THE MINI NUTRITIONAL ASSESSMENT (MNA) · PDF fileFACTS AND RESEARCH IN GERONTOLOGY 1994...

FACTS AND RESEARCH IN GERONTOLOGY 1994 SUPPLEMENT Na 2

(Reprint)

NUTRITION IN THE ELDERLY

THE MINI NUTRITIONAL ASSESSMENT (MNA)

Serdi Publishing Company

FACTS ANDRESEARCH IN GERONTQLOGY T994 (Sopplement : Nutritfofl) O

15

FACTS AND RESEARCH IN GERONTOLOGY 1994 (Supplement : Nutrition) O

The 347 subjects (140 males, 207 females) from the New Mexico Aging Process Study were assessed by the MNA at the 1993 annual visit [45].

The age and stature of the men (n = 140) were 77 f 5.8 years (mean f SD) and 173.2 f 7.0 cm, respectively. The age and stature of the women (n = 207) were 77 f 6.8 years and 158.2 f 6.3 cm, respectively.

For this report, the following evaluation was retained for each patient: "Mini Nutritional Assessment (MNA) test "Nutritional evaluation by biological markers (albumin, creatinine, cholesterol

and lymphocyte counts) and anthropometry (body mass index, mid-arm circumference and calf circumference).

Data collection The following data were collected for the developmental study (Toulouse

Anthropometric measurements were performed according to Chumlea [46]. Weight was measured to the nearest 0.1 kg, heights and circumferences to the nearest 0.1 cm, and skinfold thicknesses to the nearest 0.2 mm: Height (Ht), body weight (BW), knee height (KnHt), calf circumference(calfcirc), mid arm circumference (MAC), triceps and subscapular skinfolds (TSF and SSF), and the derived measures of body mass index (BMI, direct and derived) [46] and mid arm muscle circumference (AMA).

Biochemical measurements

Blood was taken in the morning (before 10 a.m.) after an overnight fast and samples collected in Cu- and Zn-free syringes (Monovette, Sarstedt, Nümbrecht, Germany) were handled according to the procedure used for the Euronut-Seneca

Serum albumin, transferrin, a1 -acid glycoprotein, transthyretin (prealbumin), ceruloplasmin, retinol binding protein, C-reactive protein (CRP) were analyzed by nephelometry with a Behring Nephelometer (methods and reagents from Behring, Marburg, Germany). Serum creatinine, gamma-glutamyl transferase, total protein, cholesterol, triglycerides were analyzed with a centrifugal analyzer Cobas-Fara (instrument, methods and reagents from Roche Diagnostica, Basle, Switzerland). Serum folate and vitamin BI 2 (cobalamine) were analyzed by radioimmunoassay (Dual Count, Diagnostic Product Corporation, Los Angeles, California, USA). Serum vitamin A (retinol), and vitamin E (a-tocopherol) were analyzed by reversed phase HPLC according to Hess D. et al [48]. Serum vitamin D (25-OH vitamin D) was analyzed by radioimmunoassay (25- hydroxyvitamin D 3H RIA kit, lncstar Corporation, Stillwater, Minnesota, USA). Serum zinc, and copper were analyzed by flame atomic absorption spectrometry (AAS: Spectr. AA20, Varian Techtron, PTY Ltd, Springvale, Australia). I 19


RESULTS

Characteristics of the populations

a) Developmental Study, Toulouse 91

The characteristics of the population are summarized in Table 1 (see in Annex). Forty-nine percent of the subjects were between 75 and 85 years of age with 10% lower than 65 and 21% over 85. Most of the subjects (86%) ate three meals a day, but 40% indicated loss of appetite (moderate anorexia), and 18% had to be fed with assistance. Twenty percent rated their health better than others of the same age, and 20% not as good. About half of the subjects (45%) had normal serum albumin (> 35 g/L) and hemoglobin levels >13 g/dl (data not shown), but 36% had very low serum albumin (<30 g/L) and 34% were anemic. General description of the results by sex is given in Table 2a (age, MMS, ADL, and anthropometric measurements), Table 2b (biochemical indices of nutritional status), Table 2c (hematology), Table 2d (dietary macronutrient, mineral and vitamin intakes), and Table 2e (food intakes) (See in Annex).

b) Validation Study, Toulouse 93

The characteristics of the population are summarized in Table 3 (See in Annex). Forty percent of the subjects were between 75 and 85 years of age with 8% less than 65 and 26% over 85. Seventy percent of the subjects ate three meals a day, 31% indicated loss of appetite (moderate anorexia), and about one third (31%) had to be fed with assistance. Twenty-eight percent rated their health better than others of the same age, but 43% not as good. More than half of the subjects (56%) had normal serum albumin (> 35 g/L) and 23% had very low serum albumin (<30 g/L). A general description of the results by sex is given in Table 4 (age, ADL, anthropometry, biochemistry, hematology, and grip strength) (See in Annex).

