The geriatric nutritional risk index
Emanuele Ceredaa and Carlo Pedrollib
a
International Center for the Assessment of Nutritional
Status (ICANS), University of Milan, Milan and bDietetic
and Clinical Nutrition Unit, Trento Hospital, Trento, Italy
Correspondence to Emanuele Cereda, MD,
International Center for the Assessment of Nutritional
Status (ICANS), University of Milan, via Botticelli 21,
20133 Milan, Italy
Tel: +39 02 503 16079; fax: +39 02 503 16077;
e-mail: emanuele.cereda@virgilio.it
Current Opinion in Clinical Nutrition and
Metabolic Care 2009, 12:1–7
Introduction
As the ratio of older people continues to rise, providing
better healthcare to this segment of population has
become a matter of necessity. Accordingly, designing
age-specific nutritional policies should be considered.
It is in regard to these considerations that the literature
addressing the Geriatric Nutritional Risk Index (GNRI)
will be reviewed.
Rationale of nutritional screening
Paradoxically, defect malnutrition, otherwise called
protein-calorie malnutrition (PCM), is a widespread
problem also in industrialized countries, ranging between
10 and 85% of those admitted to healthcare settings
[1–3,4
]. Despite increasing awareness of its negative
prognostic impact [3], PCM still goes largely undiagnosed
and undertreated, thus being responsible for consistent
National Health System costs [5]. Along with this, it has
been demonstrated that nutritional status might deterior-
ate further during the stay [6]. However, treatment
studies have proved that timely nutritional support might
1363-1950 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Purpose of review
A new nutrition-related risk assessment tool, the Geriatric Nutritional Risk Index (GNRI),
has been recently proposed. The aim of this review is to summarize current evidences
on the use of this tool with particular focus on the rationales of its application in
elderly healthcare.
Recent findings
Structured as a dichotomous index, based on serum albumin values and the
discrepancy between real and ideal weight, the GNRI seems to account for both acute
and chronic reasons of nutrition-related complications. It allows us to face the frequent
difficulties in obtaining a profitable participation of the old patient to nutritional
assessment. Its application appears feasible in all healthcare settings in which it shows
adequacy to discriminate different profiles of nutritional risk. A GNRI less than 92 might
be suggested as clinical trigger for routine nutritional support.
Summary
In maths of nutrition ‘recognize and treat’ has become a clinical imperative. Actually,
clinical judgement by an expert is still considered the reference standard to
diagnose malnutrition but the use of simplified tools profitably assists in nutritional risk
screening process. The GNRI is easy to use and preliminary results show that it is
promising. Its routine application, next to the other validated tools already available,
might be enforced in the assessment of the old patient.
Keywords
elderly, geriatric nutritional risk Index, nutritional assessment, nutritional risk, simplified
nutritional screening tools
Curr Opin Clin Nutr Metab Care 12:1–7
ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
1363-1950
profit not only to outcome improvement [7,8], but
also quality of life, while being cost effective too [9
].
‘Recognize and treat’ is a clinical imperative.
Thus, despite initial controversy about whether all
adults receiving healthcare should be timely and
regularly screened for nutritional problems, there is
now overwhelming evidence that the use of simple
screening procedures should be included in routine
clinical practice as a standard [2,3,4
,10]. Unfortunately,
recent insights into the current clinical practice still
reveal poor nutritional routines and attitudes among
doctors and nurses [11].
As highlighted by recent reviews [12,13

