Nutrition Screening
as as
A guide to completing the
Mini Nutritional Assessment (MNA®)
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Nutrition can make a difference.
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Mini Nutritional Assessment (MNA®). The MNA® is a screening tool to help identify elderly persons who are malnourished or at risk of malnutrition.
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Nutrition Screening
as as
A guide to completing the
Mini Nutritional Assessment (MNA®)
Print CMYK | Blue = C 100% / M 72% / B 18% | Green = C 80% / Y 90%
Screen and intervene.
Nutrition can make a difference.
Mini Nutritional Assessment (MNA®)
The MNA® is a screening tool to help identify elderly persons who are malnourished or at risk of malnutrition. This User Guide will assist you in completing the full MNA® accurately and consistently. It explains how the full MNA® and the MNA®-SF differ, how to complete each question and how to assign and interpret the score.
Introduction:
While the prevalence of malnutrition in the free-living elderly population is relatively low, the risk of malnutrition increases dramatically in the institutionalized and hospitalized elderly.^1 The prevalence of malnutrition is even higher in cognitively impaired elderly individuals and is associated with cognitive decline.^2
Patients who are malnourished when admitted to the hospital tend to have longer hospital stays, experience more complications, and have greater risks of morbidity and mortality than those whose nutritional state is normal.^3 By identifying elderly persons who are malnourished or at risk of malnutrition either in the hospital or community setting, the MNA® allows clinicians to intervene earlier to provide adequate nutritional support, prevent further deterioration, and improve patient outcomes.^4
Full MNA® vs. MNA®-SF
The full MNA® is a validated screening tool that identifies elderly persons who are malnourished or at risk for malnutrition. The full MNA® is the original version of the MNA® and takes 10-15 minutes to complete. The revised MNA®-SF is a short form of the MNA® that takes less than 5 minutes to complete. It retains the accuracy and validity of the full MNA®.^5 Currently, the MNA®-SF is the preferred form of the MNA® for clinical practice in community, hospital, or long term care settings, due to its ease of use and practicality.
The full MNA® is an excellent tool for the research setting. It may provide additional information about the causes of malnutrition in persons identified as malnourished or at risk for malnutrition. However, the full MNA® is not a substitute for a full nutritional assessment done by a trained nutrition professional. Recommended intervals for screening with the MNA® are annually in the community, every three months in institutional settings or in persons who have been identified as malnourished or at risk for malnutrition, and whenever a change in clinical condition occurs.
The MNA® was developed by Nestlé and leading international geriatricians. Well validated in international studies in a variety of settings6-8, the MNA® correlates with morbidity and mortality.
Instructions to complete the MNA®
Enter the patient’s information on the top of the form:
- Name • Gender • Age
- Weight (kg) – To obtain an accurate weight, remove shoes and heavy outer clothing. Use a calibrated and reliable set of scales. Pounds (lbs) must be converted to kilograms (1 lb = 0.45 kg).
- Height (cm) – Measure height without shoes using a stadiometer (height gauge). If the patient is bedridden, measure height by demispan, half arm-span, or knee height (see Appendix 2). Inches must be converted to centimeters (1 inch = 2.54 cm).
- Date of screen
Introduction
B
Involuntary weight loss during the last 3 months? Score 0 = Weight loss greater than 3 kg (6.6 pounds) 1 = Does not know 2 = Weight loss between 1 and 3 kg (2.2 and 6.6 pounds) 3 = No weight loss
Ask patient / Review medical record (if long term or residential care)
- “Have you lost any weight without trying _over the last 3 months?”
- “Has your waistband gotten looser?”
- “How much weight do you think you have_ lost? More or less than 3 kg (or 6 pounds)?” Though weight loss in the overweight elderly may be appropriate, it may also be due to malnutrition. When the weight loss question is removed, the MNA® loses its sensitivity, so it is important to ask about weight loss even in the overweight.
D
Has the patient suffered psychological stress or acute disease in the past three months? Score 0 = Yes 2 = No
Ask patient / Review medical record / Use professional judgment
_- “Have you been stressed recently?”
- “Have you been severely ill recently?”_
C
Mobility? Score 0 = Bed or chair bound 1 = Able to get out of bed/chair, but does not go out 2 = Goes out
Ask patient / Patient’s medical record / Information from caregiver
- “How would you describe your current _mobility?”
- “Are you able to get out of a bed, a chair, or a_ wheelchair without the assistance of another person?” – if not, would score 0 - “Are you able to get out of a bed or a chair, but unable to go out of your home?” – if yes, would score 1 - “Are you able to leave your home?” – if yes, would score 2
Screen and intervene. Nutrition can make a difference. 5
E
Neuropsychological problems?
