A Guide to Completing the Mini Nutritional · The MNA® is an assessment tool that can be used to identify patients at risk of malnutrition. The aim of the user guide is to assist

CLINICAL NUTRITION

A Guide toCompleting the

Mini NutritionalAssessment

MNA®

7852 MNA® Guide final 4/2/00 1:56 pm Page 1

CLINICAL NUTRITION

Aim:The MNA® is an assessment toolthat can be used to identify patientsat risk of malnutrition. The aim ofthe user guide is to assist you tocomplete the assessmentaccurately and consistently. Eachquestion on the MNA® form will beexplained in turn and the scoringdescribed.

Introduction:Recent research has shown thatwhilst the prevalence ofmalnutrition in the free-livingelderly population is low (3-6 %),the risk of malnutrition increases inthe institutionalised elderly, and onadmission to hospital1. Manystudies have shown that anindividual who is malnourishedwhen admitted to hospital tends tohave a longer hospital stay,experiences more complicationsand has a greater risk of morbidityand mortality than a person withthe same illness whose nutritionalstate is normal2.

By identifying patients who aremalnourished or at risk ofmalnutrition either in the hospitalor community setting, it may bepossible to provide adequate andimmediate nutritional support toprevent further deterioration.

Mini Nutritional AssessmentMNA®

The MNA® provides a simple andquick method of identifyingpatients who are at risk from

malnutrition, or who are alreadymalnourished. The MNA® can becompleted at regular intervals inthe community, and in hospital.

The MNA® has been developed byNestlé and leading internationalgeriatricians. It is both a screeningand assessment tool for theidentification of malnutrition in theelderly. This tool eliminates the needfor more invasive tests such asblood sampling. The MNA® hasbeen validated in international3 andUK4,5 based studies in elderlyindividuals.

Before beginning the MNA®

Questionnaire please enter the

patients details on the top of

the form:

- name

- gender

- age

- weight (kg) - weight should be measured by removing shoes andheavy outer clothing using a calibrated and reliable set of scales(see appendix 1 for conversion of stones to kg).

- height (cm) - height should be measured without shoes using a stadiometer (height gauge) or, if the patient is bedridden, by demispan (see appendix 2) (see appendix 4 for conversion of feet to centimetres).

- ID number (e.g hospital number)

• Please enter today’s date

MNA®


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B

A

Screening

Complete the Screening section by filling in the boxes with the appropriatenumbers. Add the numbers for the screen. If the score is 11 or less, continue withthe assessment to gain a Malnutrition Indicator Score.

Questions that should be answered by the patient are clearly marked and samplequestions are offered. The remaining questions should be answered from patient’snotes or using professional judgement.

A Has food intake declined over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0 = Severe loss of appetite

1 = Moderate loss of appetite

2 = No loss of appetite

Ask patient

• ‘Have you eaten less than normal over the past three months?’

• If so, ‘is this because of lack of appetite, chewing or swallowing difficulties?’

• If yes, ‘have you eaten much less than before or only a little less?’

If this is a re-assessment, then rephrase the question

• ‘Has the amount of food you have eaten changed since your last assessment?’

B Weight loss during the last 3 months?

0 = weight loss greater than 3kg (6.6lbs)

1 = does not know

2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)

3 = no weight loss

Ask patient / from notes if long term patient or residential care

• ‘Have you lost any weight over the last 3 months?’

• ‘Has your waistband got looser?’

• ‘How much weight do you think you have lost?’

Then prompt:

• ‘More or less than half a stone (3kg) in weight?’


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E

C

D

C Mobility?

0 = bed or chair bound

1 = able to get out of bed/chair but does not go out

2 = goes out

Patient notes/ information from carer/ ask patient if necessary

• ‘Are you presently able to get out of bed/ chair?’

• ‘Are you able to get out of the house?’

D Has the patient suffered psychological stress or acute disease in the past three months?

0 = yes

2 = no

Patient notes/ professional judgement/ ask patient

• ‘Have you suffered a bereavement recently?’

• ‘Have you recently moved home?’

• ‘Have you been unwell recently?’

If the patient’s notes specify an acute disease score 0

E Neuropsychological problems?

0 = severe dementia or depression

1 = mild dementia

2 = no psychological problems

Patient notes/ professional judgement

Some indication of mental state of the patient may be obtained from the carer,nursing staff or medical notes.

If the patient is severely confused answers to the following questions should bechecked for accuracy with carer/ nursing staff (questions A, B, C, D, G, J, K, L, M, O & P)


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FF Body mass index (BMI)? (weight in kg/height in m2)

0 = BMI less than 19

1 = BMI 19 to less than 21

2 = BMI 21 to less than 23

3 = BMI 23 or greater

Calculated by assessor

BMI is used as an indicator of whether the patient is an appropriate weight for theirheight. BMI is calculated by dividing the weight in kg by the height in m2.

• BMI = weight (kg)

height (m2)

Before calculating BMI, ensure that the patient’s weight and height are recorded onthe MNA® form.