This group of subjects was very similar to the one of the baseline study, with a wide spectrum of health and nutritional status. The self-perception of health was however more negative while the nutritional status, assessed by albumin alone, was better.

c)

The characteristics of this healthy population are summarized in Table 5 (See in Annex). Forty-six percent of the subjects were between 75 and 85 years of age and 11% over 85. Seventy-six percent of the subjects ate three meals a day, only 9% indicated loss of appetite (moderate anorexia), and 3 subjects (from 347 subjects) had some difficulty or had to be fed with assistance. Sixty-seven percent rated their health better than others of the same age, and only 1% not as good. Most of the subjects (89%) had normal serum albumin (> 35 g/L) and one subject had very low serum albumin (<30 g/L).

Study on Healthy Elderly, Albuquerque 93

21

MINI NUTRITIONAL ASSESSMENT (M.N.A.)

A general description of the results by sex is given in Table 6 (age, anthropometry, biochemistry, and hematology) (See in Annex). This group of subjects represent successful aging, even for those more than 85 years of age. Most of them were independent, had a good appetite, had a serum albumin above 35 g/L, took less than 3 drugs per day, and rated their nutritional status as normal.

Overall, we can conclude that the populations studied represent the whole spectrum of elderly subjects, from the very active healthy to the very frail house- bound or demented hospitalized ones. The developmental study (Toulouse 91) was first done to test the MNA, and the second study (Toulouse 93) was used to validate it. The study on healthy elderly (Albuquerque 93) was used to evaluate the potentials of the MNA in a healthy population and to validate it in different cultural contexts.

.

Validation of the MNA, Toulouse 91

Clinical Status

Due to lack of standards to classify the elderly subjects according to their nutritional status and the variability within the elderly, we used as “gold standard” the clinical status, a nutritional assessment done independently by two physicians, trained in nutrition, on the basis of the subjects’ clinical file without knowledge of the MNA results.

Using clinical status as a standard, the subjects were classified as 53 (34%) well-nourished (normal), 89 (57%) undernourished and 13 (8%) (= uncertain) who were not classified. Tables 7a to 7e (See in Annex) give a summary of the results for the general characteristics and MNA scores, anthropometric measurements, clinical biochemistry for protein, vitamins and minerals, hematological parameters, nutrient intakes, and food consumptions.

The relationship between serum albumin and transthyrethin levels, and the clinical status is shown on Figures 1 and 2 (See in Annex). These two serum proteins are strongly related to the nutritional and disease (mainly inflammatory) status of an individual. Body mass index (BMI), an index of long term malnutrition also showed a significant difference within the subjects classified as well- nourished (normal) or under-nourished (Figure 3 in Annex):

Body mass index (BMI) (mean f SD) in kg/m2 normal undernutrition

26.3 f 3.54 19.7 * 3.48

24.8 2.76 20.8 f 3.83.

In general these results (Figures 1-3) indicate that the clinical status is of value to measure the validity of the MNA, since no simple clinical definition of nutritional status exists. I

,

I 22


Biological signs such as serum abumin betow 30 g/l, body mass index below 20 kg/m2, lymphocyte count below 1500/ml, are, however signs of established undernutrition, which need an intervention (nutritional support).

MNA Score and Clinical Status

Classification based on the clinical status gives the following MNA score when

MNA score

the biochemical indices are included (total: max. 30 pts):

normal undernutrition

26.7 f 3.9 26.1 ? 2.1

14.7 f 4.4 15.5 f 3.5.

MNA score without clinical biochemistry (max.: 23 pts) normal undernutrition

20.3 f 2.5 20.5 f 2.0

11.9 f 4.1 12.7 f 3.4.

These results indicate that nutritional status is correctly assessed by the MNA, both with or without biochemistry. As for the clinical status, the MNA is corelated with serum albumin and transthyretin. Figures 4, 5 and 6 (in Annex) illustrate the selection capacity of the MNA, including biochemical indices, in relation to that of albumin, transthyretin and of body mass index. Figures 7, 8 and 9 (in Annex) illustrate the selection capacity of the MNA without biochemical indices in relation to the same variables. These results suggest that the selective capacity of the MNA either with or without clinical biochemistry (biochemical indices) is similar.

