancer (in press).
In this study, the investigators demonstrated that MNA score is associated not only to biochemical markers of nutritional status but also with those of cachexia.
28. Gioulbasanis I, Baracos VE, Giannousi Z, et al. Baseline nutritional evaluation in metastatic lung cancer patients: Mini Nutritional Assessment versus weight loss history. Ann Oncol 2011; 22:835–841.
29. Kaburagi T, Hirasawa R, Yoshino H, et al.
Nutritional status is strongly correlated with grip strength and depression in community-living elderly Japanese. Public Health Nutr (in press).
30. Khater MS, Abouelezz NF. Nutritional status in older adults with mild cognitive impairment living in elderly homes in Cairo, Egypt. J Nutr Health Aging 2011; 15:104–108.
31. Leandro-Merhi VA, De Aquino JL. Anthropometric parameters of nutritional assessment as predictive factors of the Mini Nutritional Assessment (MNA) of hospitalized elderly patients. J Nutr Health Aging 2011; 15:181–186.
32. Nip WF, Perry L, McLaren S, Mackenzie A. Dietary intake, nutritional status and rehabilitation outcomes of stroke patients in hospital. J Hum Nutr Diet (in press).
33. O’Leary F, Flood VM, Petocz P, et al. B vitamin status, dietary intake and length of stay in a sample of elderly rehabilitation patients. J Nutr Health Aging 2011; 15:485–489.
34. Ribeiro RS, da Rosa MI, Bozzetti MC. Malnutrition and associated variables in an elderly population of Criciúma, SC. Rev Assoc Med Bras 2011; 57:56–61.
35. Santomauro F, Olimpi N, Baggiani L, et al. Bioelectrical Impedance Vector Analysis and Mini Nutritional Assessment in elderly nursing home residents. J Nutr Health Aging 2011; 15:163–167.
36. Söderhamn U, Flateland S, Jessen L, Söderhamn O. Perceived health and risk of undernutrition: a comparison of different nutritional screening results in older patients. J Clin Nurs 2011; 20:2162–2171.
37. Tsai AC, Chang MZ. Long-form but not short-form Mini-Nutritional Assessment is appropriate for grading nutritional risk of patients on hemodialysis: a cross-sectional study. Int J Nurs Stud (in press).
38. Tsai AC, Hsu WC, Chan SC, Chang TL. Usefulness of the mini nutritional assessment in predicting the nutritional status of patients with liver cancer in Taiwan. Nutr Cancer 2011; 63:334–341.
39. Tsai AC, Chou YT, Chang TL. Usefulness of the Mini Nutritional Assessment (MNA) in predicting the nutritional status of people with mental disorders in Taiwan. J Clin Nurs 2011; 20:341–350.
40. Velasco C, García E, Rodríguez V, et al. Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study. Eur J Clin Nutr 2011; 65:269–274.
41. Vikstedt T, Suominen MH, Joki A, et al. Nutritional status, energy, protein, and micronutrient intake of older service house residents. J Am Med Dir Assoc 2011; 12:302–307.
42. Wyka J, Biernat J, Mikołajczak J, Piotrowska E. Assessment of dietary intake and nutritional status (MNA) in Polish free-living elderly people from rural environments. Arch Gerontol Geriatr (in press).
43. Yang Y, Brown CJ, Burgio KL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc 2011; 12:287–294.
44. Aaldriks AA, Maartense E, le Cessie S, et al.
Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol 2011; 79:205–212.
45. Amirkalali B, Sharifi F, Fakhrzadeh H, et al. Low serum leptin serves as a biomarker of malnutrition in elderly patients. Nutr Res 2010; 30:314–319.
46. Amirkalali B, Sharifi F, Fakhrzadeh H, et al. Evaluation of the Mini Nutritional Assessment in the elderly, Tehran, Iran. Public Health Nutr 2010; 13:1373–1379.
47. Bahat G, Saka B, Tufan F, et al. Prevalence of sarcopenia and its association with functional and nutritional status among male residents in a nursing home in Turkey. Aging Male 2010; 13:211–214.
48. Buffa R, Mereu RM, Putzu PF, et al. Bioelectrical impedance vector analysis detects low body cell mass and dehydration in patients with Alzheimer's disease. J Nutr Health Aging 2010; 14:823–827.
49. Buffa R, Floris G, Lodde M, et al. Nutritional status in the healthy longeval population from Sardinia (Italy). J Nutr Health Aging 2010; 14:97–102.
50. Cabre M, Serra-Prat M, Palomera E, et al. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing 2010; 39:39–45.
51. Cereda E, Bertoli S, Vanotti A, Battezzati A. Estimated height from knee-height in Caucasian elderly: implications on nutritional status by mini nutritional assessment. J Nutr Health Aging 2010; 14:16–22.
52. Chang HH, Tsai SL, Chen CY, Liu WJ. Outcomes of hospitalized elderly patients with geriatric syndrome: report of a community hospital reform plan in Taiwan. Arch Gerontol Geriatr 2010; 50 (Suppl 1):S30–S33.
53. Charton KE, Nichols C, Bowden S, et al. Older rehabilitation patients are at high risk of malnutrition: evidence from a large Australian database. J Nutr Health Aging 2010; 14:622–628.
54. Chen SH, Acton G, Shao JH. Relationships among nutritional self-efficacy, health locus of control and nutritional status in older Taiwanese adults. J Clin Nurs 2010; 19:2117–2127.
55. De Oliveira MR, Leandro-Merhi VA. Food intake and nutritional status of hospitalised older people. Int J Older People Nurs 2011; 6:196–200.
56. Drescher T, Singler K, Ulrich A, et al. Comparison of two malnutrition risk screening methods (MNA and NRS 2002) and their association with markers of protein malnutrition in geriatric hospitalized patients. Eur J Clin Nutr 2010; 64:887–893.
Ferdous T, Cederholm T, Kabir ZN, et al. Nutritional status and cognitive function in community-living rural Bangladeshi older adults: data from the poverty and health in ageing project. J Am Geriatr Soc 2010; 58:919–924.
In this study, it has been demonstrated that prevalence of malnutrition in community-dwelling elderly living in a rural country is higher than that of well developed ones, thus supporting the MNA is appropriate in different socio-economic conditions.
58. Hafsteinsdóttir TB, Mosselman M, Schoneveld C, et al. Malnutrition in hospitalised neurological patients approximately doubles in 10 days of hospitalisation. J Clin Nurs 2010; 19:639–648.
59. Hsieh YM, Sung TS, Wan KS. A survey of nutrition and health status of solitary and nonsolitary elders in Taiwan. J Nutr Health Aging 2010; 14:11–14.
60. Kim YJ, Kim JH, Park MS, et al. Comprehensive geriatric assessment in Korean elderly cancer patients receiving chemotherapy. J Cancer Res Clin Oncol 2011; 137:839–847.
61. Mesas AE, Andrade SM, Cabrera MA, Bueno VL. Oral health status and nutritional deficit in noninstitutionalized older adults in Londrina, Brazil. Rev Bras Epidemiol 2010; 13:434–445.
62. Niedźwiedzka E, Wądołowska L. A mini-nutritional assessment of older Poles in relation to the food intake model and food intake variety. Adv Med Sci 2010; 55:172–178.
63. Saka B, Kaya O, Ozturk GB, et al. Malnutrition in the elderly and its relationship with other geriatric syndromes. Clin Nutr 2010; 29:745–748.
64. Tsai AC, Ku PY, Tsai JD. Population-specific Mini Nutritional Assessment can improve mortality-risk-predicting ability in institutionalised older Taiwanese. J Clin Nurs 2010; 19:2493–2499.
65. Tsai HJ, Tsai AC, Hung SY, Chang MY. Comparing the predictive ability of population-specific Mini-Nutritional Assessment with Subjective Global Assessment for Taiwanese patients with hemodialysis: a cross-sectional study. Int J Nurs Stud (in press).
66. Tsai AC, Chang TL, Yang TW, et al. A modified mini nutritional assessment without BMI predicts nutritional status of community-living elderly in Taiwan. J Nutr Health Aging 2010; 14:183–189.
67. Vanderwee K, Clays E, Bocquaert I, et al. Malnutrition and associated factors in elderly hospital patients: a Belgian cross-sectional, multicentre study. Clin Nutr 2010; 29:469–476.
Vedantam A, Subramanian V, Rao NV, John KR. Malnutrition in free-living elderly in rural south India: prevalence and risk factors. Public Health Nutr 2010; 13:1328–1332.
