Annals of Long Term Care

Best Practices in Nursing Care to Older Adults
From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

Issue Number 9, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: While poor nutrition is not a natural concomitant of aging, older adults who experience several concurrent diseases are at higher risk for under- or malnutrition. Persons who are underweight (Body Mass Index < 19) and those who are overweight (Body Mass Index > 25) often have loss of muscle mass, a compromised immune system and have increased complications and premature death. The progression to malnutrition is often insidious, and is often undetected. The nurse plays a key role in prevention and early intervention of nutritional problems.

BEST TOOL: The Mini Nutritional Assessment (MNA) is an assessment tool that can be used to identify older adults (>65 years) who are at risk of malnutrition. It is a clinician-completed instrument with two components: screening and assessment. A score of 11 or less on the screen indicates a problem and the need for a completion of the assessment portion. The assessment score is then added to the screen score; if the total score on both parts totals 17 – 23.5, there is a risk of malnutrition, while a score of < 17 indicates existing malnutrition. The MNA should be supplemented with information regarding the patient’s cultural factors, preferences, social needs/desires surrounding meals. A review of symptoms and objective clinical findings, including pertinent physiological measures used to assess nutritional status should be assessed (including serum pre-albumin, serum albumin, transferrin, and total lymphocyte count, as well as hemoglobin and hematocrit). A 72-hour food dairy, recording the patent’s consumption, is another important supplement to the MNA.

TARGET POPUTLATION: The MNA provides a simple and quick method of identifying older adults who are at risk of malnutrition. The MNA should be completed at regular intervals, no matter the setting.

VALIDITY AND RELIABILITY: The MNA is both a screening and assessment tool for the identification of malnutrition in the older adult. This tool eliminates the need for more invasive tests such as blood sampling. The MNA has been validated in many research studies in older adults throughout the world in hospital, nursing home and ambulatory care patients and in community screening. Internal consistency, inter-observer reliability and validity were shown to be acceptable (Beck, Oversen, & Schroll, 2001; Bleda, Bolibar, Pares, & Salva, 2002).

STRENGTHS AND LIMITATIONS: Unlike many other nutritional instruments, the MNA was developed to be user-friendly, quick, non-invasive, and inexpensive. The MNA has been tested predominantly on Caucasians with involvement of Mexican-Americans in studies conducted in New Mexico (Sheirlinkx, K., et al., 1998). A limiting factor may be clinician lack of familiarity with the requirement, in the assessment portion, of measuring both the mid-arm and calf circumference. One criterion to determine risk is based on a BMI less than 19 and actually gives maximum points for a BMI over 23 (item F in Screen). At this time, with the percent of Medicare enrollees who are classified as obese (BMI ≥ 30) at 22.5% (up from 11.7% in 1997), overweight (BMI ≥ 25 – 29.9) at 34.3% (up from 32.1% in 1997), and those underweight (BMI < 18.5) actually decreasing from 9.0% in 2002 from 16.9% in 1997, a reexamination of this criterion is needed (Thorpe & Howard, 2006).

MORE ON THE TOPIC:
Best practice information on care of older adults: www.GeroNurseOnline.org.
Beck, A.M., Ovesen, L., & Schroll, M.