Score 0 = Severe dementia or depression 1 = Mild dementia 2 = No psychological problems
Review patient medical record / Use professional judgment / Ask patient, nursing staff or caregiver
_- “Do you have dementia?”
- “Have you had prolonged or severe sadness?”_ The patient’s caregiver, nursing staff or medical record can provide information about the severity of the patient’s neuropsychological problems (dementia).
F
Body mass index (BMI)? (weight in kg / height in m^2 ) Score 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater
Determining BMI BMI is used as an indicator of appropriate weight for height (Appendix 1) BMI Formula – US Units
- BMI = ( Weight in Pounds / [Height in inches x Height in inches] ) x 703 BMI Formula – Metric Units
- BMI = ( Weight in Kilograms / [Height in Meters x Height in Meters] ) 1 Pound = 0.45 Kilograms 1 Inch = 2.54 Centimeters Before determining BMI, record the patient’s weight and height on the MNA® form.
- If height has not been measured, please measure using a stadiometer or height gauge (Refer to Appendix 2).
- If the patient is unable to stand, measure height using indirect methods such as measuring demi-span, arm span, or knee height. (See Appendix 2).
- Using the BMI chart provided (Appendix 1), locate the patient’s height and weight and determine the BMI.
Screen and intervene. Nutrition can make a difference. 7
G
Lives independently (not in a nursing home)? Score 1 = Yes 0 = No
Ask patient This question refers to the normal living conditions of the individual. Its purpose is to determine if the person is usually dependent on others for care. For example, if the patient is in the hospital because of an accident or acute illness, where does the patient normally live?
- “Do you normally live in your own home, or in an assisted living, residential setting, or nursing home?”
H
Takes more than 3 prescription drugs per day? Score 0 = Yes 1 = No
Ask patient / Review patient’s medical record Check the patient’s medication record / ask nursing staff / ask doctor / ask patient
I
Pressure sores or skin ulcers? Score 0 = Yes 1 = No
Ask patient / Review patient’s medical record
- “Do you have bed sores?” Check the patient’s medical record for documentation of pressure wounds or skin ulcers, or ask the caregiver / nursing staff / doctor for details, or examine the patient if information is not available in the medical record.
Additional Information
J
How many full meals does the patient eat daily? Score 0 = One meal 1 = Two meals 2 = Three meals
Ask patient / Check food intake record if necessary
- “Do you normally eat breakfast, lunch and _dinner?”
- “How many meals a day do you eat?”_ A full meal is defined as eating more than 2 items or dishes when the patient sits down to eat. For example, eating potatoes, vegetable, and meat is considered a full meal; or eating an egg, bread, and fruit is considered a full meal.
K
Selected consumption markers for protein intake Select all that apply.
- At least one serving of dairy products (milk, cheese, yogurt) per day? _Yes No
- Two or more servings of legumes or eggs_ per week? _Yes No
- Meat, fish or poultry every day?_ Yes No
Score 0.0 = if 0 or 1 Yes answer 0.5 = if 2 Yes answers 1.0 = if 3 Yes answers
Ask the patient or nursing staff, or check the completed food intake record
- “Do you consume any dairy products (a glass of milk / cheese in a sandwich / cup of yogurt / can of high protein supplement) _every day?”
- ”Do you eat beans / eggs? How often do you_ _eat them?”
- “Do you eat meat, fish or chicken every day?”_
O
Self-View of Nutritional Status
Score 0 = Views self as being malnourished 1 = Is uncertain of nutritional state 2 = Views self as having no nutritional problems
Ask the patient
- “How would you describe your nutritional state?” Then prompt ”Poorly nourished?” “Uncertain?” “No problems?” The answer to this question depends upon the patient’s state of mind. If you think the patient is not capable of answering the question, ask the caregiver / nursing staff for their opinion.
P
In comparison with other people of the same age, how does the patient consider his/her health status? Score 0.0 = Not as good 0.5 = Does not know 1.0 = As good 2.0 = Better
Ask patient
- “How would you describe your state of health compared to others your age?” Then prompt ”Not as good as others of your age?” “Not sure?” “As good as others of your age?” “Better?”
Again, the answer will depend upon the state of mind of the person answering the question.
Q
Mid-arm circumference (MAC) in cm Score 0.0 = MAC less than 21 0.5 = MAC 21 to 22
1.0 = MAC 22 or greater
Measure the mid-arm circumference in cm as described in Appendix 4.
