User Guide - Link 3

A Guide to Completing the
Mini Nutritional Assessment MNA®
1
Mini Nutritional Assessment (MNA®)
The MNA® is a screening and assessment tool
that can be used to identify elderly patients at
risk of malnutrition. The User Guide will assist
you in completing the MNA® accurately and
consistently. It explains each question and how
to assign and interpret the score.
Introduction:
While the prevalence of malnutrition in the freeliving 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
INSTRUCTIONS TO COMPLETE THE MNA®
Before beginning the MNA®, please 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. If applicable: convert
pounds (lbs) to kilograms (1kg = 2.2lbs).
-
Height (cm) – Measure height without
shoes using a stadiometer (height
gauge) or, if the patient is bedridden, by
knee height or demispan (see
Appendices 4 or 5). Convert inches to
centimeters (1inch = 2.54cm).
-
ID number (e.g. hospital number)
-
Date of screen
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 patients 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
Mini Nutritional Assessment MNA®
The MNA® provides a simple and quick method
of identifying elderly patients who are at risk for
malnutrition, or who are already malnourished.
It identifies the risk of malnutrition before severe
changes in weight or serum protein levels
occur.
The MNA® may be completed at regular
intervals in the community and in the hospital or
long term care setting.
The MNA® was developed by Nestlé and
leading international geriatricians and remains
one of the few validated screening tools for the
elderly. It has been well validated in
international studies in a variety of settings5-7
and correlates with morbidity and mortality.
2
Screening (MNA®-SF)
Complete the screen by filling in the boxes with the appropriate numbers. Then, add together the
numbers to determine the total score of the screen. If the score is 11 or less, continue on with the
assessment to determine the Malnutrition Indicator Score.
Key Points
Ask the patient to answer questions A – E, using the suggestions in the shaded areas. If the patient
is unable to answer the question, ask the patient’s caregiver to answer. Using the patient’s medical
record or your professional judgment, answer any remaining questions.
A.
Has food intake declined over the past three months due to loss of appetite, digestive
problems, chewing or swallowing difficulties?
Score 0 = Severe decrease in food intake
1 = Moderate decrease in food intake
2 = No decrease in food intake
Ask patient
ð “Have you eaten less than normal over the past three months?”
ð If so, “is this because of lack of appetite, chewing, or swallowing difficulties?”
ð If yes, “have you eaten much less than before or only a little less?”
ð If this is a re-assessment, then rephrase the question:
ð “Has the amount of food you have eaten changed since your last assessment?”
3
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 / medical record (if long term or residential care)
ð “Have you lost any weight without trying over the last 3 months?”
ð “Has your waistband gotten looser?”
ð “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.
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
ð “Are you presently able to get out of the bed / chair?”
ð “Are you able to get out of the house or go outdoors on your own?
4
D.
Has the patient suffered psychological stress or acute disease in the past three
months?
Score 0 = Yes
1 = No
Ask patient / Patient medical record / Professional judgment
ð “Have you suffered a bereavement recently?”
ð “Have you recently moved your home?
ð “Have you been sick recently?”
E.
Neuropsychological problems?
Score 0 = Severe dementia or depression
1 = Mild depression
2 = No psychological problems
Review patient medical record / Professional judgment / Ask nursing staff or caregiver
The patient’s caregiver, nursing staff or medical record can provide information about the severity
of the patient’s neuropsychological problems (dementia).
If a patient cannot respond (i.e. one with dementia) or is severely confused, ask the patient’s
personal or professional caregiver to answer the following questions or check the patient’s
answers for accuracy (Questions A, B, C, D, G, J, K, L, M, O, P).
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F.
Body mass index (BMI)? (weight in kg / height in m2)
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. BMI is calculated by dividing the
weight in kg by the height in m2 (Appendix 1).
BMI =
weight (kg)
height (m2)
Before determining BMI, record the patients’ weight and height on the MNA® form.
1. Convert subject’s weight to metric using formula 1kg = 2.2lbs
Convert subject’s height to metric using formula 1inch = 2.54cm
2. If height has not been measured, please measure using a stadiometer or height gauge (Refer
to Appendix 3).
3. If the patient is unable to stand, measure height using indirect methods such as measuring
demi-span (half arm span) or knee height (See Appendices 4 and 5). If height cannot be
measured either directly or by indirect methods, use a verbal or historical height to calculate a
BMI. Verbal height will be the least accurate, especially for bedridden patients and patients
who have lost height over the years.
4. Using the BMI chart provided (Appendix 1), locate the patient’s height and weight and
determine the BMI. It is essential that a BMI is included in the MNA® – without it the tool
is not valid.
