© Borgis - New Medicine 4/2003, s. 125-129
Ewa Borowiak1, Tomasz Kostka2
Usefulness of short (MNA-SF) and full version of the Mini Nutritional Assessment (MNA) in examining the nutritional state of older persons
1 Institute of Nursing, Medical University of Lodz, Lodz, Poland
Head: dr J. Kobos, MD, PhD
2 Department of Social and Preventive Medicine, Medical University of Lodz, Poland
Head: prof. W. Drygas, MD, PhD
Summary
Aim of the study: To assess the usefulness of the short (MNA-SF) and full versions of the Mini Nutritional Assessment (MNA) in examining the nutritional state of older persons.
Material and methods: 311 subjects aged more than 65 years participated in the study: 151 living in an institution (DPS) (111 women and 40 men) and 160 community-dwelling elderly (116 women and 44 men).
Results: In comparison with MNA, the MNA-SF had a sensitivity of 73.6% in the community-dwelling elderly, and 64.4% in those institutionalised. In the community-dwelling elderly, 95% of persons with a good nutritional state and 73.6% of undernourished subjects were correctly classified. In an institution environment 100% persons with good nutritional state and 64.4% undernourished subjects were correctly classified by MNA-SF. In both groups MNA-SF and MNA corresponded with the findings of other measures of geriatric assessment (ADL, IADL, MMSE, GDS).
Conclusions: The study supports the usefulness of MNA-SF as a screening tool for examination of the nutritional state in the community-dwelling elderly. Generally, the full version of MNA confirmed the results of MNA-SF in this group. The relatively low sensitivity of MNA-SF in older and frailer institutionalised elderly persons requires further study.
INTRODUCTION
Malnutrition, which affects a great many subjects above the age of 65 years, is a significant medical problem (1-3). In Sweden, 38% of the elderly have an unsatisfactory nutritional state, and 49% are at high risk of malnutrition (4). Among the Danish population above the age of 65 years, the percentage of persons with an unsatisfactory nutritional state equals 38% (5). Malnutrition can often be both the cause as well as the result of a poor psychophysical state in the elderly. Its frequency correlates with the incidence of acute diseases and increased mortality (5, 6). Therefore, it is necessary to systematically assess the nutritional state of the elderly.
The methods most often used in clinical studies are: Body Mass Index (BMI), serum albumins, protein, transferrine, cholesterol, body fatty tissue%, calf circumference and biochemical transformation markers of osseous tissue (7, 8). One of the most popular screening tools used to assess the nutritional state is the Mini Nutritional Assessment (MNA). In clinical practice two versions of this questionnaire are used: the full version, worked out in 1994 (13), and the short version known as the MNA-SF (9). The short version was introduced in order to shorten the time of study, as a potential tool in geriatric screening (9). The MNA questionnaire turned out to be an effective tool in assessing the nutritional state of older persons with diabetes (10), in the preoperational period (11), in orthopaedics (7) and in institutionalised subjects (12). In the available literature only two studies were found on comparative assessment of MNA and MNA-SF (9, 11). Apart from these, there are no results of comparative studies carried out in Poland. Therefore, the aim of this study was to assess the usefulness of the short (MNA-SF) and full versions of Mini Nutritional Assessment in examining the nutritional state of the community-dwelling and institutionalised elderly.
MATERIAL AND METHODS
The study was carried out in the city of Lodz in 2001-2002 among 311 respondents above the age of 65 years. The respondents were divided into two groups:
1.institutionalised subjects – residents of two nursing homes in Lodz (from nine existing) – 111 women and 40 men.
2.community-dwelling subjects – 116 women and 44 men. These home-dwelling persons were included into the study by random choice based on their statements at the community health centre. The criteria for taking part in the study were: age, verbal communication efficiency and patient´s agreement to the study.
Every respondent was interviewed in order to gain information about their diseases, medications taken and tobacco smoking.
