The Mini Nutritional Assessment Tool and Critically Evaluate the Clinimetrics of This Method - Essay Example

Topic:  Compare and Contrast Literatures about the Mini Nutritional Assessment (MNA) tool and critically evaluate the Clinimetrics of this Method. Mini Nutritional Assessment (MNA) tool, developed by the Nestlé Research Center, in collaboration with hospital clinicians, is comprised of 15 questions, and four anthropometric measures, a validated screening and assessment tool that identifies the risk of malnutrition among geriatric patients. According to Amella (2007), MNA is the best tool to identify the risk of malnutrition in an older adult. This innovative clinical evaluation, which has been validated in the United States (US) and internationally, monitors the nutritional status of the elderly through a pen and a paper as well as computer. Hence, through this tool, the risk of elderly patients for malnutrition can be quickly and effectively assessed. Harris et al (2007) in an observational study compares sensitivity, specificity, and the predictive positive and negative values of the screening measures in the elderly who leaves in a sheltered accommodation. These are: body mass index, mid – arm circumference, albumin, hemoglobin, lymphocyte count, cholesterol, and the Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment (MNA). In this study, the gold standard used to establish malnutrition risk was the assessment of a dietitian. Harris et al (2007) noted that out of 100 recruited people (31 male and 69 female having an average age of 79.3 year), ten of which categorized by the assessment of dietitian were at risk for malnutrition. The most sensitive and specific measure of screening, with 100% and 98% respectively, was the MUST score. The aforementioned has a specific predictive value of 1. On the other hand, the sensitivity and specificity of other values were the following: MNA 80% and 90%, mid-arm circumference 70% and 99%, BMI 60% and 90%, albumin 30% and 77%, hemoglobin 50% and 61%, lymphocyte count 20% and 86%, low cholesterol 30% and 90%. From this study, Harris et al (2007) concluded that in a sheltered housing, ten percent of the elderly were at risk for malnutrition. They further concluded that the most sensitive and specific method for further nutritional assessment identification is the MUST screening tool. In contrast of the aforementioned study, Kulnik and Elmadfa (2008) in their nutritional assessment of elderly nursing home residents in Vienna made use of MNA (Mini Nutritional Assessment) and NuRAS (Nutritional Risk Assessment Scale) tools to assess the general nutritional and health status of the residents. During the seven consecutive day study, the intake of energy and nutrients of the individual were measured using weighed food intake method. It was noted from the results of MNA (n = 245) that 13.9% belongs to satisfactory nutritional status, 48.3% were risk of malnutrition, and 37.8% were malnourished. Evidence noted that the assessed number of nutritional risk factors has an impact on the status of nutrition of the individual and a link between assessed nutritional status and the residents’ individual nutrient intake was correlated. Kulnik and Elmadfa (2008) concluded that an evidence for nutritional problems in frail, institutionalized elderly residents of the nursing home was noted. Unlike the study made by Harris et al (2007) where it concluded the MUST screening tool to be the most sensitive and specific method to assess nutritional status of the patient compared to the MNA, the study of Kulnik and Elmadfa (2008) concluded that the reliable tool to identify individuals who are at risk for malnutrition was the MNA having high sensitivity of 96%. From this study, it was recommended that for an effective nutritional intervention, strategies should be implemented in long-term care facilities to prevent and treat malnutrition as well as to ensure high – quality care for the elderly. Charlton et al (2005), in a cross – sectional validation study consisting of 283 free – living and institutionalized black South Africans ages 60 years old and above, noted that 24-hour recall and the Mini Nutritional Assessment (MNA) screening tool were administered by trained fieldworkers. Anthropometric measurements and physical function tests were also performed. Using a validated version of Six – Item Cognitive Impairment Test, cognitive function was assessed. Biochemical indicators assessed includes the following: (1) Serum albumin, (2) hemoglobin, (3) ferritin, (4) vitamin B12, (5) red-blood-cell folate, (6) cholesterol, and (7) vitamin C. Charlton et al (2005) noted that the MNA is a novel screening tool which was developed with the use of six – step systematic approach. These are correspondence analysis; identification of key questions; determination of internal consistency; correlational analyses with objective measures; determination of reference cut-off values for categories of nutritional risk; and determination of sensitivity and specificity. From this study, Charlton et al (2005) concluded that a simplified screening tool that has been proposed have shown to have content -, construct -, and criterion – related validity against the MNA tool (with only 87.5% sensitivity and 95% specificity) and a good internal consistency was noted in the individual items. Charlton et al (2005) further concluded that in this population, mid – upper arm circumference (MUAC) measurement can be used as the BMI proxy, and a reference cut – off values was identified. Comparison between the populations of the elderly from different African countries was allowed by the inclusion of standardized set of short questions. It also identifies sectors of population in the elderly within the country who are in need of nutritional intervention. Furthermore, Stechmiller (2003) made another study on the efficacy of MNA to detect the state of malnutrition. Stechmiller acknowledged that on the quality of life of the elderly, malnutrition on protein – energy and its consequence plays a considerable impact. It is the challenge of health care providers who works with older adults to recognize individuals who are at risk for undernutrition and to initiate early assessment in nutritional status and intervention strategies to prevent the occurrence of malnutrition. As a result, the quality of life of older adults improves and healthcare cost decreases. Stechmiller (2003) noted that through the use of quick and easy nutritional screening assessment tool such as Mini Nutritional Assessment (MNA), the occurrence of malnutrition can be prevented. Stechmiller (2003) reported in his study that MNA was highly correlated to the following nutritional variables, namely: dietary intake, anthropometry, and biochemical indices. Stechmiller added that that the scale has the sensitivity of 96%, specificity of 98%, and predictive value of 97%. In conclusion, Stechmiller (2003) noted that a major problem so called malnutrition has been often overlooked in older adults. In the life of the elderly, poor nutrition and the management of acute and chronic illness in the elderly have their significant consequence. Hence, to identify elderly patients at risk for undernutrition or malnutrition, weekly assessments of nutritional status using MNA tool can be taken by nurses and other healthcare workers. Through this, early undernutrition identification can be evaluated using comprehensive differential approach of diagnosis for identification of the cause and treatment options. Therefore, nutritional care and clinical outcomes can be improved through swift recognition of undernutrition. Christensson, Unosson and Ek (2002) in a cross – sectional study with consecutive selection of residents aged 65 years old aimed to evaluate the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment (MNA) with the combination of anthropometric and serum – protein measurements in assessing protein – energy malnutrition (PEM). The study started in October 1996 consisting of 148 females and 113 males aged 65 – 104 years old. It was noted that on admission, 53% were assessed as malnourished or moderately malnourished according to SGA. On the other hand, 79% were malnourished or at risk of malnutrition according to MNA tool. Anthropometric values and serum proteins were lowered significantly in residents that were classified as malnourished (P 65 years), FNA, MNA, and SSM were carried out. In comparison with FNA, sensitivity and specificity for MNA and SSM were calculated. Questions from two screening tools were used in a multivariate, stepwise linear regression to construct a short and simple tool in screening. For suitable clinical routines, regression model was simplified. Thordottir, Jonsson, Asgeirsdottir, et al (2005) concluded that according to FNA, malnutrition is frequent in hospitalized elderly patients. Thordottir, Jonsson, Asgeirsdottir, et al (2005) added that an exceptionally high sensitivity of 98.1% that validates MNA in the population of the elderly with a specificity of 25% was found (cited from Donini et al (2002). On the other hand, the sensitivity of MNA in the study of Harris et al (2007) was 80% and 90%, while the study of Kulnik and Elmadfa (2008) reportedly attained a sensitivity of MNA tool of 96%, Charlton et al (2005) having only 87.5% sensitivity, and Stechmiller (2003) and Christensson, Unosson and Ek (2002) having sensitivity of MNA of 96% in their studies. In another study, Cuervo, Ansorena, Martinez – Gonzalez et al (2008) noted that mini nutritional assessment (MNA) test identifies a condition commonly found in the elderly, malnutrition. The objective of this research is to study independent value of MNA questions that are global and subjective to predict undernutrition and to analyze the gender and age influence. In this research, 22, 007 Spaniards were evaluated ages 65 years and older. The subjective assessment was evaluated further on the basis of sensitivity and specificity using receiver operating characteristic (ROC) curves. According to the full MNA test, about 4.3% of the populations studied were classified as undernourished. It was found out that the two questions form the subjective subscore presented better that predictive value than the six questions from the global. Using two subjective questions, 99.5% subjects were detected as malnourished. An efficient tool for quick screening to rule our non undernourished subjects, two subjective MNA questions was identified in the present study. Harris et al (2007), Christensson, et al (2002), Kulnik and Elmadfa (2008), Charlton et al (2005), Stechmiller (2003), and Cuervo et al (2008) in their studies identified MNA test to detect malnutrition in the elderly patients. In a different study, Norman, Smoliner, Valentini, et al (2007) made use of bioelectrical impedance vector analysis for calculation of body composition in elderly nursing home residents since it was presumed that bioelectrical impedance analysis is difficult in the elderly especially in the malnourished elderly because most equations were found to be inadequate. Nutritional status was determined in this study by Mini Nutritional Assessment (MNA). Functional status was assessed through handgrip strength, knee extension strength, and Barthel’s index as well as bioelectrical impedance analysis using Nutriguard M (Data Input, Darmstadt, Germany). In this study, one hundred twelve nursing home residents consisting of 34 men, 78 women with an age ranging from 79.1 to 91.4 years old were included. A significant displacement of the mean vector of MNA II (classified as nutritional risk), and MNA III (classified as malnourished) were