], there are now
over 70 tests or tools for nutritional assessment, 21 of which
are designated for use for an older population, but this is
probably an underestimation. Unfortunately, it should be
noted that these tests, depending on the nutritional items
or principles on which they are based, perform differently
in terms of accuracy (sensitivity and specificity), reliability
and prognostic meaning and are more or less appli-
cable according to ease of use and patient acceptability.
DOI:10.1097/MCO.0b013e3283186f59
 2 Ageing: biology and nutrition
According to these desirable features the use of only a few
is enforced and it is well accepted that validity should be
primarily discussed in view of outcome prediction [10,14].
Along with this, it should mention that nutrition screening
is consistently impacted by health status and comorbidities
as well as by PCM, settings and age. Usually, nutrition
screening is looking for evidence of PCM. Aging and the
presence of comorbidities makes actual PCM more diffi-
cult to diagnose [2,4
,10,15].
Acute complications are demonstrated to affect nutri-
tional status to a significant extent. Thus, patients
admitted to hospital are more frequently at nutritional
risk, and recording the disease severity might be
important for correct assessment [3,16
]. Though, chronic
nutritional depletion is consistently documented also in
long-term care settings [1,4
].
Indeed, changes in body composition occurring with and
intrinsic factors related to aging make the old patient
more prone to health complications and hospitalization
[15]. Moreover, comorbidities are frequently present in
the elderly, thus leading to worse prevalence data [3,4
].
Geriatric Nutritional Risk Index: structure and
purposes
As suggested by the name itself, the GNRI has been
introduced as an age-specific screening and extensive
application to other age groups should be validated
[17,18]. Particularly, it has been proposed as a ‘nutri-
tion-related’ risk index rather than an index of malnu-
trition. This means that the GNRI can be used to classify
patients according to a risk of complications (mortality,
infections, and bedsores) in relation to illnesses often
associated with malnutrition and not as a tool for grading
nutritional status [17]. However, there is still confusion
between the two concepts that literature frequently
treated as synonyms. This should be theoretically correct
but a focus there appears to be due. Not so far, we have
already supported that the interest in poor nutritional
status must be primarily addressed to clinical outcome
and the possibility to prevent complications by prompt
nutritional support [9
,19].
It is reasonable to argue that the prognostic value of the
GNRI as a scoring system lies in the calculation formula
on which it is structured. As dichotomous index, it
combines two nutritional indicators: albumin and actual
weight compared with desirable weight. Particularly,
GNRI is an adaptation of the Nutritional Risk Index
(NRI) designed by Buzby et al. [20] to score nutrition-
related risk in surgical patients (Fig. 1).
Bouillanne et al. [17] thought above all to the frequent
difficulties in obtaining a profitable participation of
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1 Nutritional Risk Index and Geriatric Nutritional Risk
Index
Nutritional risk index (NRI) CUTOFF
RISK
Severe < 83.5
Actual weight
NRI = 1,519 × albumin (g/L) + 41,7 × ---------------(Kg) Moderate 83.5 to <97.5
Usual weight Low 97.5 to 100
Absent > 100
Geriatric nutritional risk index (GNRI)
Severe < 82
Actual weight Moderate 82 to <92
NRI = 1,519 × albumin (g/L) + 41,7 × ---------------(Kg) Low 92 to 98
Ideal weight*
Absent > 98
*calculated by the Lorentz formula
Formula and threshold values for grading nutritional risk.
the old patient to nutritional assessment. Accordingly,
the usual body weight of the NRI formula was replaced
by the ideal one predicted from height calculated
by the Lorentz equations. It is in fact well demon-
strated that weight loss and usual body weight are
often not documentable in elderly patients, even
under professional care [4
,21]. Along with this, the
suggested use of estimated height from knee-hell
length has been demonstrated to accurately overcome
the unavailability of reliable standing height data due
to bed confination or spinal curvature deformities (e.g.
kyphosis) [22].
The weight given to albumin in the formula remained,
however, unchanged. Though, the prognostic value of
the GNRI is based not only on measurement of serum
albumin but also on degrees of weight loss that were
considered when setting its cutoff values [17]. Moreover,
we highlight that, according to the general tendency of
the elderly to badly adapt to both calorie restriction and
malnutrition and to lose more lean body mass than
adipose tissue [15,23,24

], a normal value (¼1) for the
(actual weight/ideal weight) factor was established for a
BMI above 22 kg/m2, a level that is considered to define
the old patient ‘at nutritional risk’ [25,26

].
With this in mind, when discussing the relationships
between GNRI and muscle dysfunction, a well known
prognostic marker [27], as well as those with short and
long-term outcomes, we argued that siding a proper
systemic indicator of disease severity (albumin) with a
descriptor of body store (weight factor) might be better in
accounting for both acute and chronic reasons of nutri-
tional complications [28–33]. This is to say that, as it
is structured, the GNRI seems to mirror the presence of
an acute stress, possibly leading to weight loss, in a
patient progressively lacking of protein-calorie stores to
cope with. Nevertheless, we underscored that in uncom-
plicated patients, albumin might also reflect chronic
undernutrition and deconditioning, probably related to

Table 1 Prevalence of nutritional risk in various settings according to the Geriatric Nutritional Risk Index
Severe
Setting n <82, %
Acute hospitala 153 18.3
Rehabilitation careb 2474 12.2
Long-term carec 1047 5.0
Long-term carec,d 1397 – 22.0
a
Data from Cereda et al. [36].
b
Data from Bouillanne et al. [17].
c
Weighted means of pooled prevalence data analysis from studies by Cereda et al. [22,28,32–34].
d
Further analysis including studies addressing three categories of nutritional risk [29,30].
poor dietary habits that, although, are just one aspect
and usually not that related to comorbidities [29].
These considerations, together with the associations
detected with most anthropometric parameters (BMI,
mid upper arm circumference, and triceps skinfold)
[34], further support the introduction of this tool in
routine clinical practice.
Geriatric Nutritional Risk Index and setting
We have already suggested that the setting and the tool
used in the screening process may affect each other in the
assessment of nutritional status and risk. Accordingly, as
there appears that tools provide different informations
[13

,14], current guidelines suggest that some should be
preferred to others depending on the healthcare. This is
the case for the Malnutrition Universal Screening Tool
(MUST) and the Nutritional Risk Score (NRS-2002) at
hospital admission for adults or the Mini Nutritional
Assessment (MNA) when addressing long-term cares
for the elderly. Moreover, the MNA and the MUST
might be usefully applied in the community in which
serious confounders of the effect of undernutrition are
relatively rare [10,35].
The GNRI was firstly introduced and validated for the
evaluation of midterm (6-month follow-up) nutritional
outcomes elderly medical patients admitted to a reha-
bilitation care setting in which approximately 75% of
patients came from an acute care unit [17]. Thus, one
might have assumed that it was more suitable for a
subacute care setting but a preliminary investigation
tested and demonstrated its prognostic value (1-month
risk of death) also in acutely hospitalized patients [36].
Thereafter, different studies have suggested an inter-
esting application in nursing homes [34] not only when
addressing the association with prognostic indicators,
such as muscle dysfunction [28,29], but also when
seeking for both mid (6 months) and long-term (>3
years) outcome prediction [30–33]. Moreover, patients
with pressure ulcers frequently appear characterized by
low GNRI values (32% with GNRI < 82 or 85%
with GNRI < 92) (Cereda et al., unpublished data).
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Screening tools for nutritional risk Cereda and Pedrolli 3
Geriatric Nutritional Risk Index
Moderate Low None
82–<92, % 92–98, % >98, %
13.7 17.7 50.3
31.4 29.4 27.0
17.9 36.2 40.9
36.3 41.7
An overview of all these studies allows us to provide some
highlights. Indeed, patients admitted to a tertiary care
usually suffer less from acute complications and more
frequently show signs of chronic undernutrition, whereas
those admitted to hospital or rehabilitation units are more
likely to experience, or to have experienced, acute stress
responses related to medical illnesses or surgical pro-
cedures. Accordingly, the GNRI, as it is structured in
the formula, reflecting disease severity, might appear
appropriate to discriminate patients assisted in different
healthcare settings. This is what emerges when looking
to currently existing prevalence data of nutritional risk by
this tool (Table 1). Severe risk (GNRI < 82) is more
likely to be scored at hospital admission. Along with this,
a half of the population does not appear to be at risk but is
nevertheless prone to a deterioration secondary to acute
disease effects, as suggested by changes in prevalence
of ‘low’ and ‘moderate’ risk, at expense of ‘no risk’, in
patients admitted to subacute care. On the contrary, if
long-term cares may be the last destination after dis-
charge from the above-indicated settings, personal pub-
lished and unpublished data, in agreement with recent
reports, suggest that chronic multimorbidities associated
with different degrees of physical disability and poor
cognitive functioning are the most common leading
causes of institutionalization and chronic undernutrition
[33,37–39].
Finally, it is nevertheless important that the validation of
screening tools is also done through population-specific
studies possibly allowing us to identify recommendable
methods, as was the case for the MNA, the MUST and
the NRS-2002. Given the feasibility of the measurements
on which the GNRI is based, and according to the
associations between poor outcomes and low albumin
and BMI previously reported, the practical use and
possible utility of the GNRI has been proposed for the
assessment of elderly stroke patients at hospital admis-
sion [40]. Moreover, in regard to population-specific
validations, we report the recent discussion on the useful
application of the GNRI in the evaluation of patients on
maintenance haemodialysis [18,41]. Despite the use of
the GNRI in age-mixed (middle þ elderly) population
 4 Ageing: biology and nutrition

Table 2 Summary of the most widely used screening tools for the elderly: features and application
Screening Year of Setting validation
tool validation and application Features Purposea

