The Mini Nutritional Assessment-Short Form for preoperative nutritional evaluation of elderly patients

The Global Malnutrition Composite Score: Impacting malnutrition care

The presence and impact of malnutrition in adult hospitalized patients has been well documented by a significant body of literature. However, current malnutrition care practices often vary widely and frequently lack standardization. The Global Malnutrition Composite Score (GMCS), the first nutrition-related electronic clinical quality measure, is intended to evaluate the quality of malnutrition care provided to inpatient adults. This measure aims to aid in standardizing malnutrition care through performance measurement. The four components of the measure (nutrition screening, nutrition assessment, malnutrition diagnosis, and nutrition care plans) follow the well-established Nutrition Care Process and encourage the use of standardized terminology. Facilities with high-performance scores on the GMCS are likely to experience improved outcomes associated with high-quality malnutrition care.

Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients.

METHODS

Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed.

RESULTS

In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001).

CONCLUSIONS

Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

Prealbumin as a nutrition status indicator may be associated with outcomes of geriatric hip fractures: a propensity score matching and 1-year follow-up study

AIM

Nutrition status may affect bone metabolism and regeneration in the elderly. However, few studies reported a sensitive nutrition indicator or evaluation tool for geriatric hip fractures. This study aimed to explore if prealbumin (PAB), a critical nutrition-related protein, is related to the prognosis of hip fractures.

METHODS

Patients with hip fractures who met the inclusion criteria were included in our study. Geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) were calculated. Propensity score matching (PSM) was used to reduce the influence of confounding factors and ROC curves were conducted to explore the optimal cutoff points of PAB and to compare the prognostic value between GNRI, PNI, and PAB. Then Cox and Logistics analyses were performed to identify the relation between PAB and outcomes of hip fractures.

RESULTS

Out of the 546 patients enrolled in this study, 91 patients died within one year. After a 1:1 PSM, the patients with less than 1-year survival had significantly lower PAB (p < 0.001) than those who were still alive at one year. ROC curves showed that the PAB may sensitively predict 6-month survival (AUROC: 0.695), 1-year survival (AUROC: 0.696), and 1-year-free walking ability (AUROC: 0.642). Logistics analysis showed that low PAB may be an independent risk factor for survival and 1-year-free walking ability.

CONCLUSION

Low levels of PAB may be associated with poor survival and walking abilities of older patients after surgery for hip fracture.

Factors Associated with Malnutrition and Its Impact on Postoperative Outcomes in Older Patients

Malnutrition is associated with dismal treatment outcomes in older patients but its impact in geriatric surgery has not been studied extensively. Herein, we report the prevalence of malnutrition risk, its risk factors and its association with postoperative outcomes in older patients undergoing operations of general surgery. This is a retrospective analysis of a prospectively maintained database including patients older than 65 years who were to undergo general surgery operations between 2012 and 2017. The Malnutrition Universal Screening Tool (MUST) was used for nutritional risk. Demographics, socioeconomic data, site and magnitude of the operation, various measures of comorbidity and functional dependence as well as postoperative complications based on Clavien–Dindo classification and length of stay were recorded. There were 501 patients. A total of 28.6% of them were at intermediate malnutrition risk (MUST = 1) and 14.6% were at high malnutrition risk (MUST ≥ 2). Variables independently associated with malnutrition risk (MUST ≥ 1) were smoking (Odds Ratio, OR:1.6, p = 0.041), upper gastrointestinal (GI) tract surgery (OR:20.4, p < 0.001), hepatobiliary-pancreatic surgery (OR:3.7, p = 0.001), lower GI surgery (OR:5.2, p < 0.001) and American Society of Anesthesiologists (ASA) class III/IV (OR:2.8, p = 0.001). In the multiple regression analysis adjusted for several confounding variables, the MUST score was significantly associated with postoperative death (OR:9.1, p = 0.047 for MUST = 1 and OR:11.9, p = 0.035 for MUST score ≥ 2) and postoperative hospital stay (adjusted incidence rate ratio, 1.3, p = 0.041 for MUST = 1 and 1.7, p < 0.001 for MUST ≥ 2). Malnutrition risk was highly prevalent in this sample, particularly in patients with operations of the gastrointestinal tract, in patients with poor physical status and it was associated with postoperative mortality and length of stay.

