The Journal of Nutrition, Health & Aging©
Volume 15, Number 2, 2011
JNHA: NUTRITION
ASSESSMENT OF MALNUTRITION IN OLDER PERSONS:
A FOCUS ON THE MINI NUTRITIONAL ASSESSMENT
J.E. MORLEY
GRECC, St. Louis VA Medical Center and Division of Geriatric Medicine, Saint Louis University School of Medicine St. Louis, Missouri USA. Contact: John E. Morley, MB,BCh,
Division of Geriatric Medicine; Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104, Email: [email protected]
Poor nutritional status is now well established as a major
negative prognostic indicator in older persons (1-3). Weight loss
in persons over 60 years of age approximately doubles the
chances of dying, regardless of the persons body mass index (47). There are 6 major causes of weight loss, namely: Sarcopenia,
anorexia, malabsorption, hypermetabolism, cachexia and
dehydration (8). Cachexia is most commonly associated with
excess cytokines and has both muscle and fat loss, together with
low albumin and anemia (9-12). Elevated cytokines, especially
tumor necrosis factor-alpha receptor, is associated with poor
response to treatment (13-16). Of the causes of weight loss, only
sarcopenia should not be considered to be true malnutrition, but
rather is a loss of muscle mass often replaced by fat mass (1719). Over the last 20 years, there has been important advances in
our ability to diagnose malnutrition, predominantly because of
the large body of work exploring the use of the Mini Nutritional
Assessment (MNA)(20-23). Despite this, persons with
malnutrition are still poorly recognized by physicians (24).
Screening Tests
Besides the MNA a number of screening tests for
malnutrition have been validated. The Nutritional Screening
Index was the first of these and while well constructed, it proved
to be nonspecific (24, 25). SCREEN is a Canadian instrument
with good test-retest and inter-rater reliability (26, 27). It
correlates with the dietitian nutritional risk rating. It has a
sensitivity of 84% and specificity of 62%. The Appetite, Hunger
and Sensory Perception Questionnaire (AHSP) has good internal
consistency (0.71 to 0.76) but performs poorly in non healthy
elderly (28).
The Malnutrition Universal Screening Tool (MUST) is a
simple tool using just three items – body mass index (BMI),
weight loss and acute disease effect (29, 30). It predicts
mortality and length of stay (31). In hospital both it and the
MNA predicted persons at high risk of admission, but weight
loss during hospitalization was more predictive.
SCALES was developed to recognize cachexia (25). It
consists of sadness, low cholesterol, low albumin, weight loss,
eating problems and shopping/food preparation problems. The
subjective global assessment was developed for younger persons
in hospital and validated for those with gastrointestinal
disorders. Dietary intake has reported energy intakes of 10 to
45% lower than measured intakes (25). Food diaries perform
slightly better.
Received November 27, 2010
Accepted for publication December 3, 2010
87
The anorexia of aging is closely correlated with poor
outcomes in older persons (32-36). Anorexia is a complex
behavior representing the interaction of a variety of
neurotransmitters that are easily perturbed by a variety of factors
(37-40). For these reasons, we developed the simplified nutrition
assessment questionnaire (SNAQ) (41). This predicts future
weight loss in community and nursing home persons. It has an
81.3% sensitivity and a 76.4% specificity to predict weight loss.
Numerous anthropomorphic parameters can be used to detect
nutritional changes (Table I). While serum proteins have been
widely used to measure nutrition, the fact that they are
dramatically lowered by cytokine activity (inflammation) makes
their utility as nutritional markers at best questionable (42)
(Table II).