Both the short and full versions of the MNA questionnaire (13) were used to assess the nutritional state. The following were also assessed: psychological state using Mini-Mental State Examination MMSE (14) and Geriatric Depression Scale GDS (15), physical function by means of ADL (16) and Instrumental Activities of Daily Living IADL (17).
In order to describe the usefulness of MNA-SF, its sensitivity and specificity were assessed using the full version of the MNA as the reference test (18). The MNA full version results were split: a score> 23.5 meant a satisfactory nutritional state and the score > 23.5 meant malnutrition.
STATISTICAL ANALYSIS
The one-way analysis of variance (ANOVA), the chi–square test and the Pearson product moment correlation coefficient were used to analyse the variables. Quantity variables were presented as mean ± standard deviation. The limit of significance was set at p = 0.05.
RESULTS
The average age for the community-dwelling subjects was lower than the average age for the institutionalised elderly (Table 1). The percentage of men was comparable in both groups. There were 146 persons with ischaemic heart disease, 39 with chronic lung disease, 115 with musculoskeletal disorders (rheumatoid diseases and/or degenerative changes in the locomotor system), 29 with digestive tract ulceration, 60 with diabetes, 165 with hypertension, 122 with circulatory failure, 38 with post-stroke status, 44 with post-myocardial infarction status and 33 with eye disease. The number of medications most often taken was 6 (42 persons), 5 or 4 (41 persons) and 3 (32 persons). It is also important to note that 32 respondents took no medications regularly. Tobacco was smoked by 56 subjects. In comparison with the community-dwelling elderly, there were more institutionalised subjects with stomach and/or duodendal ulcer and eye diseases. Home-dwelling persons were characterized by a higher functional efficiency, higher MMSE score and a larger calf circumference (Table 1). Institutionalised subjects were characterized by a worse nutritional state in comparison with community-dwelling persons both in MNA-SF (10.6 ± 2.5 vs 11.3 ± 2.8; F = 6.6, p = 0.01) and in MNA (21.8 ± 4.0 vs 23.6 ± 4.1; F = 14.2, p <0.001). The short version of the MNA questionnaire in comparison with the full version had a sensitivity of 73.6% in community-dwelling elderly and 64.4% in institutionalised subjects. In the community-dwelling elderly 95% of persons with a good nutritional state and 73.6% of those with malnutrition were correctly classified by MNA-SF. In the institution environment 100% of elderly with a good nutritional state and 64.4% of undernourished subjects were correctly classified. The negative predictive value in MNA-SF was 0.82 for community-dwelling persons and 0.58 for institutional residents. The positive predictive values in MNA-SF were 0.93 and 1.0, respectively.
Table 1. The characteristics of community-dwelling and institutionalised subjects.
NS – non-significant
| | Community-dwelling elderly
(n = 160) | Institutionalised
(n = 151) | P - value |
| Age | 74.1 ? 6.2 | 78.7 ? 8.0 | p < 0.001 |
| Men (%) | 27.5 | 26.5 | NS |
| Ischaemic heart disease (%) | 42.5 | 51.7 | NS |
| Lung diseases (%) | 11.2 | 13.9 | NS |
| Musculoskeletal disorders (%) | 23.1 | 31.8 | NS |
| Stomach and/or duodenal ulceration (%) | 5.0 | 13.9 | p = 0.01 |
| Diabetes (%) | 21.9 | 16.6 | NS |
| Hypertension (%) | 50.6 | 55.6 | NS |