5. Fill in the appropriate box on the MNA® form to represent the BMI of the patient.
6. To determine BMI for a patient with an amputation, see Appendix 2.
The screening section of the questionnaire is now complete. Add the numbers to obtain the
screening score.
A score of 12 points or greater indicates:
Patient is not at nutrition risk. There is no need to complete the rest of the questionnaire.
Rescreen at regular intervals.
A score of 11 points or less indicates:
Patient may be at risk for malnutrition. Please complete the full MNA® assessment by
answering questions G – R.
6
Assessment (MNA®)
G.
Lives independently (not in a nursing home)?)
Score 0 = No
1 = Yes
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?
ð “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 / Patient 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 / Patient’s medical record
ð “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.
7
J.
How many full meals does the patient eat daily?
Score 0 = 1 meal
1 = 2 meals
3 = 3 meals
Ask patient / Check food intake record if necessary
ð “Do you normally eat breakfast, lunch and dinner?”
ð “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
ð At least one serving of dairy products per day?
ð Two or more servings of legumes or eggs per week?
ð Meat, fish or poultry every day?
Yes ¨ No ¨
Yes ¨ No ¨
Yes ¨ No ¨
0.0 = if 0 or 1 Yes answer(s)
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
ð “Do you consume any dairy products (a glass of milk / cheese in a sandwich / cup of
yogurt / can of high protein supplement) every day?”
ð ”Do you eat beans/eggs? How often do you eat them?”
ð “Do you eat meat, fish or chicken every day?”
8
L.
Consumes two or more servings of fruits or vegetables per day?
Score 0 = No
1 = Yes
Ask the patient / check the completed food intake record if necessary
ð “Do you eat fruits and vegetables?”
ð ”How many portions do you have each day?”
A portion can be classified as:
One piece of fruit (apple, banana, orange, etc.)
One medium cup of fruit or vegetable juice
One cup of raw or cooked vegetables
M.
How much fluid (water, juice, coffee, tea, milk) is consumed per day?
Score 0.0 = Less than 3 cups
0.5 = 3 to 5 cups
1.0 = More than 5 cups
Ask patient
ð “How many cups of tea or coffee do you normally drink during the day?”
ð ”Do you drink any water, milk or fruit juice? What size cup do you usually use?
A cup is considered 200 – 240ml or 7-8oz.
9
N.
Mode of Feeding?
Score 0 = Unable to eat without assistance *
1 = Feeds self with some difficulty **
2 = Feeds self without any problems
Ask patient / Patient medical record/ information from caregiver
ð “Are you able to feed yourself?” / “Can the patient feed himself/herself?”
ð ”Do you need help to eat?” / “Do you help the patient to eat?”
ð “Do you need help setting up your meals (opening containers, buttering bread, or cutting
meats)?”
*Patients who must be fed or need help holding the fork would score 0.
**Patients who need help setting up meals (opening containers, buttering bread, or cutting
meats), but are able to feed themselves would score 1 point.
Pay particular attention to potential causes of malnutrition that need to be addressed to avoid
malnutrition (e.g. dental problems, need for adaptive feeding devices to support eating).
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 patient
ð “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.
10
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
ð “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 6.
11
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 7.
Measure the calf at the widest area. Take additional measurements above and below the widest
point to ensure that the first measurement was the largest.
Final Score
ð Total the points from the assessment section of the MNA® (maximum 16 points).
ð Add the assessment and screening scores together to get the total Malnutrition Indicator Score
(Maximum 30 points).
ð Check the appropriate box indicator.
ð If the score is greater than 23.5 points, the patient is in a normal state of nutrition and no further
action is required.
ð If the score is less than 23.5 points, refer the patient to a dietitian or nutrition specialist for
nutrition intervention.
Until a dietitian is available, give the patient / caregiver some advice on how to improve nutritional
intake such as:
ð Increase intake of energy/protein dense foods (e.g. puddings, milkshakes, etc).
ð Supplement food intake with additional snacks and milk.
ð If diet alone does not improve the patient’s nutritional intake, the patient may need oral nutritional
supplements.
ð Ensure adequate fluid intake; 6-8 cups / glasses per day
Follow-Up
ð Re-screen all patients every three months.
ð Please refer results of assessments & re-assessments to dietitian/doctor and record in medical
record.
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Appendices
Appendix 1
BODY MASS INDEX TABLE
Source:
Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults: The Evidence Report. National Institute of Health, National Heart Lung and Blood
Institute
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Appendix 2
DETERMINING BMI FOR AMPUTEES
ðTo determine the BMI for amputees, first
determine the patient’s estimated weight
including the weight of the missing body
part.8,9
− Use a standard reference (see table) to
determine the proportion of body weight
contributed by an individual body part.
− Multiple patient’s current weight by the
percent of body weight of the missing
body part to determine estimated weight
of missing part.