identified compared with the MNA I (Well – nourished). It was concluded in the study that bioelectrical impedance vector analysis resistance/reactance graph represents a tool that is valuable to assess body cell mass and hydration status changes in the elderly residents in the nursing home. Waitzberg and Correia (2003) noted that among hospitalized patients, malnutrition is a most frequent scenario. However, despite of having this condition, the scenario is not assessed routinely in most hospitals all over the world. One of the reasons could be the lack of tool for gold – standard nutritional assessment and advocating the technique. Waitzberg and Correia (2003) stated that several recent finding have reinforced the relationship between poor nutritional status and high complication incidence, mortality, and length of stay and costs in the hospital. For that reason, a recommendation was made that early diagnosis of malnutrition should be made available. Hence, an evaluation of nutritional status should be made available to predict the outcome of the patient, and must be performed by caregivers and has to be inexpensive, and not time – consuming. Furthermore, when defining which instrument must be adopted by an institution, health professional must be critical in instrument definition. Limitation of the study: The different size of the sample of the MNA group and the distribution of the gender. Green and Watson (2006) compiled a comprehensive literature review from electronic databases and manual research from 1982 – 2002 examining the range of published tools available for nurses to screen older patients’ nutritional status as well as the extent to which it addressed the validity, reliability, sensitivity, specificity, and acceptability of the tool. From this research, it was found out that 71 nutritional tools were located and out of which, 21 were designated for use in the population of older individuals. With these tools, it was noted that a wide variety of risk factors of malnutrition were used ranging from measuring objectively to assessing subjectively. Many tools appeared to have been used clinically and not subjected to validity and reliability testing. In conclusion, Green and Watson stated that nutritional assessment and tools in screening were determined to be useful to highlight nutritional care plan need since malnutrition was present in the older adult population. Though, in the clinical use, a lot have not been subjected to assessment and may not demonstrate sensitivity and specificity. Therefore, it must be carefully considered when deciding to use a particular tool. These are considerable limitations of the study identified and these include the following: (1) Wide variety of publications of nutritional screening and assessment tools that results to its exclusion, (2) In terms of quality and quantity, the descriptions of development and testing tools greatly varies making it difficult for the investigation and summary of issues pertaining validity, reliability, sensitivity, specificity, and acceptability, and (3) Unpublished tools in use in clinical practice may be present which have not been described in this review but subjected to testing that is rigorous. Soederhamn and Soederhamn (2002), in another study aimed to test the reliability and validity of Nutritional Form in the Elderly (NUFFE). Using NUFFE and MNA, a total of 114 chosen consecutively older patients who are newly admitted in an elder care rehabilitation ward in western Sweden were interviewed. On admission, as part of the MNA, the following were noted: arm and calf circumferences, body mass index (BMI), and presence of pressure sores and skin ulcers. On discharge, weight was monitored and BMI was calculated as well. On admission and discharge, serum albumin levels were used. As homogeneity, NUFFE reliability was measured. With different statistical methods, the criterion related to validity, concurrent validity, construct validity, and predictive validity were assessed. From this study, Soederhamn and Soederhamn (2002) concluded that in assessing older patients, NUFFE can also be used as a simple tool with an aim of detecting individuals who are undernourished and those who are at risk for undernutrition. Soederhamn and Soederhamn added that BMI ought to be calculated when doing nutritional assessment using NUFFE. Lastly, for a period of time, the assessment could be combined with recording of food intake. To validate the potential application of the tools, Yamada, Furuya, and Takita, et al (2008) tested several nutritional screening tools that are simplified on patients who are on hemodialysis. These simplified screening tools were published from 1985 to 2005 and the nutritional assessments include history taking, anthropometric and biochemical measurements on 422 patients who are hemodialysed. To obtain the score of each nutritional screening tool and malnutrition – inflammation score (MIS), the results were then applied as a standard of reference. By comparison of the MIS value and various individual nutritional measures, the usefulness of each nutritional screening tool was then assessed for the identification of nutritional risk. Yamada, Furuya, and Takita, et al (2008) concluded in this study that from the five reliable nutritional screening tools found by search of literature, the simplest and most accurate risk index for identification of patients who are hemodialyzed is the geriatric nutritional risk index (GNRI). However, this study is limited in such a way that the validation of the nutritional screening tool has not been examined fully based on the risks of morbidity and mortality. Jones (2002) made a literature research and was able to identify 44 tools. Each tool was assessed in relation to the application derivation of methodology and performance evaluation. In