| Chronic heart failure (%) | 38.1 | 40.4 | NS |
| Post-stroke (%) | 11.9 | 12.6 | NS |
| Post-myocardial infarction (%) | 11.2 | 17.2 | NS |
| Eye diseases (glaucoma, cataract) (%) | 4.4 | 17.2 | p < 0.001 |
| Number of medications taken regularly | 4.5 ? 3.5 | 4.6 ? 2.7 | NS |
| ADL-score | 5.5 ? 1 | 4.9 ? 1.5 | p < 0.001 |
| IADL-score | 6.4 ? 2.4 | 3.8 ? 2.8 | p < 0.001 |
| GDS-score | 5.8 ? 3.5 | 7.1 ? 3.9 | NS |
| MMSE-score | 25.6 ? 4.9 | 21.0 ? 6.4 | p < 0.001 |
| BMI (kg?m-2) | 26.7 ? 4.7 | 25.0 ? 4.1 | NS |
| Calf circumference (cm) | 36.0 ? 5.4 | 33.4 ? 3.8 | P = 0.03 |
| Education (years) | 9.0 ? 3.1 | 7.7 ? 3.4 | NS |
| Smokers (%) | 16.6 | 20.5 | NS |
| Satisfactory nutritional state - MNA-SF (%) | 66.9 | 56.9 | NS |
| Satisfactory nutritional state - MNA (%) | 55.0 | 33.0 | p < 0.001 |
A statistically-significant correlation between the age of community-dwelling respondents and the results of both short and full assessments of their nutritional state was observed (Table 2). The older the persons, the worse their nutritional state. A similar correlation was found between gender of community-dwelling elderly and MNA-SF. Women indicated elements of a poorer nutritional state more often than men. Both among the home–dwelling elderly and institutional residents, a statistically significant correlation of MNA-SF and MNA with some chronic illnesses was detected. Respondents with e.g. ischaemic heart disease or chronic heart failure were also in poorer nutritional state. In both groups of respondents a negative correlation between number of systematically-taken medications and MNA-SF and MNA was observed (Table 2).
Table 2. Relationship between the short and full versions of MNA with the most common chronic diseases in the community-dwelling and institutionalised elderly.
| | MNA-SF | MNA |
| | Community dwelling elderly | Institution residents | Community dwelling elderly | Institution residents |
| Age | r = -0.37, p < 0.001 | NS | r = -0.29, p < 0.001 | NS |
| Gender | F = 5.09, p = 0.025 | NS | NS | NS |
| Ischaemic heart disease | NS | F = 5.24, p = 0.02 | NS | F = 8.47, p = 0.004 |
| Lung diseases | F = 4.79, p = 0.03 | NS | F = 5.31, p = 0.02 | NS |
| Musculoskeletal disorders | F = 5.78, p = 0.02 | NS | F = 4.01, p = 0.046 | NS |
| Ulceration | NS | F = 7.72, p = 0.006 | NS | F = 10.33, p = 0.002 |
| Diabetes | NS | NS | NS | NS |
| Hypertension | NS | NS | NS | NS |
| Chronic heart failure | F = 1.37, p = 0.24 | F = 4.37, p = 0.038 | F = 4.41, p = 0.037 | F = 5.26, p = 0.02 |
| Post-stroke status | NS | NS | NS | NS |
| Post-myocardial infarction status | NS | F = 4.25, p = 0.04 | NS | NS |
| Eye diseases | NS | NS | NS | NS |
| Number of medications taken regularly | r = -0.20, p = 0.01 | r = -0.20, p = 0.01 | r = -0.27, p < 0.001 | r = -0.29, p < 0.001 |
NS – non-significant
A statistically-significant correlation of MNA-SF and full version of MNA with the scores of ADL, IADL, GDS and MMSE was proven, both in the community-dwelling elderly and in institutional residents (Table 3). Persons above the age of 65 years with a lowered ability in daily and instrumental functioning, having more points in GDS and fewer in MMSE, were identified as in a worse nutritional state (both in MNA-SF and in MNA). As expected, the correlations of BMI and calf circumference with the short and full versions of MNA were statistically-significant. Persons with lower values of BMI and calf circumference are in a worse nutritional state (Table 3).
