Matthias J. Kaiser

Frequency of Malnutrition in Older Adults: A Multinational Perspective Using the Mini Nutritional Assessment

OBJECTIVES: To provide pooled data on the prevalence of malnutrition in elderly people as evaluated using the Mini Nutritional Assessment (MNA).

The Mini Nutritional Assessment®—Its History, Today's Practice, and Future Perspectives

In the early 1990s, the Mini Nutritional Assessment (MNA; Nestle Nutrition, Vevey, Switzerland) was developed for nutrition screening in the elderly. Since then, it became the most established and widespread screening tool for older persons and has been translated into many different languages. The MNA shows prognostic relevance with regard to functionality, morbidity, and mortality of the elderly in different settings. This article recalls the development of the MNA with its short form (MNA-SF) and reviews the literature, focusing on the most recent publications. Specific features of the application of the MNA in different settings (community, nursing home, hospital) are considered. Minor shortcomings of the tool, such as the resources and the cooperation necessary for completion of the MNA, are discussed. Future options for the adaptation of this valuable tool are briefly characterized.

Nutritional status according to the mini nutritional assessment (MNA®) and frailty in community dwelling older persons: A close relationship

ObjectiveThis study investigates the association between MNA results and frailty status in community-dwelling older adults. In addition the relevance of singular MNA items and subscores in this regard was tested.DesignCross-sectional study.SettingCommunity-dwelling older adults were recruited in the region of Nürnberg, Germany.Participants206 volunteers aged 75 years or older without cognitive impairment (Mini Mental State Examination >24 points), 66.0% female.MeasurementsFrailty was defined according to Fried et al. as presence of three, pre-frailty as presence of one or two of the following criteria: weight loss, exhaustion, low physical activity, low handgrip strength and slow walking speed. Malnutrition (<17 points) and the risk of malnutrition (17–23.5 points) were determined by MNA®.Results15.1% of the participants were at risk of malnutrition, no participant was malnourished. 15.5 % were frail, 39.8% pre-frail and 44.7% non-frail. 46.9% of the frail, 12.2% of the pre-frail and 2.2% of the non-frail participants were at risk of malnutrition (p<0.001). Hence, 90% of those at risk of malnutrition were either pre-frail or frail. For the anthropometric, dietary, subjective and functional, but not for the general MNA subscore, frail participants scored significantly lower than pre-frail (p<0.01), and non-frail participants (p<0.01). Twelve of the 18 MNA items were also significantly associated with frailty (p<0.05).ConclusionsThese results underline the close association between frailty syndrome and nutritional status in older persons. A profound understanding of the interdependency of these two geriatric concepts will represent the basis for successful treatment strategies.

Sarcopenia in nursing home residents.

The age-associated loss of muscle mass and muscle strength described by the term sarcopenia is highly relevant for functionality among nursing home residents. Nevertheless, the scientific literature concentrating on sarcopenia in this population is scarce. For practical reasons, common definitions of this entity, which rely on dual energy x-ray absorptiometry (DEXA) and bioimpedance analysis (BIA), cannot be applied in this setting. Anthropometric measurements like arm muscle circumference and calf circumference seem to be most suitable. Handgrip may be used as an alternative. Prevalence data show a wide range but are mostly high. There is a close association of the degree of sarcopenia with dependence among residents. The pathophysiology of sarcopenia in this population is strongly influenced by comorbidity and often there is significant overlap with the cachexia syndrome. At present, physical exercise is regarded to be the most promising therapeutic option, with resistance training being superior to endurance programs. Physical exercise has been successful even among Alzheimer patients and physically restrained residents. It has to be accompanied by the provision of adequate and diverse meals based on individual energy and nutrient requirements. Special attention should be paid to the treatment of vitamin D deficiency if present. New therapeutic options include Whole Body Vibration, oral supplements with essential amino acids and leucine, ACE-inhibitors, and cytokine-modifying drugs.