The geriatric nutrition risk index versus the mini-nutritional assessment short form in predicting postoperative delirium and hospital length of stay among older non-cardiac surgical patients: a prospective cohort study

Backgrounds

Malnutrition has been shown to be associated with poor prognosis in older surgical patients. Several tools are available for detecting malnutrition. But little is known about their ability to assess risks of postoperative adverse outcomes. The study aimed to compare the ability of the Geriatric Nutritional Risk Index (GNRI) and the Mini-Nutritional Assessment Short Form (MNA-SF) in predicting postoperative delirium (POD) and length of stay (LOS) among older non-cardiac surgical patients.

Methods

Prospective study of 288 older non-cardiac surgical patients from the West China Hospital of Sichuan University. Preoperative nutritional status was assessed using the GNRI and MNA-SF, and patients were followed for the occurrence of POD and LOS. Multivariable logistic regression and linear regression analyses were used to identify predictors of these outcomes. The relative performance of the GNRI and MNA-SF as predictors of these outcomes were determined by Receiver Operating Characteristic curves (ROC) analyses and the area under the curve (AUC).

Results

Multivariable analysis revealed that preoperative malnutrition by the MNA-SF was significantly associated with POD. Linear regression analysis showed that preoperative low/high nutritional risk of the GNRI and malnutrition by the MNA-SF were independent predictors of prolonged LOS. Moreover, the area under the curve (AUC) of MNA-SF scores for POD was better than GNRI scores (AUC = 0.718, 95%CI: 0.64–0.80, P < 0.001 vs AUC = 0.606, 95%CI: 0.52–0.69, P = 0.019; Delong’s test, P = 0.006), but the AUC of GNRI scores and MNA-SF scores have no significant difference when predicting prolonged LOS (AUC = 0.611, 95%CI: 0.54–0.69, P = 0.006 vs AUC = 0.533, 95%CI: 0.45–0.62, P = 0.421; Delong’s test, P = 0.079).

Conclusion

The MNA-SF was more effective than the GNRI at predicting the development of POD, but the two nutrition screening methods have similar performance in predicting prolonged LOS among older non-cardiac surgical patients.

An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit

Vascular surgery patients are nutritionally vulnerable. Various malnutrition screening and assessment tools are available; however, none has been developed or validated in vascular patients. The present study aimed to: (1) investigate the validity of four commonly administered malnutrition screening tools (Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screen-2002 (NRS-2002) and the Mini-Nutritional Assessment - Short Form (MNA-SF) and an assessment tool (the Patient-Generated Subjective Global Assessment (PG-SGA)) compared against a comprehensive dietitian's assessment and (2) evaluate the ability of the instruments to predict outcomes. Vascular inpatients were screened using the four malnutrition screening tools and assessed using the PG-SGA. Each was assessed by a dietitian incorporating nutritional biochemistry, anthropometry and changes in dietary intake. Diagnostic accuracy, consistency and predictive ability were determined. A total of 322 (69·3 % male) patients participated, with 75 % having at least one parameter indicating nutritional deficits. No instrument achieved the a priori levels for sensitivity (14·9-52·5 %). Neither tool predicted EuroQoL 5-dimension 5-level score. All tools except the MNA-SF were associated with length of stay (LOS); however, the direction varied with increased risk of malnutrition on the MUST and NRS-2002 being associated with shorter LOS (P=0·029 and 0·045) and the reverse with the MST and PG-SGA (P=0·005 and <0·001). The NRS-2002 was associated with increased risk of complications (P=0·039). The MST, NRS-2002 and PG-SGA were predictive of discharge to an institution (P=0·004, 0·005 and 0·003). The tools studied were unable to identify the high prevalence of undernutrition; hence, vascular disease-specific screening and/or assessment tools are warranted.

Prediction of surgical complications in the elderly: Can we improve outcomes?

As the number of Americans aged 65 years and older continues to rise, there is projected to be a corresponding increase in demand for major surgeries within this population. Consequently, it is important to utilize accurate preoperative risk stratification techniques that are applicable to elderly individuals. Currently, commonly used preoperative risk assessments are subjective and often do not account for elderly-specific syndromes that may pose a hazard for geriatric patients if not addressed. Failure to accurately risk-stratify these patients may increase the risk of postoperative complications, morbidity, and mortality. Therefore, we aimed to identify and discuss the more objective and better-validated measurements indicative of poor surgical outcomes in the elderly with special focus on frailty, patient optimization, functional status, and cognitive ability.