1. For conversion of weight and height see appendix 1, and 4

2. If height has not been measured, please measure using a stadiometer (height gauge)

3. If the patient is unable to stand, please calculate height from demispan (appendix 2).

4. On the BMI chart provided match up the height and weight of the patient, and read off the BMI score

5. Fill in the appropriate box on the MNA® form to represent the BMI of the patient

The screening section of the questionnaire is now complete. Add up the scores toobtain the screening score.

If the score is 12 points or greater, the patient is not at risk and there is no need tocomplete the rest of the questionnaire.

If the score is 11 points or less, the patient may be at risk from malnutrition and thefull MNA® assessment should be completed.

Please contact .....................................................................................................................to complete the questionnaire.

N.B If this is a reassessment of the patient following a period of nutritional interventionby a dietitian, the dietitian should be informed of the outcome of the reassessmentregardless of the score.


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GHIJ

G Lives independently (not in a nursing home or hospital)?

0 = no1 = yes

Ask patient

This question should refer to the normal living conditions of the individual i.e. ifthe patient is in hospital because of an accident or acute illness where does thepatient normally live?

• ‘Do you normally live in your own home, or in a residential or nursing home?’

H Takes more than 3 prescription drugs per day?

0 = yes

1 = no

Patient notes

Check the patient’s drug chart/ ask nursing staff/ ask doctor to find out how manyprescription drugs are taken per day at the present time.

I Pressure sores or skin ulcers0 = yes1 = no

Ask patient/Patients notes

• ‘Do you have bed sores?’

Check the patient’s notes for the presence of bedsores or skin ulcers or ask thecarer/nursing staff/doctor for details if not available in the notes.

J How many full meals does the patient eat daily?

0 = 1 meal

1 = 2 meals

2 = 3 meals

Ask patient/check menu cards if necessary

• ‘Do you normally eat breakfast, lunch and dinner?’

A full meal is defined as an eating occasion when the patient ‘sits down’ to eat andconsumes more than two items/dishes.

Assessment


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KL

M

K Selected consumption markers for protein intake• 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 No0.0 = if 0 or 1 yes0.5 = if 2 yes1.0 = if 3 yes

Ask the patient or nursing staff, or check the completed menu cards

• ‘Do you consume any dairy products (a glass of milk/cheese in a sandwich/ pot of yoghurt) every day?’

• ‘Do you eat beans/ eggs? How often do you eat them?’• ‘Do you eat either meat, fish or chicken every day?’

L Consumes two or more servings of fruits or vegetables per day?

0 = no1 = yes

Ask the patient/check menu cards if necessary

• ‘Do you eat fruit and vegetables?’• ‘How many portions do you normally have each day?’

A portion can be classified as:one piece of fruit (apple, banana, orange etc.)a glass of fruit juicean average serving of vegetables (not including potato)

M How much fluid (water, juice, coffee, tea, milk) is consumed per day?

0.0 = less than 3 cups

0.5 = 3 to 5 cups

1.0 = more than 5 cups

Ask patient

• ‘How many cups of tea or coffee do you normally drink during the day?

• ‘Do you drink any water, milk or fruit juice?

• ‘Do you normally have teacup or mug?

N.B A cup is approximately 190ml and a mug 260ml 6. Therefore two mugs of tea areequivalent to approximately three cups of tea.


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NO

P

N Mode of feeding

0 = unable to eat without assistance

1 = self-fed with some difficulty

2 = self-fed without any problem

Ask patient/ patients notes/ information from carer

• ‘Are you able to feed yourself?’/ ‘Can the patient feed themselves?’

• ‘Do you have help to eat?’/ ‘Do you help the patient to eat?’

O Self view of nutritional status0 = view self as being malnourished1 = is uncertain of nutritional state2 = views self as having no nutritional problem

Ask patient

• ‘How well nourished do you consider yourself to be?’

Then prompt: • ‘poorly nourished?’

• ‘uncertain?’

• ‘no problems?’

The answer to this question depends upon the patient’s state of mind. If you thinkthe patient is not capable of answering the question, then the carer/ nursing staffshould be asked for their opinion.

P In comparison with other people of the same age, how do they consider their health status?

0.0 = not as good0.5 = does not know1.0 = as good2.0 = better

Ask patient

• ‘How well do you feel?’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 self view/ state of mind of the individual.


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QFinal Score• Add up points from the assessment

section of the MNA® together to givethe assessment score (max. 16 points).

• Add the assessment and screening scores together to give the total assessment score (max. 30 points).

• Refer to Malnutrition Indicator Score box.

• If the patient scored greater than 23.5points, the patient is in a normal state of nutrition and no further action is required.

• If the patient scored less than 23.5 points, the patient should be referredto a dietitian.

The dietitian to contact is:

Ext/ bleep no:

Until a dietitian is available the patient/carer should be given some advice onhow to improve nutritional intake such as:

• Increasing consumption of energy/ protein dense foods e.g fish pie casseroles, milk puddings.