Table 1
Anthropometric Parameters
•Weight change
•BMI
•Arm span
•Mid-arm or Calf Circumference
•Triceps skinfold
•MAMC and MAMA
•Waist Circumference
•Bioelectrical impedance
•Dual photon absorptiometry (DEXA)
•CT/MRI
•Ultrasound
•Underwater weighing
•Stable isotopes
BMI=Body Mass Index; MAMC=Mid-Arm Muscle Circumference; MAMA=Mid-Arm
Muscle Area
Table 2
Serum Proteins
Half-life
Age
Others
Albumin
Prealbumin
(Transthyretin)
Transferrin
RBP
18 d
? decrease
Posture, Ckines
2d
9d
12 h
none
decrease
m f
IGF-1
Fibronectin
2-4 h
4h
decrease
?
Ckines
Fe, Ckines
Ckines, Zinc,
Vitamin A
Ckines
Ckines
RBP =Retinol Binding Protein; IGF-1 = Insulin Growth Factor-1; d=days; h=hours;
m=male; f=female; Fe=Iron; Ckines=Cytokines
The Journal of Nutrition, Health & Aging©
Volume 15, Number 2, 2011
ASSESSMENT OF MALNUTRITION IN OLDER PERSONS: A FOCUS ON THE MINI NUTRITIONAL ASSESSMENT
Mini Nutritional Assessment
The MNA was developed by Vellas and Guigoz in 1989 and
has subsequently become the best validated and most widely
utilized nutritional assessment tool (43-45). Scores between 17
and 23 are considered at risk and those less than 17 represent
protein energy malnutrition. A major advantage is it requires no
laboratory testing.
Numerous studies from around the world continue to appear
using the MNA (46-53). The prevalence of either malnutrition
or risk for malnutrition is particularly high in persons
undergoing acute rehabilitation (54). The level of true
malnutrition in older persons depends on the setting studied. In
the community, values of malnutrition run from as low as 0.7%
to 5.8%. A recent review found that in 4507 persons studied
with an average age of 82.3 years the MNA identified 46.2% of
older persons as being at risk for malnutrition (55). In nursing
homes 13.8% were malnourished and in hospitals 38.7%. In a
population with early dementia 5% were malnourished and 32%
at risk (56).
As with a low BMI, the MNA is predictive of mortality (57,
58). Nurses appear to be the most appropriate persons to do the
MNA assessment (59).
In an attempt to improve the rate of screening a short form of
the MNA was developed and validated (56). As determining the
BMI in older persons is often difficult, a new revised form of the
MNA-SF was developed, showing that calf circumference can
replace BMI (60).
When the MNA identifies persons at risk, they are often also
identified as frail (61-64). This is not surprising as the
components of the MNA-SF that are key components of frailty
include weight loss, low food intake, and strength (represented
by mobility and when used calf circumference). For this reason,
all persons who score as nutrition at risk should be worked up
for frailty. If frail, an exercise regimen should be added to their
treatment (65-67). A number of components of the MNA long
form (J to O) are very helpful in identifying persons whose
problem is predominantly nutritional.
Other Screening Tests
measured (82-86). Low vitamin D levels are related to
sarcopenia, falls, hip fracture, heart disease and increased
mortality. The 25(OH) vitamin D level should be at least
70nmol/L (30ng/ml).
Conclusion
All older persons should be screened for malnutrition or
being at risk for malnutrition. The MNA is the best validated
and most widely utilized screening test for malnutrition in older
persons. When persons are recognized to be malnourished or at
risk for malnutrition, they should be carefully evaluated for
reversible causes using an instrument such as the MEALS-ONWHEELS mnemonic (Table III). Treatment algorithms such as
the ones developed for nursing homes can then be implemented
(87). If supplements are to be used, they should be given
between meals (88-91). Nutrition is a central factor in improving
function and quality of life in older persons.
Table 3
Causes of Weight Loss
Medications
Emotional (depression)
Alcoholism, anorexia tardive, abuse (elder)
Late life paranoia
Swallowing problems
Oral problems
Nosocomial infections, no money (poverty)
Wandering/dementia
Hyperthyroidism, hypercalcemia, hypoadrenalism
Enteric problems (malabsorption)
Eating problems (eg. Tremor)
Low salt, low cholesterol diet
Shopping and meal preparation problems, Stones (cholecystitis)
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