Preoperative assessment of the older surgical patient: honing in on geriatric syndromes

Nearly 50% of Americans will have an operation after the age of 65 years. Traditional preoperative anesthesia consultations capture only some of the information needed to identify older patients (defined as ≥65 years of age) undergoing elective surgery who are at increased risk for postoperative complications, prolonged hospital stays, and delayed or hampered functional recovery. As a catalyst to this review, we compared traditional risk scores (eg, cardiac-focused) to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies. Despite having a lower cardiac risk index and Charlson comorbidity score, the younger of the two patients presented with more subtle negative geriatric-specific risk predictors – including intermediate or pre-frail status, borderline malnutrition, and reduced functional/mobility – which may have contributed to her 1-day-longer length of stay and need for readmission. Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies (eg, strength, balance, and mobility prehabilitation) to reduce adverse postoperative outcomes and readmissions. Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults. A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented.

Validation of the modified mini nutritional assessment short-forms in different populations of older people in Poland

OBJECTIVE

To assess the usefulness in different populations of elderly people in Poland of both modified versions of Mini Nutritional Assessment Short-Forms (MNA-SFs) with a three-category scoring classification: one using BMI (MNA-SF-BMI) and another using calf circumference (MNA-SF-CC).

SETTING AND PARTICIPANTS

A group of 932 community-dwelling subjects from the urban environment, 812 subjects from the rural environment and 859 subjects from an institutional environment (nursing homes).

MEASUREMENTS

Agreement between both MNA-SFs and the MNA full form.

RESULTS

MNA-SF-BMI correctly classified 84.12%, 82.51% and 81.84% of subjects from urban, rural and institutional environment, respectively. For MNA-SF-CC those values were 82.4%, 71.8% and 76.6%, respectively. The sensitivity and specificity of MNA-SF-BMI and MNA-SF-CC against full MNA in screening for "at risk/malnutrition" and "malnutrition" were generally very high, except for relatively lower sensitivity (74.1%) when screening for "malnutrition" with MNA-SF-CC in nursing homes.

CONCLUSION

Both MNA-SFs can be recommended as screening tools in assessing the nutritional state of the community-dwelling and institutionalised elderly in Poland. The full version of the MNA confirmed the results of MNA-SFs in this group. The "classic" MNA-SF using BMI was found to perform better than the MNA-SF-CC. The MNA-SF-CC should be used only when measuring BMI is not possible. While using MNA-SF-CC in nursing homes, a higher MNA-SF-CC cut-point of eleven should be rather used in this population to screen for "at risk/malnutrition".

[Geriatric assessment prior to oncological therapy]

Ageing is the single most important risk factor for cancer. This is also true for most cancer diseases of the genitourinary tract. In combination with the demographic changes in Germany and most other countries, the consequence is a substantial increase in the number of elderly patients with cancer. Most therapies in oncology have a high risk for toxic side effects. Ageing is a very heterogeneous process. The chronological age of a patient insufficiently reflects the individual resources, deficits and risk factors but this can be assessed by a structured geriatric assessment. Integration of geriatric assessment into oncological treatment decisions is still low and is one of the major tasks in cancer care in the future.

Intra-erythrocyte magnesium levels and their clinical implications in geriatric outpatients

OBJECTIVES

Magnesium deficiency has been implicated as a factor in numerous chronic diseases and previous studies suggest a greater prevalence of occult magnesium deficiency among older adults. Serum is the choice for the assessment of most analyses used in clinical medicine, although serum magnesium concentrations have been shown to be poor predictors of intracellular magnesium concentration. The aim of this study was to compare intracellular and extracellular magnesium concentrations in geriatric outpatients. Moreover, we examined whether a significant correlation between magnesium parameters and clinical outcome existed.

DESIGN

Cross-sectional study.

SETTING

Geriatric medicine outpatient clinic of a university hospital.

PARTICIPANTS

A total of 246 patients with a mean age of 71.9 ± 5.7 years were involved.