• Supplementing their food intake with additional snacks and glasses of milk

• Ensure adequate fluid intake; 6-8 cups/glasses per day

• If nutritional intake cannot be improved by diet alone, oral nutritional supplements may need to be prescribed e.g Clinutren ISO, Clinutren 1.5, Clinutren Dessert.

Follow - Up• If a patient identified as malnourished

or at risk of malnutrition has been referred for nutritional support, additional nutritional screening shouldbe carried out at monthly intervals to monitor progress.

• Please refer results of re-assessment to dietitian/doctor

R

Q Mid-arm circumference (MAC) in cm

0.0 = MAC less than 21

0.5 = MAC 21 to 22

1.0 = MAC 22 or greater

Mid arm circumference should be measured in cm as described in appendix 5

R Calf circumference (CC) in cm

0 = CC less than 31

1 = CC 31 or greater

Calf circumference should be measured in cm as described in appendix 3


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Conversion

Chart for

Weight

Source:British Standards

Institute

Appendix 2

Measurement of Demispan 7

• You will need to use the tape measure

and pen provided in the MNA® pack

1. Locate and mark the edge of the rightcollar bone (in the sternal notch) with the pen

2. Ask the patient to place the left arm ina horizontal position

3. Check patients arm is horizontal and in line with shoulders

4. Take tape measure in left hand and

extend to mark on neck (check arm is flat and wrist is straight), and take reading in cm.

Calculation of height from demispan:

Females

Height in cm =(1.35 x demispan (cm)) + 60.1

Males

Height in cm =(1.40 x demispan (cm)) + 57.8

Appendices

Appendix 1


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Appendix 3

Measurement of Calf Circumference

• You will need to use the tape

measure provided in the MNA® pack

1. The subject should be sitting with the leg hanging loosely or standing with their weight evenly distributed on both feet.

2. Ask the patient to roll up their trouserleg to uncover the calf.

3. Wrap the tape around the calf at the widest part and observe the measurement.

4. Take additional measurements above and below this point to ensure that thefirst measurement was the largest.

5. An accurate measurement can only beobtained if the tape is at a right angle to the length of the calf, and should be recorded to the nearest 0.1cm.

Conversion

Chart for

Height

Source:British StandardsInstitute

Appendix 4


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References

1. Finch S., Doyle W., Lowe C., Bates C.J., Prentice A., Smithers G. & Clarke P.C. (1998) National Diet and Nutrition Survey: people aged 65 years and over. 1 London: Her Majesty’s Stationery Office

2. Malnutrition Advisory Group (BAPEN) (1999) Malnutrition in the UK: A public health problem: Parliamentary briefing document

3. Guigoz Y., Vellas B.J. & Garry P.J (1994) Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 4 (suppl. 2): 15-59

4. Murphy M.C., Brooks C.N., New S.A. & Lumbers M.L. (1999) The use of the Mini Nutritional Assessment (MNA) Tool in Elderly Orthopaedic patients. Submitted to European Journal of Clinical Nutrition

5. Nayak U.S.L & Sinclair A.J (1999) The use of the MNA tool in community settings. Awaiting publication

6. Food Portion Sizes: Ministry of Agriculture, Fisheries and Food: HMSO, London

7. PEN Group (1997) A pocket guide to clinical nutrition: Assessment of nutritional status. British Dietetic Association

8. Moore M.C. (1993) Pocket Guide to Nutrition and Diet Therapy

The MNA User Guide was produced in

association with:

• Dr. M.C. Murphy, Senior Lecturer in Clinical Nutrition, European Institute of Health and Medical Sciences, University of Surrey, Guildford, Surrey, GU2 5XH

• Dr. M. Lumbers, Lecturer in Nutrition/ Registered Public Health Nutritionist, Centre for Food and Health Care Management, School of Management for the Service Sector, University of Surrey, Guildford, Surrey, GU2 5XH

• Professor A.J. Sinclair, Charles Hayward Professor of Geriatric Medicine, The University of Birmingham, Birmingham

• Dr. U.S.L Nayak, Director, Centre for Applied Gerontology, The University of Birmingham, Edgbaston, Birmingham B15 2TT

Appendix 5

Measurement of Mid Arm Circumference 7

• You will need to use the tape measure

and pen provided in the MNA pack

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 previously marked mid-point on the upper arm and tighten snugly, but not too tightly to cause indentation or pinching

6. Record measurement in cm.

7. If MAC is less than 21, score = 0If MAC is 21-22, score = 0.5If MAC is 22 or greater, score = 1.0

Ref 8

Ref 7

St. George’s House, Croydon, Surrey CR9 1NR. Tel: 020 8667 5130 Fax: 020 8667 6061


Documents

A Guide to Completing the Mini Nutritional · The MNA® is an assessment tool that can be used to identify patients at risk of malnutrition. The aim of the user guide is to assist