Prospective Validation of the Modified Mini Nutritional Assessment Short-Forms in the Community, Nursing Home, and Rehabilitation Setting

To validate the modified Mini Nutritional Assessment (MNA) short‐forms (MNA‐SFs) with respect to agreement with full MNA classification in the target populations of the MNA.

Evaluation of nutritional status in older persons: nutritional screening and assessment.

Purpose of reviewMalnutrition is highly prevalent in the older population. It is associated with declining functionality and relevant health deficits. This review presents the principles of successful nutritional screening and assessment in older persons. Recent findingsAlthough no gold standard for the diagnosis of malnutrition can serve as reference, a large number of nutritional screening tools have been developed during the past two decades. For efficient screening, the most appropriate tool has to be selected based on setting and practicability. The screening intervals have to be chosen according to the population screened. Although screening has to be performed routinely and systematically in a very practical and efficient manner, nutritional assessment has to be individualized to provide information on the grade of malnutrition and its cause. The development of a local guideline that reflects local expertise and resources will prove essential for successful nutritional management. ConclusionNutritional screening and assessment should be a standard of care for older persons. It has to be considered as a clearly defined two-step procedure, which has to reflect setting and local resources. Further adaptations of the available screening tools with regard to ethnic characteristics are indicated.

Restrictive diets in the elderly: never say never again?

Restrictive diets have long been an essential part of standard nutritional therapy for a wide range of diseases like obesity, diabetes, hyperlipidaemia, arterial hypertension and chronic renal failure. Although a relevant number of studies have been published in this field, most of these have concentrated on adults below age 65. Data on the effects of restrictive diets in older persons are still scarce. With increasing age, restrictive diets seem to be less effective with regard to relevant study endpoints like morbidity, quality of life and mortality. This applies in particular to chronic indications which are in most cases associated with additional co-morbidities. Here the focus shifts towards providing adequate nutritional intake rich in macro- and especially micronutrients and a diet that is also highly palatable as older individuals are at increased risk of becoming malnourished and sarcopenic. In this context, nutritional prevention and therapy are of utmost importance for maintaining quality of life. This review summarizes the present evidence for the application of restrictive diets in older persons and balances it against potential risks.

Screening for malnutrition among nursing home residents — a comparative analysis of the Mini Nutritional Assessment, the Nutritional Risk Screening, and the Malnutrition Universal Screening Tool

BackgroundThe European Society for Clinical Nutrition and Metabolism (ESPEN) has recommended the Mini Nutritional Assessment (MNA®), the Nutritional Risk Screening 2002 (NRS), and the Malnutrition Universal Screening Tool (MUST) for nutritional screening in various settings and age groups. While in recent years all three tools have been applied to nursing home residents, there is still no consensus on the most appropriate screening tool in this specific setting.AimThe present study aims at comparing the MNA, the NRS, and the MUST with regard to applicability, categorization of nutritional status, and predictive value in the nursing home setting.MethodMNA, NRS, and MUST were performed on 200 residents from two municipal nursing homes in Nuremberg, Germany. Follow-up data on infection, hospitalization, and mortality were collected after six and again after twelve months.ResultsAmong 200 residents (mean age 85.5 ±7.8 years) the MNA could be completed in 188 (94.0%) and the NRS and MUST in 198 (99.0%) residents. The prevalence of ‘malnutrition’ according to the MNA was 15.4%. The prevalence of ‘risk of malnutrition’ (NRS) and ‘high risk of malnutrition’ (MUST), respectively, was 8.6% for both tools. The individual categorization of nutritional status showed poor agreement between NRS and MUST on the one hand and MNA on the other. For all tools a significant association between nutritional status and mortality was demonstrated during follow-up as classification in ‘malnourished’, respectively ‘high risk of malnutrition’ or ‘nutritional risk’, was significantly associated with increased hazard ratios. However, the MNA showed the best predictive value for survival among well-nourished residents.ConclusionThe evaluation of nutritional status in nursing home residents by MNA, NRS, and MUST shows significant differences. This observation may be of clinical relevance as nutritional intervention is usually based on screening results. As the items of the MNA reflect particularities of the nursing home population, this tool currently appears to be the most suitable one in this setting.