In this study, it has been demonstrated that prevalence of malnutrition in community-dwelling elderly living in a rural country is higher than that of well developed ones, thus supporting the MNA is appropriate in different socio-economic conditions.
69. Vischer UM, Perrenoud L, Genet C, et al. The high prevalence of malnutrition in elderly diabetic patients: implications for antidiabetic drug treatments. Diabet Med 2010; 27:918–924.
70. Volkert D, Saeglitz C, Gueldenzoph H, et al. Undiagnosed malnutrition and nutrition-related problems in geriatric patients. J Nutr Health Aging 2010; 14:387–392.
71. Wang G, Wan Y, Cheng Q, et al. Malnutrition and associated factors in Chinese patients with Parkinson's disease: results from a pilot investigation. Parkinsonism Relat Disord 2010; 16:119–123.
72. Amer MS, Mousa SM, Abdel Rahman TT, Saber HG. Malnutrition and its risk factors in nursing home residents in Cairo. J Am Geriatr Soc 2009; 57:1716–1718.
73. Bernabeu-Wittel M, Jadad A, Moreno-Gaviño L, et al. Peeking through the cracks: an assessment of the prevalence, clinical characteristics and health-related quality of life (HRQoL) of people with polypathology in a hospital setting. Arch Gerontol Geriatr 2010; 51:185–191.
74. Buffa R, Floris G, Marini E. Assessment of nutritional status in free-living elderly individuals by bioelectrical impedance vector analysis. Nutrition 2009; 25:3–5.
75. Cansado P, Ravasco P, Camilo M. A longitudinal study of hospital undernutrition in the elderly: comparison of four validated methods. J Nutr Health Aging 2009; 13:159–164.
76. Cereda E, Pusani C, Limonta D, Vanotti A. The ability of the Geriatric Nutritional Risk Index to assess the nutritional status and predict the outcome of home-care resident elderly: a comparison with the Mini Nutritional Assessment. Br J Nutr 2009; 102:563–570.
77. Correa B, Leandro Merhi VA, Pagotto Fogaca K, Marques de Oliveira MR. Caregiver's education level, not income, as determining factor of dietary intake and nutritional status of individuals cared for at home. J Nutr Health Aging 2009; 13:609–614.
78. Elkan AC, Engvall IL, Cederholm T, Hafström I. Rheumatoid cachexia, central obesity and malnutrition in patients with low-active rheumatoid arthritis: feasibility of anthropometry, Mini Nutritional Assessment and body composition techniques. Eur J Nutr 2009; 48:315–322.
79. Essed NH, Oerlemans P, Hoek M, et al. Optimal preferred MSG concentration in potatoes, spinach and beef and their effect on intake in institutionalized elderly people. J Nutr Health Aging 2009; 13:769–775.
80. Ghasemi S, Sharifi F, Maghsoodnia S, et al. Nutrition Educational Program and health promotion in aged people in Iran. Middle East J Age Ageing 2009; 6:12–17.
81. Gillioz AS, Villars H, Voisin T, et al. REAL.FR GroupSpared and impaired abilities in community-dwelling patients entering the severe stage of Alzheimer's disease. Dement Geriatr Cogn Disord 2009; 28:427–432.
82. Grieger JA, Nowson CA, Ackland LM. Nutritional and functional status indicators in residents of a long-term care facility. J Nutr Elder 2009; 28:47–60.
83. Guerra RS, Amaral TF. Comparison of hand dynamometers in elderly people. J Nutr Health Aging 2009; 13:907–912.
84. Han Y, Li S, Zheng Y. Predictors of nutritional status among community-dwelling older adults in Wuhan, China. Public Health Nutr 2009; 12:1189–1196.
85. Hengstermann S, Laemmler G, Hanemann A, et al. Total serum homocysteine levels do not identify cognitive dysfunction in multimorbid elderly patients. J Nutr Health Aging 2009; 13:121–126.
86. Johansson L, Sidenvall B, Malmberg B, Christensson L. Who will become malnourished? A prospective study of factors associated with malnutrition in older persons living at home. J Nutr Health Aging 2009; 13:855–861.
Kaiser R, Winning K, Uter W, et al. Comparison of two different approaches for the application of the mini nutritional assessment in nursing homes: resident interviews versus assessment by nursing staff. J Nutr Health Aging 2009; 13:863–869.
With this research it has been demonstrated that the application of the MNA by nursing staff in a long-term care setting is superior and better correlated with mortality (outcome) compared to one-on-one interviews of the residents. Accordingly, the completion by the caregiver should be recommended.
88. Lei Z, Qingyi D, Feng G, et al. Clinical study of mini-nutritional assessment for older Chinese inpatients. J Nutr Health Aging 2009; 13:871–875.
89. O’Dwyer C, Corish CA, Timonen V. Nutritional status of Irish older people in receipt of meals-on-wheels and the nutritional content of meals provided. J Hum Nutr Diet 2009; 22:521–527.
90. Oliveira MR, Fogaça KC, Leandro-Merhi VA. Nutritional status and functional capacity of hospitalized elderly. Nutr J 2009; 8:54.
91. Orsitto G, Fulvio F, Tria D, et al. Nutritional status in hospitalized elderly patients with mild cognitive impairment. Clin Nutr 2009; 28:100–102.
92. Salva A, Andrieu S, Fernandez E, et al. NutriAlz Group. Health and nutritional promotion program for patients with dementia (NutriAlz Study): design and baseline data. J Nutr Health Aging 2009; 13:529–537.
93. Serra-Prat M, Palomera E, Clave P, Puig-Domingo M. Effect of age and frailty on ghrelin and cholecystokinin responses to a meal test. Am J Clin Nutr 2009; 89:410–1417.
94. Smoliner C, Norman K, Wagner KH, et al. Malnutrition and depression in the institutionalised elderly. Br J Nutr 2009; 102:1663–1667.
95. Tsai AC, Chang TL, Chen JT, Yang TW. Population-specific modifications of the short-form Mini Nutritional Assessment and Malnutrition Universal Screening Tool for elderly Taiwanese. Int J Nurs Stud 2009; 46:1431–1438.
96. Tsai AC, Chou YT, Chang TL, et al. A modified Mini Nutritional Assessment without BMI can effectively assess the nutritional status of neuropsychiatric patients. J Clin Nurs 2009; 18:1916–1922.
97. Tsai AC, Ku PY, Tsai JD. Population-specific anthropometric cutoff standards improve the functionality of the Mini Nutritional Assessment without BMI in institutionalized elderly in Taiwan. J Nutr Health Aging 2008; 12:696–700.
98. Tsai AC, Shih CL. A population-specific Mini-Nutritional Assessment can effectively grade the nutritional status of stroke rehabilitation patients in Taiwan. J Clin Nurs 2009; 18:82–88.
99. Vidal K, Rolland Y, Moulin J, et al. MNA and frailty syndrome in free-living elderly. J Nutr Health Aging 2009; 13 (Suppl 2):S13.
100. Wengstrom Y, Wahren LK, Grodzinsky E. Importance of dietary advice, nutritional supplements and compliance for maintaining body weight and body fat after hip fracture. J Nutr Health Aging 2009; 13:632–638.
101. Adams NE, Bowie AJ, Simmance N, et al. Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients. Nutr Dietetics 2008; 65:144–150.
102. Aliabadi M, Kimiagar M, Ghayour-Mobarhan M, et al. Prevalence of malnutrition in free living elderly people in Iran: a cross-sectional study. Asia Pac J Clin Nutr 2008; 17:285–289.
103. Amici A, Baratta A, Linguanti A, et al. The Marigliano-Cacciafesta polypathological scale: a tool for assessing fragility. Arch Gerontol Geriatr 2008; 46:327–334.
104. Cabré M, Serra-Prat M, Force L, et al. Functional status as a risk factor for mortality in very elderly patients with pneumonia. Med Clin (Barc) 2008; 131:167–170.
105. Carlsson M, Gustafson Y, Eriksson S, Håglin L. Body composition in Swedish old people aged 65–99 years, living in residential care facilities. Arch Gerontol Geriatr 2009; 49:98–107.
106. Chevalier S, Saoud F, Gray-Donald K, Morais JA. The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status. J Nutr Health Aging 2008; 12:721–726.
107. Cuervo M, Ansorena D, García A, et al. Food consumption analysis in Spanish elderly based upon the mini nutritional assessment test. Ann Nutr Metab 2008; 52:299–307.
108. De Marchi RJ, Hugo FN, Hilgert JB, Padilha DM. Association between oral health status and nutritional status in south Brazilian independent-living older people. Nutrition 2008; 24:546–553.