MEASUREMENTS

Intra-erythrocyte magnesium levels were analyzed with atomic absorption spectrophotometry.

RESULTS

Serum magnesium levels were within normal range in all patients, whereas intra-erythrocyte magnesium measurements were low in 57% of the patients. Increase in serum levels were together with just only a slightly increase in intra-erythrocyte measurements and the relationship was very weak. Intra-erythrocyte Mg levels were not significantly correlated with many laboratory or clinical parameters.

CONCLUSION

Our results confirm that intra-erythrocyte Mg does not correlate with serum levels and clinical parameters in geriatric outpatients, but further studies are needed to define the correlation.

Mini Nutritional Assessment (short form) and functional decline in older patients admitted to an acute medical ward

BACKGROUND AND AIMS

Protein and/or energy malnutrition is common in hospitalized older patients and is associated with poor outcomes. Among recommended nutritional screening tools, contrasting data exist about the usefulness of the Mini Nutritional Assessment Short-Form (MNA-SF). We evaluated whether the MNA-SF, alone or integrated with serum albumin levels, is a reliable predictor of functional decline in older patients.

METHODS

We studied 275 elderly patients (mean age 76.5, 60.7% males) admitted to an acute medical ward of a tertiary-care teaching hospital over a 12-month period. In this observational study, we evaluated nutritional status, with the MNA-SF alone or integrated with albumin. Data were collected at admission and related to laboratory and geriatric assessment features, and length of stay (LOS). Functional decline (defined as a loss >or=10% in terms of Barthel Index score at discharge compared with 2 weeks before admission) was considered as outcome.

RESULTS

The MNA-SF estimated 46% patients at risk of malnutrition. These subjects had worse clinical features (lower total cholesterol and albumin levels), longer LOS (13.3 vs 11.2 days, p=0.014) and considerable functional decline (OR 4.25, 95% CI 1.83-9.9, p=0.001). Integrating the MNA-SF with albumin values, we obtained an effective instrument to detect older inpatients with protein-energy malnutrition, at higher risk of undergoing functional decline (OR 16.19, 95% CI 4.68-56.03, p<0.0001).

CONCLUSIONS

The MNA-SF is a useful screening tool for hospitalized elders at risk of malnutrition. It is associated with poor clinical outcomes and is able to predict functional decline. Together with hypoalbuminemia, it better identifies patients with true protein-energy malnutrition.

Nutrition in patients receiving home care in Finland: tackling the multifactorial problem

This study describes the nutritional status of Finnish home care patients (n=178), their problems related to eating, digestion, and diet; their use of Meals on Wheels services; and informal caregivers' role in nutritional support. Half of the patients were at risk for malnutrition and 3% were malnourished according to Mini Nutritional Assessment (MNA) results. Most patients had problems with food intake, which were related to lower MNA scores. One-third of the participants had an unbalanced diet, and approximately half received assistance with shopping and food preparation from an informal caregiver. Home care patients' nutritional status, including all related aspects, such as shopping, food preparation, eating, and digestion, must be evaluated regularly and comprehensively.

No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture

BACKGROUND AND AIMS

Malnutrition in general and protein deficiency in particular, both upon admission and during the recovery period, may adversely influence the clinical outcome after hip fracture. This study investigates the relationship between nutritional status measured by the Mini-Nutritional Assessment short form (MNA-SF) and biological markers in elderly hip-fractured patients.

METHODS

A prospective study in a university hospital. The MNA-SF nutritional scale and laboratory values (serum albumin, cholesterol, total lymphocyte count) were assessed within three days after hip fracture surgery.

RESULTS

Seventy-three patients were included: 61 (84%) were women and 12 men. Mean age was 81.5+/-7.1 years. Inhospital mortality was 10%. The mean MNA-SF score was 11+/-0.5 (range 3-14); according to these values, 39 patients (53%) were at risk of malnutrition. MNA-SF scores were not significantly correlated to patients' laboratory values. Fourteen episodes of nosocomial infection were diagnosed in 11 patients, and 6 patients developed pressure ulcers during hospitalization.

CONCLUSIONS

MNA-SF test scale values reflect a clinical process in post-operative hip-fractured patients which is different from serum albumin, cholesterol or lymphocyte count.