GNRI 2005 Acute hospital, It requires only fasting albumin assessment To detect different degrees of
rehabilitation care, and weight and knee-height measurements nutrition-related risk of complications
long-term care
MNA 1994 Validated in all Multidimensional assessment tool, based To detect overt malnutrition and
the settings on 30 questions grouped in four rubrics, to identify patients who might
it addresses nutritional status by benefit from preventive nutritional
anthropometry, general state evaluation support (‘at risk’)
(e.g. functional and cognitive states),
dietary assessment and self perception
about health and nutrition
MUST 2000 Acute hospital, It combines information about weight To detect overt malnutrition and
community status, weight loss history (%), an altered to identify patients who might
nutritional intake and the effect of acute benefit from further monitoring
disease of conditions
NRS-2002 2002 Acute hospital It combines information about To detect overt malnutrition and
weight status, weight loss history (%) to identify patients who might
and the impairment of oral intake; benefit from further monitoring
differently from MUST, it grades the of conditions
severity of disease as a reflection
of increased nutritional requirements
SGA 1987 All hospital It allows patient assessment by physical signs To detect overt malnutrition
specialties of malnutrition, the evaluation of functional
capacity, gastrointestinal functions and
disease according to nutritional requirements
GNRI, Geriatric Nutritional Risk Index [17]; MNA, Mini Nutritional Assessment [35]; MUST, Malnutrition Universal Screening Tool [43]; NRS-2002,
Nutritional Risk Score 2002 [10]; SGA, Subjective Global Assessment [14].
a
Treatment should always be considered as compulsory when malnutrition or moderate-to-severe risk is detected.

justified also by outcome data, we underscore that further
improvements of this assessment method, particularly in
view of cutoff accuracy and extensive performing, should
take into account changes in body composition and
albumin values occurring with aging [18,42].
Geriatric Nutritional Risk Index in the ‘world
of screening tools’
Actually, clinical judgement by an expert is considered
the goal standard in the assessment of both nutritional
status and risk. Unfortunately, the presence of skilled
personnel is still a major shortcoming and the introduc-
tion of simplified screening methods was aimed to over-
come this. The wide spectrum is growing larger and the
GNRI is certainly one more among those available.
Indeed, finding a screening tool that is useful for des-
cribing both nutritional status and related conditions, and
risk of complications should be the primary goal
[2,6,10,13

,28,29,34].
However, selection of the most appropriate instruments
for use is hampered by the fact that many of these have
not been rigorously developed and evaluated. Partic-
ularly, evaluations and validations should concern with
three main issues: age, setting and outcomes. In this
regard, an overview of current literature suggests that
not one of the tools available is really comprehensive.
For the elderly, widely accepted and performed simpli-
fied screening instruments are the MNA, the NRS-2002
and the MUST (Table 2). Despite showing good agree-
ment in grading the patient [6,43], there is evidence that
they provide different information for clinical practice.
Both the NRS-2002 and MUST identify patients who
require further monitoring but, taking considerably into
account the effect of disease, they are more likely to fit a
hospital setting best, also in view of outcome prediction
[3,10,43–45]. However, the prognostic meaning of the
MNA appears slightly weaker at expense of a higher
preventive recognition of patients who need preventive
nutritional measures [35]. Finally, it should mention the
use of the Subjective Global Assessment (SGA). This
system, which classifies patients on the basis of history
and physical examination [46], has been validated in
several ways. However, its use is suggested particularly
to detect overt malnutrition [14] and ‘the lack of a direct
connection between the observations and the classifi-
cation of patients leaves the tool more complex and less
focused than desired for rapid screening purposes’ [10].
Thus, performing more assessment methods, and
combining their results, would probably allow a better
evaluation and categorization of the patient. This has
been recently pointed out for the GNRI [29,30]. Particu-
larly, we observed that the periodical documentation of
changes in overall (percentage of food consumed to that
delivered) and protein (g/kg per day) intakes might
improve the recognition of initial stages of muscle
dysfunction in institutionalized elderly not suffering
from acute complications [29]. Moreover, when addres-
sing short-term outcome prediction in long-term care