R
Calf circumference (CC) in cm Score 0 = CC less than 31 1 = CC 31 or greater
Calf circumference should be measured in cm as described in Appendix 5.
Screen and intervene. Nutrition can make a difference. 11
Final Score
- Total the points from the assessment section of the full MNA® (maximum 16 points).
Intervention and Monitoring
- For recommended intervention and follow-up monitoring, please refer to Full MNA® Intervention Algorithm. For more information, go to www.mna-elderly.com
Final Score
Screen and intervene. Nutrition can make a difference. 13
Appendices
Appendix 1 Appendix 1 • Body Mass Index table
This abbreviated BMI table is provided for your convenience and facilitates completing the MNA®. It is accurate for the MNA®. In some cases, calculating the BMI may yield a more precise BMI determination.
Weight (pounds)
Weight (kg)
n 0 = BMI less than 19
n 1 = BMI 19 to less than 21
n 2 = BMI 21 to less than 23
n 3 = BMI 23 or greater
MNA® BMI Table for the Elderly (age 65 and above) Height (feet & inches) 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 45 20 20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 13 100 48 21 21 20 19 19 18 17 17 16 16 16 15 15 14 14 14 13 105 50 22 22 21 20 20 19 18 18 17 17 16 16 15 15 15 14 14 110 52 23 23 22 21 20 20 19 19 18 18 17 17 16 16 15 15 14 115 55 24 23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 120 57 25 24 24 23 22 22 21 20 20 19 19 18 17 17 17 16 16 125 59 26 25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 130 61 27 26 26 25 24 23 23 22 21 21 20 19 19 18 18 17 17 135 64 28 27 26 26 24 24 23 23 22 21 21 20 19 19 18 18 18 140 66 29 28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 145 68 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19 150 70 31 30 29 28 28 27 26 25 24 24 23 22 22 21 20 20 19 155 73 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20 160 75 33 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 165 77 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 170 80 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22 175 82 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 180 84 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 185 86 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 190 89 39 38 37 36 35 34 32 32 31 30 29 28 27 26 26 25 24 195 91 40 39 38 37 35 34 33 32 31 31 30 29 28 27 26 26 25 200 93 41 40 39 38 36 35 34 33 32 31 30 29 29 28 27 26 26 205 95 42 41 40 38 37 36 35 34 33 32 31 30 29 29 28 27 26 210 98 43 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 215 100 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 28 28 220 102 45 44 43 41 40 39 37 36 35 34 33 32 31 31 30 29 28 225 105 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 30 29 230 107 48 46 44 43 42 40 39 38 37 36 35 34 33 32 31 30 29 234 109 48 47 45 44 43 41 40 39 38 37 35 34 34 33 32 31 30 240 111 49 48 46 45 43 42 41 40 38 37 36 35 34 33 32 32 31 245 114 51 49 48 46 44 43 42 40 39 38 37 36 35 34 33 32 32 250 150 152.5 155 157.5 160 162.5 165 167.5 170 172.5 175 177.5 180 182.5 185 188 190 Height (cm)
Appendix 2 • Ways of Measuring Height
Demispan is the distance from the midline at the sternal notch to the web between the middle and ring fingers along outstretched arm. Height is then calculated from a standard formula.^9
- Locate and mark the midpoint of the sternal notch with the pen.
- Ask the patient to place the left arm in a horizontal position.
- Check that the patient’s arm is horizontal and in line with shoulders.
- Using the tape measure, measure distance from mark on the midline at the sternal notch to the web between the middle and ring fingers.
- Check that arm is flat and wrist is straight.
- Take reading in cm.
Calculate height from the formula below: Females Height in cm = (1.35 x demispan in cm) + 60. Males Height in cm = (1.40 x demispan in cm) + 57.
Demi-span
2.2 • Measuring height using demispan
2.1 • Measuring height using a stadiometer
- Ensure the floor surface is even and firm.
- Have subject remove shoes and stand up straight with heels together, and with heels, buttocks and shoulders pressed against the stadiometer.
- Arms should hang freely with palms facing thighs.
- Take the measurement with the subject standing tall, looking straight ahead with the head upright and not tilted backwards.
- Make sure the subject’s heels stay flat on the floor.
- Lower the measure on the stadiometer until it makes contact with the top of the head.
- Record standing height to the nearest centimeter.
Accessed at: http://www.ktl.fi/publications/ehrm/product2/part_iii5.htm Accessed January 15, 2011.