her paper, Jones aimed to give critical methodology appraisal of nutritional screening and assessment tools. In this research study, Jones (2002) revealed that the tools were published with details that are insufficient regarding their intended use, derivation method, and inadequate assessment of effectiveness. Regarding the scientific merit, it was evaluated that no tool satisfied a set of criteria. Jones concluded that a need to ensure to develop nutritional screening and assessment tools using procedure based on good design and statistical practice that is sound is required. A significant contribution to this process can be made available through unified approach using multivariate techniques. Vellas, Guigoz, Garry, et al (1998) reported that the MNA, which has been translated into several languages and has been validated in many clinics all over the world, has been designed and validated recently to provide a single, rapid assessment in outpatient clinics of the nutritional status of the elderly patients. Vellas, Guigoz, Garry, et al (1998) reported that MNA test can be completed in about 10 minutes and is composed of simple measurements as well as brief questions. To compare the findings of MNA, discriminant analysis was used, with the nutritional status determined by physicians, using the standard nutritional assessment that is inclusive of complete anthropometric clinical biochemistry and dietary parameters. Vellas, Guigoz, Garry, et al (1998) noted that the sum of MNA scores distinguishes elderly patients with the following: (1) Adequate nutritional status, MNA, 24; (2) protein-calorie malnutrition, MNA, 17; and (3) risk of malnutrition, MNA between 17 and 23.5. Sensitivity of 96%, specificity of 98%, and predictive value of 97% was found in this scoring. Moreover, the predictive of mortality and cost of hospitalization was made through MNA scale. Most importantly, the risk for malnutrition, with scores between 17 and 23.5 was identified prior to severe weight changes or levels of albumin. Hence, a decrease in caloric intake is identified from these individuals that can be corrected easily through nutritional intervention. Like Harris et al (2007), Kulnik and Elmadfa (2008), Charlton et al (2005), Stechmiller (2003), Christensson, et al (2002) and Cuervo, et al (2008), Vellas, Guigoz, Garry, et al (1998) also made use in their studies MNA test to detect malnutrition in the elderly patients. In another cross – sectional study with 283 black South Africans ages 60 years old who are free – living and institutionalized, Charlton, et al (2007) made a 24 – hour recall DETERMINE and MNA screening tools and performed anthropometric measurements and physical function tests administered by trained fieldworkers. Biochemical indicators assessed were serum albumin, hemoglobin, ferritin, vitamin B12, red blood cell folate, cholesterol, and vitamin C and to assess cognitive function, the six – item Cognitive Impairment test was used. From the study, it was found that MNA score was associated positively and significantly with anthropometric measurements, cognitive function, activities of daily living and, in women, percentage of body fat, handgrip strength, and activities of daily living. It was also found out that the DETERMINE test had low positive predictive value of 55.6% and specificity of 11.2% compared with the MNA, and resulted in high false positive rate classified being malnourished. In conclusion, the MNA screening tool is appropriate to identify older back South African who is at risk or malnutrition and who are malnourished. Harris et al (2007), Kulnik and Elmadfa (2008), Charlton et al (2005), Stechmiller (2003), Christensson, et al (2002), Cuervo, et al (2008), Vellas, Guigoz, Garry, et al (1998) and Charlton et al (2007) concluded in their studies that MNA is an effective tool to detect malnutrition in the elderly. Lastly, Wikby, Ek, and Christensson (2007), in their study aimed to test internal consistency and interrater reliability of a two – step Mini Nutritional Assessment procedure (short form of MNA versus MNA) in community resident homes, as well as to test sensitivity, specificity, and diagnostic predictivity of short form of MNA versus MNA in 127 elderly admitted to eight residential homes. Registered nurses performed simultaneously the procedure in the three homes, namely, A, B, and C. Out of 68, 45 residents MNA was carried out by the registered nurses in homes A, B, and C. Between the author and registered nurses, the agreement level was 62%. Furthermore, the agreement level of 89%, 89%, and 44% in residential home A, B, and C, respectively, was noted. Also, the sensitivity, specificity, and diagnostic predictivity of MNA – short versus MNA were 89%, 82%, and 92%, respectively. Wikby, Ek, and Christensson (2007) concluded that to identify residents who are in need of nutritional intervention, the two – step MNA turned out to be a useful tool, despite of noncompliance of the registered nurses to carry out MNA in all residents and low agreement in home C. Hence, to implement and use the MNA in nursing care necessitates resources of staff inclusive of adequate staffing, sufficient education and continual supervision. In conclusion, from the literatures reviewed, it was found out that the MNA proved to be an effective tool in detecting and treating malnutrition in the elderly. References: Amella E. 2007. Assessing Nutrition in Older Adults. The Hartford Institute of Geriatric Nursing, 9(2007. Charlton K, Kolbe – Alexander T, and Nel J. 2005. Development of a novel nutrition screening tool for use in elderly South Africans. Public Health Nutrition, 8(5), 468–479. Charlton K, Kolbe – Alexander T, and Nel J. 2007. 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American Journal of Clinical Nutrition, 87(2008), pp. 106 – 113. Read More