Table 3. Correlation analysis of short and full versions of MNA with other elements of geriatric assessment.
| | MNA-SF | MNA |
| | Community dwelling elderly | Institution residents | Community dwelling elderly | Institution residents |
| ADL | r = 0.46, p < 0.001 | r = 0.34, p < 0.001 | r = 0.52, p < 0.001 | r = 0.46, p < 0.001 |
| IADL | r = 0.46, p < 0.001 | r = 0.30, p < 0.001 | r = 0.51, p < 0.001 | r = 0.42, p < 0.001 |
| GDS | r = -0.39, p < 0.001 | r = -0.33, p < 0.001 | r = -0.51, p < 0.001 | r = -0.35, p < 0.001 |
| MMSE | r = 0.39, p < 0.001 | r = 0.30, p < 0.001 | r = 0.38, p < 0.001 | r = 0.34, p < 0.001 |
| BMI | r = 0.25, p = 0.0013 | r = 0.43, p < 0.001 | r = 0.19, p = 0.02 | r = 0.42, p < 0.001 |
| Calf circumference | r = 0.20, p < 0.001 | r = 0.28, p < 0.001 | r = 0.15, p = 0.06 | r = 0.41, p < 0.001 |
| Education (years) | NS | NS | NS | NS |
NS – non-significant
DISCUSSION
In the study questionnaires for the short and the full versions of the Mini Nutritional Assessment were used. A satisfactory nutritional state was shown in 55% of community-dwelling respondents and in only 33% of institutional residents. These results are generally similar to those found in foreign studies. In France 67.7% of the older population shows a satisfactory nutritional state (11, 19). In Belgium 37% of institutional residents are classified as well-nourished (12). In Sweden there are 33% of the institutionalised elderly, 21% of community-dwelling persons, 38% of patients in mentally-handicapped wards and 71% of private clinic patients with no risk of malnutrition (4). In analysing this data, the higher mean age of Swedish respondents (84.5 years) in comparison with our study should be stressed (4).
In this study a significant association between a number of factors and the nutritional state of 311 older inhabitants of Lodz was found. Several chronic diseases such as chronic heart failure, ischaemic heart disease, lung diseases, stomach and/or duodenal ulceration, musculoskeletal disorders and post-myocardial infarction status were related to the nutritional state. In opposition to one of the previous studies, an association with diabetes was not found (10). However, in agreement with previous studies a correlation between the number of medications taken and the nutritional state was found. More medications were taken by subjects with lower nutrition scores (3, 12). The study also showed an important correlation between nutritional state and age, living environment, BMI and calf circumference. The nutritional state reflects the daily basic and instrumental functional efficiency, depression self-assessment and psychological state assessment of the elderly (4, 20).
The results of this study confirm the considerable usefulness of the MNA questionnaire in assessing the nutritional state of the community-dwelling elderly. Our data support results presented in earlier studies (5, 7, 11, 21). Some studies published so far suggest also the high usefulness of the short version of MNA. MNA-SF among the older population of France, in comparison with MNA, showed 100% sensitivity in eliminating subjects with malnutrition. The MNA-SF sensitivity in establishing possible malnutrition was 85.6% and the negative predictive value was 92.8% (11). In another study the MNA-SF sensitivity in establishing undernourished elderly was 97.9% (9). The above-mentioned results stress high usefulness, low cost and simplicity in use of MNA-SF in comparison with its full version. In this study satisfactory level of MNA-SF sensitivity and specificity were found in the community-dwelling elderly in comparison with the MNA full version. Further, both MNA-SF and MNA reflect other measures of geriatric assessment. Further studies should pursue the problem of outcomes in institutionalised persons (relatively low sensitivity in establishing malnutrition). For these reasons MNA-SF can be recommended as a screening tool in assessing the nutritional state of the community-dwelling elderly. Its usefulness in institutional residents should be investigated further.
CONCLUSIONS
1.The study supports the usefulness of MNA-SF as a screening tool for examination of the nutritional state in the community-dwelling elderly. Generally, the full version of MNA confirmed the results of MNA-SF in this group.
2.The relatively low sensitivity of MNA-SF in older and frailer institutionalised elderly persons requires further study.
The study was supported by grant 502-11-635 from the Medical University of Lodz. We appreciate the assistance of Wiesława Bogusz, Grażyna Ryszkiewicz and Danuta Wantkiewicz in carrying out the study.
Piśmiennictwo
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