Source: Reproduced here with the kind permission of BAPEN ( British Association for Parenteral and Enteral Nutrition ) from the ‘MUST’ Explanatory Booklet. For further information see www.bapen.org.uk (http://www.bapen.org.uk/pdfs/must/must_explan.pdf)
Knee height is one method used to determine statue in the bed- or chair-bound patient and is measured using a sliding knee height caliper. The patient must be able to bend both the knee and the ankle of one leg to 90 degree angles.
2.4 • Measuring height using knee height
Using population-specific formula, calculate height from standard formula: Population and Gender group
Equation: Stature (cm) = Non-Hispanic white men (U.S.) 11 [SEE = 3.74 cm]
78.31 + (1.94 x knee height)
- (0.14 x age) Non-Hispanic black men (U.S.)^11 [SEE = 3.80 cm]
79.69 + (1.85 x knee height)
- (0.14 x age) Mexican-American men (U.S.)^11 [SEE = 3.68 cm]
82.77 + (1.83 x knee height)
- (0.16 x age) Non-Hispanic white women (U.S.)^11 [SEE = 3.98 cm]
82.21 + (1.85 x knee height)
- (0.21 x age) Non-Hispanic black women (U.S.)^11 [SEE = 3.82 cm]
89.58 + (1.61 x knee height)
- (0.17 x age) Mexican-American women (U.S.)^11 [SEE = 3.77 cm]
84.25 + (1.82 x knee height)
- (0.26 x age) Taiwanese men^12 [SEE = 3.86 cm]
85.10 + (1.73 x knee height)
- (0.11 x age) Taiwanese women 12 [SEE = 3.79 cm]
91.45 + (1.53 x knee height)
- (0.16 x age) Elderly Italian men^13 [SEE = 4.3 cm]
94.87 + (1.58 x knee height)
- (0.23 x age) + 4. Elderly Italian women 13 [SEE = 4.3 cm]
94.87 + (1.58 x knee height)
- (0.23 x age) French men^14 [SEE = 3.8 cm]
74.7 + (2.07 x knee height)
- (-0.21 x age) French women 14 [SEE = 3.5 cm]
67.00 + (2.2 x knee height)
- (0.25 x age) Mexican Men^15 [SEE = 3.31 cm] 52.6 + (2.17 x knee height) Mexican Women^15 [SEE = 2.99 cm]
73.70 + (1.99 x knee height)
- (0.23 x age)
Filipino Men^16 96.50 + (1.38 x knee height)– (0.08 x age)
Filipino Women^16 89.63 + (1.53 x knee height)– (0.17 x age)
Malaysian men 17 [SEE = 3.51 cm]
(1.924 x knee height)
Malaysian women 17 [SEE = 3.40]
(2.225 x knee height)
SEE = Standard Error of Estimate^11
Source: http://www.rxkinetics.com/height_estimate.html. Accessed January 15, 2011.
- Have the subject bend the knee and ankle of one leg at a 90 degree angle while lying supine or sitting on a table with legs hanging off the side.
- Place the fixed blade of the knee caliper under the heel of the foot in line with the ankle bone. Place the fixed blade of the caliper on the anterior surface of the thigh about 3.0 cm above the patella.
- Be sure the shaft of the caliper is in line with and parallel to the long bone in the lower leg (tibia) and is over the ankle bone (lateral malleolus). Apply pressure to compress the tissue. Record the measurement to the nearest 0.1 cm.
- Take two measurements in immediate succession. They should agree within 0.5 cm. Use the average of these two measurements and the patient’s chronological age in the population and gender-specific equations in the table on the right to calculate the subject’s stature.
- The value calculated from the selected equation is an estimate of the person’s true stature. The 95 percent confidence for this estimate is plus or minus twice the SEE value for each equation.
Screen and intervene. Nutrition can make a difference. 17
To determine the BMI for amputees, first determine the patient’s estimated weight including the weight of the missing body part.18,
- Use a standard reference (see table) to determine the proportion of body weight contributed by an individual body part.
- Subtract the percentage of body weight contributed by the missing body part(s) from 1.0.
- Then, divide the current weight by the difference of 1 minus the percentage of body weight contributed by the missing body part. Calculate BMI using estimated height and estimated weight.
Appendix 3 • Determining BMI for Amputees
Example: 80 year old man, amputation of the left lower leg, 1.72 m, 58 kg
- Estimated body weight: Current body weight ÷ (1 - proportion for the missing leg) 58 (kg) ÷ [1-0.059] = 58 (kg) ÷ 0.941 = 61.6 kg
- Calculate BMI: Estimated body weight / body height (m)^2
61.6 ÷ [1.72 x 1.72] = 20.
