UWL: Screening and Assessment Methods (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To assess the risk of malnutrition among elderly people living at home and receiving regular home care services using the Mini Nutritional Assessment (MNA) and to study the characteristics of the instrument in this patient group.

Inclusion Criteria:
  • Age 75 and older
  • Receiving a home care visit at least once every fortnight
  • Ability to understand and answer questions.
Exclusion Criteria:

Patients with severe cognitive impairment.

Description of Study Protocol:


The study population comprised home-care patients from three rural municipalities in southern Finland, with a combined population of 41,400, of whom 7% were aged 75 years and older.


Cross-sectional study.

Statistical Analysis

  • Means, standard deviations, crosstabulation and frequency tables were used as descriptive statistics
  • Spearman's correlation coefficients were determined in correlation analysis
  • For statistical comparisons, ANOVA was used for normally distributed data and nonparametric methods, such as the Wilcoxon two-sample test and the Kruskal-Wallis test, were used for data that had a skewed distribution.
Data Collection Summary:

Timing of Measurements

Data were collected with a structured questionnaire.

Dependent Variables

Risk of malnutrition.

Independent Variables

  • Mini Nutritional Assessment (MNA) questions
  • Information about diet and eating problems, fluid intake, alcohol intake, special diets, chewing and swallowing
  • Other information concerning the use of services and living conditions, amount of home-care received, home help services, meals-on-wheels services
  • Weight, height, BMI, knee height, mid upper-arm and calf circumferences
  • Study protocol was pilot-tested with 10 home care patients who were not included in the study.
Description of Actual Data Sample:
  • Initial N: 272 eligible patients
  • Attrition (final N): 178 (65%) agreed to participate; main reasons for nonparticipation were fatigue or being too ill to meet new people
  • Age: 75 years to 94 years; mean age. 83.5±4.6 years
  • Ethnicity: Not mentioned
  • Location: Rural Finland.
Summary of Results:

Correlations of MNA questions to total MNA score (N=178)

MNA Question

Spearman's R


Weight Loss During the Last Three Months



Psychological Stress


Self-Perceived Nutritional Status


Food Intake Declined


Self-Perceived Health Status


Mid-Arm Ccircumference






Number of Meals Eaten per Day


Calf Circumference
Three Pprescription Drugs per Day
Use of Vegetables
Ability to Eat
Neuro-Psychological Problems
Skin Problems
Use of Fruits
Use of Drinks
Protein Intake




Other Findings

  • According to MNA, 3% were malnourished (MNA, under 17 points), 48% at risk for malnutrition (17 points to 23.5 points) and 49% well nourished (more than 23.5 points)
  • The mean MNA score was 23.4
  • There was a significant negative correlation between age and BMI (P=0.0016)
  • Weight loss, psychological stress, nutritional status, decline in food intake, self-perceived health status and mid-arm circumference showed the strongest significant correlations (P=0.0001) to total MNA score
  • MNA questions with the strongest significant intercorrelations (P=0.0001) were body mass index with mid-arm circumference and calf circumference and the decline of food intake and self-perceived nutritional status
  • The number of eating problems correlated significantly to the MNA score (P=0.0011)
  • Those with chewing and swallowing problems (N=64, 36%) had a significantly lower MNA score than the others (P=0.0001)
  • Dry mouth, together with chewing and swallowing problems (N=40, 22%) reduced the MNA score even further (P=0.0001).
Author Conclusion:

The results suggest that the MNA is a useful tool in the identification of elderly home-care patients at risk for malnutrition.

Funding Source:
Other: Not reported
Reviewer Comments:
  • Since patients with severe cognitive impairment were excluded, this sample represents healthier home care patients living in rural Finland
  • Authors note that healthier people were over-represented among the participants
  • Questionnaire not shown to be valid and reliable measurement tool.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? ???
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? ???
  7.5. Was the measurement of effect at an appropriate level of precision? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes