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).
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