Weight of selected body components It is necessary to account for the missing body component(s) when estimating IBW. Table: Percent of Body Weight Contributed by Specific Body Parts Body Part Percentage Trunk w/o limbs 50. Hand 0. Forearm with hand 2. Forearm without hand 1. Upper arm 2. Entire arm 5. Foot 1. Lower leg with foot 5. Lower leg without foot 4. Thigh 10. Entire leg 16.
References cited: Lefton, J., Malone A. Anthropometric Assessment. In Charney P, Malone A, eds. ADA Pocket Guide to Nutrition Assessment, 2nd^ edition. Chicago, IL: American Dietetic Association; 2009:160-161. Osterkamp LK., Current perspective on assessment of human body proportions of relevance to amputees, J Am Diet Assoc. 1995; 95 :215-218.
Screen and intervene. Nutrition can make a difference. 19
- Guigoz Y, Vellas B. Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996; 54 :S59-S65.
- Fallon C, Bruce I, Eustace A, et al. Nutritional status of community dwelling subjects attending a memory clinic. J Nutr Health Aging 2002; 6 (Supp):21.
- Kagansky N, Berner Y, Koren-Morag N, Perelman L, Knobler H, Levy S. Poor nutritional habits are predictors of poor outcomes in very old hospitalized patients. Am J Clin Nutr 2005; 82 :784-791.
- Vellas B, Villars H, Abellan G et al. Overview of the MNA® – It’s history and challenges. J Nutr Health Aging 2006; 10 :456-
- Kaiser MJ, Bauer JM, Ramsch C, et al. Validation 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.
- Guigoz Y, Vellas J, Garry P (1994). Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 4 (supp. 2):15-59.
- Guigoz Y. The Mini-Nutritional Assessment (MNA®) review of the literature – what does it tell us? J Nutr Health Aging 2006; 10 :466-485.
- Murphy MC, Brooks CN, New SA, Lumbers ML. The use of the Mini Nutritional Assessment (MNA) tool in elderly orthopaedic patients. Eur J Clin Nutr 2000; 54 :555-562.
- HIckson M, Frost G. A comparison of three methods for estimating height in the acutely ill elderly population. J Hum Nutr Diet 2003; 6 :1-3.
- Kwok T, Whjitelaw, MN. The use of armspan in nutritional assessment of the elderly. J Am Geriatric Soc 1991; 39 :492-496.
- Chumlea WC, Guo SS, Wholihan K, Cockram D, Kuczmarski RJ, Johnson CL. Stature prediction equations for elderly non- Hispanic white, non-Hispanic black, and Mexican-American persons developed from NHANES III data. J Am Diet Assoc 1998; 98 :137-142.
- Cheng HS, See LC, Sheih YH. Estimating stature from knee height for adults in Taiwan. Chang Gung Med J. 2001; 24 :547-556.
- Donini LM, de Felice MR, De Bernardini L, et al. Prediction of stature in the Italian elderly. J Nutr Health Aging. 2000; 4 :72-76.
- Guo SS, Wu X, Vellas B, Guigoz Y, Chumlea WC. Prediction of stature in the French elderly. Age & Nutr. 1994; 5 :169-173.
- Mendoza-Nunez VM, Sanchez-Rodrigez MA, Cervantes-Sandoval A, et al. Equations for predicting height for elderly Mexican-Americans are not applicable for elderly Mexicans. Am J Hum Biol 2002; 14 :351-355.
- Tanchoco CC, Duante CA, Lopez ES. Arm span and knee height as proxy indicators for height. J Nutritionist-Dietitians’ Assoc Philippines 2001; 15 :84-90.
- Shahar S, Pooy NS. Predictive equations for estimation of statue in Malaysian elderly people. Asia Pac J Clin Nutr. 2003: 12 (1):80-84.
- Lefton J, Malone A. Anthropometric Assessment. In Charney P, Malone A, eds. ADA Pocket Guide to Nutrition Assessment. 2nd edtion Chicago, IL: American Dietetic Association; 2009:160-161.
- Osterkamp LK. Current perspective on assessment of human body proportions of relevance to amputees. J Am Diet Assoc. 1995; 95 :215-218.
References
Print CMYK | Blue = C 100% / M 72% / B 18% | Green = C 80% / Y 90%
Screen and intervene.
Nutrition can make a difference.