109. Ferreira LS, Nascimento LF, Marucci MF. Use of the mini nutritional assessment tool in elderly people from long-term institutions of southeast of Brazil. J Nutr Health Aging 2008; 12:213–217.
110. Gil-Montoya JA, Subirá C, Ramón JM, González-Moles MA. Oral health-related quality of life and nutritional status. J Public Health Dent 2008; 68:88–93.
111. Hengstermann S, Laemmler G, Hanemann A, et al. Total serum homocysteine levels do not identify cognitive dysfunction in multimorbid elderly patients. J Nutr Health Aging 2008; 12:411–416.
112. Iizaka S, Tadaka E, Sanada H. Comprehensive assessment of nutritional status and associated factors in the healthy, community-dwelling elderly. Geriatr Gerontol Int 2008; 8:24–31.
113. Kulnik D, Elmadfa I. Assessment of the nutritional situation of elderly nursing home residents in Vienna. Ann Nutr Metab 2008; 52 (Suppl 1):51–53.
114. Miller M, Wong WK, Wu J, et al. Upper-arm anthropometry: an alternative indicator of nutritional health to body mass index in unilateral lower-extremity amputees? Arch Phys Med Rehabil 2008; 89:2031–2033.
115. Odencrants S, Ehnfors M, Ehrenberg A. Nutritional status and patient characteristics for hospitalised older patients with chronic obstructive pulmonary disease. J Clin Nurs 2008; 17:1771–1778.
116. Odlund Olin A, Koochek A, Cederholm T, Ljungqvist O. Minimal effect on energy intake by additional evening meal for frail elderly service flat residents: a pilot study. J Nutr Health Aging 2008; 12:295–301.
117. Pérez-Llamas F, López-Contreras MJ, Blanco MJ, et al. Seemingly paradoxical seasonal influences on vitamin D status in nursing-home elderly people from a Mediterranean area. Nutrition 2008; 24:414–420.
118. Soto ME, Nourhashemi F, Arbus C, et al. Special acute care unit for older adults with Alzheimer's disease. Int J Geriatr Psychiatry 2008; 23:215–219.
119. Tsai AC, Ho CS, Chang MC. Assessing the prevalence of malnutrition with the Mini Nutritional Assessment (MNA) in a nationally representative sample of elderly Taiwanese. J Nutr Health Aging 2008; 12:239–243.
120. Tsai AC, Ku PY. Population-specific Mini Nutritional Assessment effectively predicts the nutritional state and follow-up mortality of institutionalized elderly Taiwanese regardless of cognitive status. Br J Nutr 2008; 100:152–158.
121. Wikby K, Ek AC, Christensson L. The two-step Mini Nutritional Assessment procedure in community resident homes. J Clin Nurs 2008; 17:1211–1218.
122. Cereda E, Lucchin L, Pedrolli C, et al. Nutritional care routines in Italy: results from the PIMAI (Project: Iatrogenic MAlnutrition in Italy) study. Eur J Clin Nutr 2010; 64:894–898.
123. Kondrup J, Allison SP, Elia M, et al. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening. Clin Nutr 2003; 22:415–421.
Task Force on Nutrition and Ageing of the IAGG and the IANA. Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA. J Nutr Health Aging 2009; 13:475–483.
This consensus study reports an updated list of recommendations for managing nutritional management of elderly people in long-term cares.
Cereda E, Pedrolli C, Zagami A, et al.
Nutritional screening and mortality in newly institutionalized elderly: a comparison between the Geriatric Nutritional Risk Index and the Mini Nutritional Assessment. Clin Nutr (in press).
With this prospective study, the authors have demonstrated that in newly institutionalized elderly nutritional risk by the Geriatric Nutritional Risk Index but not nutritional status by the Mini Nutritional Assessment is associated with mortality. Accordingly, in this patient population the use of the GNRI is suggested.
126. Beck AM, Holst M, Rasmussen HH. Efficacy of the Mini Nutritional Assessment to predict the risk of developing malnutrition or adverse health outcomes for old people. e-SPEN 2008; 3:e102–e107.
127. Darmon P, Lochs H, Pichard C. Economic impact and quality of life as endpoints of nutritional therapy. Curr Opin Clin Nutr Metab Care 2008; 11:452–458.
128. Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med 2006; 144:37–48.
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