Selectivity of the MNA

Principal Component Analysis

In order to analyze the results the most objectively, they were grouped by principal component analysis in 5 different variables, “components”, which contain the majority of the information [52]. The variables for nutrition (energy intake, protein, lipid and carbohydrate intakes), for clinical biochemistry (albumin at hospitalization, transferrin, albumin, alpha acid glycoprotein, transthyretin, ceruloplasmin, retinol binding protein, C-reactive protein, gamma- glutamyltransferase, total protein, cholesterol, triglycerides, folate, vitamin BI 2, A and E, zinc, copper, and activation factors for vitamin B I , 52, and B6), for hematology (hemoglobin, hematocrit, red blood cell count, mean corpuscular volume, mean corpuscular hemoglobin concentration, leukocytes, neutrophiles, eosinophiles, basophiles, monocytes, lymphocytes, and thrombocytes), and for anthropometry (weight, body mass index, calculated body mass index, knee- height, calf circumference, mid-arm circumference, triceps and subscapular skinfolds), as well as for age and cut off points for albumin at hospitalization (> 35, 2: 30-35, 3: < 30 g/L) and healthy elderly and subjects with inflammation (CRP>20 mg/L) were computed by principal components analysis. I 23


The 5 new composite variables ("components") distinguish clearly between the healthy elderly and the subjects with inflammatory disease, while the other subjects are spread in between. For the variables distribution, the anthropometric variables are grouped together, the serum protein are placed according to their response to inflammation (data not shown).

Using the same procedure, the subjects were analyzed based on the MNA: Figure 10 (see Annex) represents the subject distribution computed according to the parameters of the MNA (anthropometric, global, dietetic, and subjective assessment) without biochemical assessment. It appears from these results that the well-nourished subjects (1) are well separated from the malnourished subjects (2). The variable axis F1 and F2 explained 74% of the variance.

These results indicate that the MNA without clinical biochemistry can also be used to screen for the nutritional status.

Discriminant analysls

Discriminant analysis was used to test the MNA in comparison with the clinical status set by the physicians, which is used as standard. According to the classification in the clinical status , for each variable listed above (see principal component analysis) a linear equation was computed and all the equations were used to reclassify the subjects. Due to computation rejection, the hematological variables were not used in these analysis. The re-classification gave the following

Classification matrix (clinical status versus complete assessment)

Classification variable: clinical status Independent variables: energy intake, protein intake, lipid intake,

carbohydrate intake, transferrin, albumin, alphal acid glycoprotein, transthyretin, ceruloplasmin, retinol binding protein, C-reactive protein, gamma-glutamyl transferase, total protein, cholesterol, triglycerides, folate, vitamin B12, A and E, zinc, copper, weight, body mass index, calf circumference, mid-arm circumference, triceps and subscapular skinfolds.

Group Counts Table calculated values well-nourished malnourished

all Observed Values (clinical status)

well-nourished 50 49 1 malnourished 75 2 73

From this table, we can see that only 3 subjects out of 125 were misclassified by computation. I 24


These results indicate that even in a healthy elderly group as in the New Mexico Aging Process Study (Albuquerque 93), about 20% of the elderly are borderline and should be assessed for risk of malnutrition, even if albumin levels and BMI are in the normal range (Table 9 in Annex).

DISCUSSION

A rapid assessment tool, the MNA, was validated in two populations of elderly (Toulouse 91 and Toulouse 93) using discriminant analysis. The present results show that the MNA test can accurately assess the nutritional status of elderly: a) normal or well-nourished, borderline or at risk of malnutrition, and presence of undernutrition. Both normal and malnutrition classifications were the same as those obtained using the nutritional clinical assessment by a physician (trained in nutrition), with comprehensive clinical files (referred to here as clinical status). The borderline status identifies elderly at risk of malnutrition, who need further assessment. About 75% (3/4) of the elderly can be identified without further assessment. While the normal or well-nourished group show normal values for albumin,, the assessment as malnourished corresponds to low serum albumin levels, a general indicator of health status and a prognostic of death in hospitalized elderly patients [53].

In contrast to other assessment tools actually developed from acute care conditions [26-301 or too general and not yet validated [22,23], the MNA was developed and cross-validated in elderly populations from the very frail to the healthy elderly.

The MNA can become an important tool in evaluating the risk of malnutrition in the elderly, if integrated in geriatric assessment programs [33-351. Nutritional assessment using MNA can be easily done by health professionals at admission to hospital, into nursing homes, or by general physicians for early detection of risks of malnutrition. When malnutrition is detected , early management by nutritional intervention is of high importance and is associated with improvement in nutritional parameters [54].

