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Mini Nutritional Assessment in geriatric rehabilitation: inter-rater reliability and relationship to body composition and nutritional biochemistry.

Article Excerpt
Abstract

Aim: To determine the inter-rater reliability of the Mini Nutritional Assessment (MNA) and relationship with body composition and nutritional biochemistry among older Australians undergoing rehabilitation.

Methods: Thirty-eight adults aged [greater than or equal to]65 years were prospectively and consecutively recruited from an Australian rehabilitation ward. Two dietitians independently administered the 18-item MNA to determine inter-rater reliability. MNA classifications (well nourished, at risk of malnutrition, malnourished) were compared with body composition (using dual-energy X-ray absorptiometry) and serum albumin. These analyses were also performed for the short-form version of the MNA (six items).

Results: In this cross-sectional study, inter-rater reliability of the 18-item MNA score, estimated by the intraclass correlation coefficient, was 0.833, while inter-rater reliability estimated by the weighted kappa index was 0.53. The two raters reached agreement on MNA classification for 26 of 38 cases (68%). Women classified as malnourished/at risk of malnutrition using the 18-item MNA had lower total body fat (11 kg vs 29 kg, P < 0.01) and per cent body fat (25% vs 40%, P < 0.01), compared with women classified as well nourished. Similar findings were not apparent for men, although men classified as malnourished/at risk of malnutrition had lower serum albumin (32 g/L vs 36 g/L, P = 0.04) compared with men classified as well nourished. Similar findings were evident for the short-form version of the MNA.

Conclusion: The MNA was found to be useful for identifying older women with lower body fat in the Australian rehabilitation setting. The 18-item MNA score has substantial inter-rater reliability, and fair inter-rater reliability when used according to the classifications. Inclusion of subjective and self-reported items in surveys can be problematic for optimal reliability as can the use of such items in a subject population that is experiencing rapid progress in recovery.

Key words: aged, body composition, Mini Nutritional Assessment.

INTRODUCTION

Poor nutrition is common among older adults undergoing rehabilitation, with reports of prevalence between 14% and 63%. (1-4) Older adults who are malnourished on admission to rehabilitation often have poorer morbidity and mortality outcomes than those who are well nourished. (5,6)

Malnutrition often goes unrecognised due in part to a lack of standardised diagnostic criteria. (7-9) To enable the treatment of malnutrition, rapid and effective methods of early identification and evaluation of treatment are required that include evaluation of dietary intake, anthropometric measurements and detection of nutritional risk factors.

The Mini Nutritional Assessment (MNA) is a simple, rapidly administered tool designed to evaluate the potential risk of malnutrition of older adults in the hospital setting. (10,11) The development of the MNA was a collaborative effort between investigators from France, the USA and Switzerland in the late 1990s. The MNA incorporates a screening section and an assessment section. The short-form MNA (screening section) consists of six items and classifies individuals as not at risk of malnutrition or possibly malnourished. For individuals classified as possibly malnourished, the complete MNA (assessment section) is required. The complete MNA (18 items), which also incorporates the items of the short-form MNA, assesses anthropometry, dietary intake, global assessment and subjective assessment, and classifies individuals as well nourished, at risk of malnutrition or malnourished. The comprehensive nutrition screening and assessment tool has been tested among a diverse collection of older adults, including the active healthy (10) and inpatients of acute care, (12) and has been used extensively in these settings and in rehabilitation facilities. (2,4,13)

The complete MNA has been shown to have a high level of inter-rater reliability among older adults in a Spanish residential care facility. (14) Guigoz et al. demonstrated high sensitivity (96%) and specificity (98%) of the MNA in a sample of 600 men and women aged 60-90 years from France, Mexico and Spain in residential care when compared with a 'clinical status assessment' (nutritional assessment performed by two independent, trained clinicians). (10)

Because there is currently no 'gold standard' measure of nutritional status, it is important that findings of clinical tools demonstrate a consistent and relatively strong relationship to measures that have traditionally represented nutritional status such as body composition and nutritional biochemistry. (15,16) One of two studies has demonstrated such a relationship when a comparison of the complete MNA was made with a direct measure of body composition, dual-energy X-ray absorptiometry (DXA). Persson et al. examined 60 women and found that those classified by the complete MNA as having protein energy malnutrition, or being at risk of developing protein energy malnutrition, had significantly lower total body fat and per cent body fat than those classified as well nourished. (17) In the study performed by Persson et al., total body fat was reported as 12 kg for those classified as having protein energy malnutrition, and this was significantly different from both those at risk of protein energy malnutrition (23 kg, P < 0.05) and those classified as well nourished (29 kg, P < 0.05). (17) Similar findings were...

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