− Add the estimated weight of the missing
body part to patient’s current weight to
determine estimated weight prior to
amputation.
ð Divide estimated weight by estimated
body height2 to determine BMI.
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
Trunk w/o limbs
Percentage
50.0
Hand
Forearm with hand
0.7
2.3
Forearm without hand
Upper arm
Entire arm
Foot
Lower leg with foot
Lower leg without foot
Thigh
Entire leg
1.6
2.7
5.0
1.5
5.9
4.4
10.1
16.0
References cited:
Malone A. Anthropometric Assessment. In Charney P,
Malone E, eds. ADA Pocket Guide to Nutrition
Assessment. Chicago, IL: American Dietetic
Association; 2004:142-152.
Osterkamp LK. Current perspective on assessment of
human body proportions of relevance to amputees. J Am
Diet Assoc. 1995;95:215-218.
Example: 80 year old man, amputation of the left lower leg, 1.72 m, 58 kg
1. Estimate body weight: Current body weight + Proportion for the missing leg
58 (kg) + [58 (kg) x 0.059] = 61.4 kg
2. Calculate BMI: Estimated body weight / body height (m) 2
61.4 / 1.72 x 1.72 = 20.8
3. Calculate energy intake:
ð Recommended energy intake – 5.9%
ð Empirical formula (30 kcal/kg/day):
30 kcal/kg/d X [61.4 kg – (61.4 x 0.059)] = 1,832 kcal/day
Conclusion: Corrected BMI is 21, and estimated energy intake is 1,800 – 1,900
kcal/d
14
Appendix 3
MEASURING HEIGHT USING A STADIOMETER
Accessed at:
http://www.ktl.fi/publications/ehrm/product2/part_
iii5.htm
1. Ensure the floor surface is even and firm.
2. Have subject remove shoes and stand up
straight with heels together, and with
heels, buttocks and shoulders pressed
against the stadiometer.
3. Arms should hang freely with palms facing
thighs.
4. Take the measurement with the subject
standing tall, looking straight ahead with
the head uprights and not tilted
backwards.
5. Make sure the subjects heels stay flat on
the floor.
6. Lower the measure on the stadiometer
until it makes contact with the top of the
head.
7. Record standing height to the nearest
centimeter.
15
Appendix 4
MEASUREMENT OF DEMISPAN
ð Demispan (half-arm span) is the
distance from the midline at the sternal
notch to the tip of the middle finger
Height is then calculated from a
standard formula.10
1. Locate and mark the edge of the right
collar bone (in the sternal notch) with the
pen.
2. Ask the patient to place the left arm in a
horizontal position.
3. Check that the patient’s arm is horizontal
and in line with shoulders.
4. Using the tape measure, measure
distance from mark on the midline at the
sternal notch to the tip of the middle finger.
5. Check that arm is flat and wrist is straight.
6. Take reading in cm.
Calculate height from the formula below:
Females
Height in cm =
(1.35 x demispan in cm) + 60.1
Males
Height in cm =
(1.40 x demispan in cm) + 57.8
Source:
http://www.rxkinetics.com/height_estimate.htm
l . Accessed December 12, 2006.
16
Appendix 5
MEASUREMENT OF KNEE HEIGHT
ð Knee height is one method to determine
statue in the bed- or chair-bound patient
and is measured using a sliding knee
height caliper. The subject must be able
to bend the knee and the ankle to 90
degree angles.
1. 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 of the table.
2. 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.
3. 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.
4. Take two measurements in immediate
auccession. They should agree within 0.5
cm. Use the average of these two
measurements
and
the
person's
chronological age in the Country and
ethnic group specific equations in the
following table.
5. 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 and minus twice the
SEE value for each equation.
Source:
http://www.rxkinetics.com/height_estimate.htm
l . Accessed December 12, 2006.