Acknowledgments : The authors wish to thank particularly the field dietitians C. Hum and S. Lauque for collecting data, and J.A. Antonioli for statistical analysis, as well as B. Decarli for the preparation of the food table, I. Stebenet, A. Blondel, S. Guinchard, C. Nielsen Moënnoz and R. Mansourian for clinical analysis and J. Haller, Hoffmann-La Roche Basle for vitamin B1, B2 and B6 status analysis. We also wish to thank C. Faisant, M. Sedeuilh, Prof. P. Vellas from the Université du 3ème âge in Toulouse, I. de Naurois, P.J. Dusset, A. Ghisolfi- Marave, Prof J.L. Albarede from the C.H.U. Purpan Toulouse, H. Dirren, E. Fern, R. Muñoz-Box, from the Nestle Research Centre, Lausanne, and R. Acheson for critical reading of this manuscript.

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36

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W

2

W

W

P

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Tabl

e 4:

Tou

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e 93

: Age

, AD

L. a

nthr

opom

etry

, bio

chem

istly

, hem

ato

my

and

grip

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phoc

fle

1 O

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prot

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min

e m

unts

st

reng

th

“1 [p

mol

/L]

[mm

oVLj

I

g4

[%

I [W

ml]

lksw

l 9

6

34

35

23

23

25

25

23

27

36 9

30

11

1 2

0

13 2

35

4

1368

Iglu

66

50

26

0

6

54

7.

3 60

4 11

2

mal

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mea

n f

SD

n

I I

34

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11.5

34.3

1542

3.

1

83

82

53

47

58

57

52 I

64

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43

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Of D

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206

40.7

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207

207

207

207

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4.3

2.7

2.9

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14

14

14

14

12

14

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29.2

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8.8

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32

32

32

33

32

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29.8

35.6

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26.6

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Table 7e Toulouse 91 Mean daily food intake by dinical Slatus: I

cheese mska q g s 6 meat a poullry flsha mOYUSC5 yoghun egg meat

m d u h omduds

lemaies normal mean 64 253 17 74 22 32 f so 43 168 12 54 15 17 n 39 38 39 39 39 39

umer- mean 51 217 10 52 14 12 nourished * S O 41 128 9 34 12 11

n 54 54 54 54 54 54

Table le : Toulouse 91 Mean daily food intake by clinical Status: II

sugar beer wine liqueur drinks soups& soirit non- sauces

almholic

under- mean 29 0.4 nourished t S D 20 2.5 1 O8 463

n 32 32 32 J

iemabs noimal mean 25 0.3 70 O 1345 160 * SD 19 1 8 109 O 493 I W n 39 39 38 39 39 38

under- mean 27 0.0 38 O 784 1M nourished t S D 21 0.0 85 O 318 129

n 54 54 54 54 54 54 -

40

Table 9: Albuquerque 93: Age, anthropometry albumin, and MNA score

Age Weight Height BMI Albumin MNA Score

lmales normal mean I 76.21 ([year] I[kg] ([cm] l[kg/m2] I[g/L] I(3Öpts)

76.31 173.01 25.51 41.41 26.6 I f SD 5.71 11.01 7.01 3.31 2.81 1.5 n 113

atrisk mean 79.5 75.3 174.6 24.8 40.7 21.6 f SD 5 1 10.2 7.0 3.8 3.2 1.6 " 3n

~

Undemowished: only huo subjects

50


Faure 1 Box plot of 88wm album wnw Clinml slms (ClIPIcaI slatus normal = 1. undamou* = 2)

Serum Abmin (@I 50.00

30.00

23.33

16.67

I 2 C1i"lEsl slalus

. 3 8

.32

.25

. I 8

.lZ a 8

I

.O5 E I 2

Cl1"Ical *latus

35.00

30.00

25.00

20.00

15.00

lO.00' I 2 ClinCa1 Stahls

51


FI- 4 Plot of 58- album wr8w MNA smre with blachemlstry maximum 30 FOINS Clinlcal status 1 =normal, 2 = malnounshed

Figure 5 Plot of tansthyretin (preabumm) w s u s MNA smre wdh biah%misby maximum 30 points. Clinical status: 1 = n m d 2 =malnourished.

52

FACTS AND RESEARCH IN GERONTOLOGY 1994 (Supplement : Nutrition) O Figure 6: Pbl ot BMI nmus MNA ron tob1

Y N A ~ C O ~ mw: " v m 30 peina including me Modanicsl IndkES. CllnkaI slalw I= "al: 2 = malmunahed.