17
Using population-specific formula, calculate height from standard formula:
Gender and
ethnic group
Equation
Non-Hispanic white men (U.S.)11
[SEE = 3.74 cm]
Stature (cm) = 78.31+(1.94 x knee height) – (0.14 x age)
Non-Hispanic black men (U.S.)11
[SEE = 3.80 cm]
Stature (cm) = 79.69+(1.85 x knee height) – (0.14 x age)
Mexican-American men (U.S.)11
[SEE = 3.68 cm]
Stature (cm) = 82.77+(1.83 x knee height) – (0.16 x age)
Non-Hispanic white women (U.S.)11
[SEE = 3.98 cm]
Stature (cm) = 82.21+(1.85 x knee height) – (0.21 x age)
Non-Hispanic black women (U.S.)11
[SEE = 3.82 cm]
Stature (cm) = 89.58+(1.61 x knee height) – (0.17 x age)
Mexican-American women (U.S.)11
[SEE = 3.77 cm]
Stature (cm ) = 84.25+(1.82 x knee height) – (0.26 x age)
Taiwanese men12
[SEE = 3.86 cm]
Stature (cm) = 85.10 + (1.73 x knee height) – (0.11 x age)
Taiwanese women12
[SEE = 3.79 cm]
Stature (cm) = 91.45 + (1.53 x knee height) – (0.16 x age)
Elderly Italian men13
[SEE = 4.3 cm]
Stature (cm) = 94.87 – (1.58 x knee height) – (0.23 x age)
+4.8
Elderly Italian women13
[SEE = 4.3 cm]
Stature (cm) = 94.87 + (1.58 x knee height)– (0.23 x age)
French men14
[SEE = 3.8 cm]
Stature (cm) = 74.7 + (2.07 x knee height) – (-0.21 x age)
French women14
[SEE = 3.5 cm]
Stature (cm) = 67.00 + (2.2 x knee height) – (0.25 x age)
Mexican Men15
[SEE = 3.31 cm]
Stature (cm) = 52.6 + (2.17 x knee height)
Mexican Women15
[SEE = 2.99 cm]
Stature (cm) = 73.70 + (1.99 x knee height) – (0.23 x age)
Filipino Men16
Stature (cm) = 96.50 + (1.38 x knee height) – (0.08 x age)
16
Stature (cm) = 89.63 + (1.53 x knee height) – (0.17 x age)
17
Malaysian men
[SEE = 3.51 cm]
Stature (cm) = (1.924 x knee height) + 69.38
Malaysian women17
[SEE = 3.40]
Stature (cm) = (2.225 x knee height) + 50.25
Filipino Women
18
Appendix 6.
MEASURING MID ARM CIRCUMFERENCE
1. Ask the patient to bend their non-dominant
arm at the elbow at a right angle with the
palm up.
2. Measure the distance between the
acromial surface of the scapula (bony
protrusion surface of upper shoulder) and
the olecranon process of the elbow (bony
point of the elbow) on the back of the arm.
3. Mark the mid-point between the two with
the pen.
4. Ask the patient to let the arm hang loosely
by his/her side.
5. Position the tape at the mid-point on the
upper arm and tighten snugly. Avoid
pinching or causing indentation.
6. Record measurement in cm.
7. If MAC is less than 21, score = 0.
If MAC is 21-22, score = 0.5.
If MAC is 22 or greater, score = 1.0.
Source: Moore MC Pocket Guide to Nutrition
and Diet Therapy. 1993
Source: PEN Group. A pocket guide to
clinical nutrition: Assessment of nutritional
status. British Dietetic Association. 1997
Appendix 7
MEASURING CALF CIRCUMFERENCE
1. The subject should be sitting with the left hanging loosely or standing with their weight evenly
distributed on both feet.
2. Ask the patient to roll up their trouser leg to uncover the calf
3. Wrap the tape around the calf at the widest part and note the measurement.
4. Take additional measurements above and below the point to ensure that the first measurement
was the largest.
5. An accurate measurement can only be obtained if the tape is at a right angle to the length of the
calf, and should be recorded to the nearest 0.1 cm.
19
References
1. 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.
2. 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.
3. 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;82:784791.
4. Vellas B, Villars H, Abellan G et al. Overview of the MNA® – It’s history and challenges. J Nutr
Health Aging 2006;10:455-465.
5. 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.
6. Guigoz Y. The Mini-Nutritional Assessment (MNA®) review of the literature – what does it tell
us? J Nutr Health Aging 2006;10:465-487.
7. 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.
8. Malone A. Anthropometric Assessment. In Charney P, Malone E, eds. ADA Pocket Guide to
Nutrition Assessment. Chicago, IL: American Dietetic Association; 2004:142-152.
9. Osterkamp LK. Current perspective on assessment of human body proportions of relevance to
amputees. J Am Diet Assoc. 1995;95:215-218.
10. 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.
11. 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.
12. Cheng HS, See LC, Sheih. Estimating stature from knee height for adults in Taiwan. Chang
Gung Med J. 2001;24:547-556.
13. Donini LM, de Felice MR, De Bernardini L, et al. Prediction of stature in the Italian elderly. J Nutr
Health Aging. 2004;8:386-388.
14. Guo SS, Wu X, Vellas B, Guigoz Y, Chumlea WC. Prediction of stature in the French elderly.
Age & Nutr. 1994;5:169-173.
15. Mendoz-Nunez VM, Sanchez-Rodriguez 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.
16. 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.
17. Shahar S, Pooy NS. Predictive equations for estimation of statue in Malaysian elderly people.
Asia Pac J Clin Nutr. 2003:12(1):80-84.
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