B M Wdl r - i ' J ~ " ' I ~ ' ' ' I ' ' ' ' I ~ ' ' ' l " ' ' I ~ ' ' ' I ........

1 ;

: t

, . , !- ,( _. ....................................................

3 , . j S 1 * 1 2 j

I I I

; O , ~

. ................. , * . ,............... I...;.-

I , ,*:[ e I , I , I ' i 1

1 : 2 , 2 : ,f*2z(*;I*

........ 1 ......... i' I .... zk*..-.$ .... '...:: ......... L

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i , , , , l , l , l l l , l l l , , l l l l , l . l l l I I I I 2D I 24

MNA xon trm

Figure 7 plot of serum albumin wrsus MNA scam withod biohemMry MNA score 0xck~Iing I h e bioChendcaI indices: mlodmum 23 pints Clinical Status: I= normal: 2= malnourished , ¡Y . ~-

1 ........ .....

53


54


Figurs I o : Principal mmponents anaCis using MNA indcss withaul biochemulry Scatter plDl of subi& WBh idenliflcation for clinical *lus. (csnicalst;aus: normal = 1; mslnouhhed = 2.

abscissa: component FI; ordinale: component F,.

F I

8.00 2

5 .00

2.00

-1 .00

I 1

I

1

I l I

I

1:' 1

2

2 a

2 2 1 : 2 2

l 2 2 2 I ' I 2 2 2

2

2 2

z ? 2

2 2

2 : 2 2 22 2 2

I 2 2 2 2 P

2

2 z 2 2 2

2 2

2

d 2

2

-4.001 3 -2

F2

Figure 11: Box plot of MNA swre with biochemistry versus clinical status maximum 30 points. Clinlcal status: normal = 1; malnourished = 2.

MNA score with biochemistry 30.001

25.00

20 .00

15.00

10.00

5.00

O

97 O

0.00 1 2

Clinical status

55


Figure 12 Box plot of MNA swre wllrcul biocnemislry versu clincal status MNA scire exclhd ng lhe biochemical Indices maximm 23 po,nls

C inical slalus norfrat = 1, malnourished = 2

MNA score without biochemistry < , . " Y

20.00

15.00

10.00

5.00

0.00 O O

-5.001 1 2

Clinical status

Figure 1 3 Cliniml diagnostic compared to computed diagnastic Box plot 10, Toulouse 03 compuled nutriUonals18111s bydisuininant analysis equatian lmm Toulouse 91 MNA SCOR wkhaul blochemistv to 30 points. Change in status compared to cunical slalus: O = normal to undemourished (n = 25: 21%) 1 =caned, normal (n = 41; 35%) 2 = correct. undernourished (n = 48: 41%) 3 - undemourished Io normal (n = 4 3%)

MNA swre (30 points)

3 5 . 0 0

2 9 . 1 7

1 7 . 5 0

11.67

O 1 2 3 Clinical slalus

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Figure 14. Clinical diagnostic compared to computed diagnostic Box plot for Toulouse 91 computed nutrtllonal status by dbcllmnant analysis equation fmm Toulouse 83. MNA score inhout biochemistry IO 30 points. Change in slalus "pared lo clinical slaius: 0 = normallo undemourished (n = 1; 0.7%) 1 = cored, normal (n - 5 3 37%) 2 = comcI. undemourished (n = 4 6 34%) 3 = urmemodhed lo normal (n = 4 0 28%)

MNA score (Y) paints)

2 9 . 1 7

O

23.331 O

11.671 H 5.83 T

O

O 1 2 3 Clinical status

Figure 15: Toulouse 93: Box plot for MNA score versus serum albumin cut off

MNA score

29.17

23 .33

17 .50

1 1 . 6 7

5 . 8 3

0 O

Q

0.00

c 2 0 e25 c30 c 3 5 e40 >40

Albumin cut off V L I

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Figure 16: Albuquerque 93: Box plot for status set by MNA score Cut off. malnourished = 1 MNA more €17 (n= 2) borderline = 2 MNA score 17-23.5 n= 60) normal 3 MNA score 2224 [n=268), missing values (n=17).

MNA score 30.001 1

5 . 0 0 I 2 3

MU4 nutritional status

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THE MINI NUTRITIONAL ASSESSMENT (MNA) · PDF fileFACTS AND RESEARCH IN GERONTOLOGY 1994...

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Transcript of THE MINI NUTRITIONAL ASSESSMENT (MNA) · PDF fileFACTS AND RESEARCH IN GERONTOLOGY 1994...