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residents, the concomitant evaluation of total lympho-
cytes count could still provide useful information in
assessing the risk for infectious complications [30].
The GNRI lets us grade the patient when unfavourable
changes in both weight and visceral proteins have
already been established. The association with overall
complications is good but that with death is even stron-
ger [17,18,30–34,36]. However, death is a terminal
condition that might be a consequence of other nutrition
and not nutrition-related complications. Accordingly,
other comorbidities (e.g. infection and bedsores) should
be considered as the main issues of evaluation and
validation in future studies.
Risk detection should be intended to guide prompt
nutritional treatment. Unfortunately, intervention stu-
dies in patients screened at risk by these tools, including
the GNRI, are still few. On the contrary, recently meta-
analysed data suggest that oral nutritional support (ONS)
in the elderly might be profitable to outcome and nutri-
tional status, specifically in the hospital setting [7] in
which patients frequently present with acute diseases
and low albumin. Accordingly, the use of the GNRI
might be probably enforced but we do not know if similar
risk scoring in other settings can produce comparable
improvements when ONS is provided. Actually, current
evidences suggest GNRI below 92 as a clinical trigger for
routine nutritional support, at least in a long-term care
setting [18,31–33].
Comparison with other validated tools might be of inter-
est not only to obtain information on which instrument
should be used in relation to specific aims and settings
but also to check and assess sensitivity and specificity.
Though, the choice of a gold standard that does not exist
still remains a strong limitation. Up to know, only three
investigations have been designed with this purpose. In
the first, GNRI resulted in the simplest and most accurate
risk index for identifying age-mixed (middle plus old age)
haemodialysis patients at nutritional risk when the mal-
nutrition-inflammation score was used as the reference
standard [41]. In the other two, the comparison was
performed in long-term care elderly residents with the
NRI and the MNA [32,34]. Compared with the NRI, the
GNRI not only showed similar association with prognos-
tic correlates of nutritional status (albumin, prealbumin,
total lymphocytes count, and weight loss) but also,
in contrast, shows a relationship with anthropometric
parameters [34]. Unfortunately, no comparison for out-
come prediction was possible. However, when compared
with the MNA, given the features of this screening tool
and the items on which it is based, the GNRI appears to
be less reliable in detecting differences among frequently
used nutritional parameters at the expense of a higher
prognostic value [32]. In conclusion, these preliminary
experiences suggest that information derived from both
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Screening tools for nutritional risk Cereda and Pedrolli 5
MNA and GNRI should be probably considered in
nutritional screening.
Finally, we must highlight that the choice of nutritional
screening tools obviously depends on the resources avail-
able. The GNRI is clearly less time consuming than other
assessment procedures and requires minimal participa-
tion, thus being suitable for less self-sufficient elderly
who are institutionalized. However, depending on serum
albumin quantification, it is a little more expensive.
Accordingly, also cost-effectiveness analysis might be
hypothesized. However, regardless of first-step evalu-
ation results, as highlighted by the European Society
of Parenteral and Enteral Nutrition, ‘. . .there are four
principles that screening must embody:
(1) What is the condition now? It means to obtain a
reliable picture of current nutritional status through
the use of available techniques.
(2) Is the condition stable? This implies that the patient
should be followed and timely evaluated.
(3) Will the condition get worse?
(4) Will the disease process accelerate nutritional
deterioration? This is related to the catabolic back-
ground (e.g. cytokines related to acute-phase reac-
tion) associated with many illnesses’ [10].
Conclusion
Actually, clinical judgement by an expert is considered
the goal standard for nutritional status and risk assess-
ment. Unfortunately, the presence of skilled personnel is
still a major shortcoming. To overcome that, many
screening tools are now available but a lack of sensitivity
by single-taken indices is commonly reported. Thus, we
have to assess as many as possible dimensions of the old
patient (e.g. social and health, anthropometry, functional
status and biochemistry).
Multidimensional screening tools, that give us the chance
to simplify, accelerate but reliably perform nutritional
risk assessment, are to be preferred. The MNA, the
MUST and the NRS-2002, according to extensive vali-
dation, are now widely accepted and used in most
settings. On their side, the GNRI might be considered,
particularly in the screening of all institutionalized
elderly. In view of preliminary results, its use appears
promising and there is a rationale for further evaluations.
Moreover, given the predictivity of albumin in acutely
complicated patients, its application on hospital admis-
sion could be strongly enforced and investigated.
Acknowledgements
The authors gratefully acknowledge Ronni Chernoff, Paolo Suter and
the Editorial Board of ‘Current Opinion in Clinical Nutrition and Metabolic
Care’ for present review invitation.
 6 Ageing: biology and nutrition
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest


of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 97).
1 Thomas DR, Ashmen W, Morley JE, et al. Nutritional management in long-
term care: development of a clinical guideline. Council for Nutritional
Strategies in Long-Term Care. J Gerontol A Biol Sci Med Sci 2000;
55:M725–M734.
2 Elia M, Zellipour L, Stratton RJ. To screen or not to screen for adult malnutri-
tion? Clin Nutr 2005; 24:867–884.
3 Norman K, Pichard C, Lochs H, et al. Prognostic impact of disease-related
malnutrition. Clin Nutr 2008; 27:5–15.
4 Labossiere R, Bernard MA. Nutritional considerations in institutionalized

elders. Curr Opin Clin Nutr Metab Care 2008; 11:1–6.
This review emphasizes the importance of malnutrition in and the nutritional
peculiarities of frail institutionalized elderly.
5 Amaral TF, Matos LC, Tavares MM, et al. The economic impact of
disease-related malnutrition at hospital admission. Clin Nutr 2007;
26:778–784.
6 Kyle UG, Genton L, Pichard C. Hospital length of stay and nutritional status.
Curr Opin Clin Nutr Metab Care 2005; 8:397–402.
7 Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementa-
tion in older people. Ann Intern Med 2006; 144:37–48.
8 Baldwin C, Weekes CE. Dietary advice for illness-related malnutrition in
adults. Cochrane Database Syst Rev 2008:CD002008.
9 Darmon P, Lochs H, Pichard C. Economic impact and quality of life as

endpoints of nutritional therapy. Curr Opin Clin Nutr Metab Care 2008;
11:452–458.
This review highlights that several endpoints should be considered when providing
nutritional support. In this regard, there is a need for well designed clinical trials
from which cost-utility performance of and quality-of-life improvement by nutritional
interventions have to be assessed.
10 Kondrup J, Allison SP, Elia M, et al., Educational and Clinical Practice
Committee, European Society of Parenteral and Enteral Nutrition (ESPEN).
ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22:415–
421.
11 Bavelaar JW, Otter CD, van Bodegraven AA, et al. Diagnosis and treatment of
(disease-related) in-hospital malnutrition: the performance of medical and
nursing staff. Clin Nutr 2008; 27:431–438.
12 Green SM, Watson R. Nutritional screening and assessment tools for older
adults: literature review. J Adv Nurs 2006; 54:477–490.
13 Donini LM, Savina C, Rosano A, et al. Systematic review of nutritional status


evaluation and screening tools in the elderly. J Nutr Health Aging 2007;
11:421–432.
This review provides a good overview of the worldwide nutritional screening tools
currently available.
14 Kyle UG, Kossovsky MP, Karsegard VL, et al. Comparison of tools for
nutritional assessment and screening at hospital admission: a population
study. Clin Nutr 2006; 25:409–417.
15 Morley JE. Anorexia, body composition, and ageing. Curr Opin Clin Nutr
Metab Care 2001; 4:9–13.
16 Barendregt K, Soeters PB, Allison SP, et al. Basic concepts in nutrition:

diagnosis of malnutrition – screening and assessment. e-SPEN, Eur e-J Clin
Nutr Metab 2008; 3:e121–e125.
This is an educational study describing basic concepts in nutritional screening and
assessment of nutritional risk and status.
17 Bouillanne O, Morineau G, Dupont C, et al. Geriatric Nutritional Risk Index: a
new index for evaluating at-risk elderly medical patients. Am J Clin Nutr 2005;
82:777–783.
18 Cereda E, Pedrolli C. The use of the Geriatric Nutritional Risk Index (GNRI) as
simplified nutritional screening tool. Am J Clin Nutr 2008; 87:1966–1967;
author reply 1967.
19 Lochs H, Pichard C, Allison SP. Evidence supports nutritional support. Clin
Nutr 2006; 25:177–179.
20 Buzby GP, Knox LS, Crosby LO, et al. Study protocol: a randomized clinical
trial of total parenteral nutrition in malnourished surgical patients. Am J Clin
Nutr 1988; 47 (2 Suppl):366–381.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
21 Kuczmarski MF, Kuczmarski RJ, Najjar M. Effects of age on validity of self-
reported height, weight, and body mass index: findings from the Third National
Health and Nutrition Examination Survey, 1988–1994. J Am Diet Assoc
2001; 101:28–34; quiz 35–36.
22 Cereda E, Limonta D, Pusani C, et al. Feasible use of estimated height for
predicting outcome by the Geriatric Nutritional Risk Index in long-term care
resident elderly. Gerontology 2007; 53:184–186.
23 Schneider SM, Al-Jaouni R, Pivot X, et al. Lack of adaptation to severe
malnutrition in elderly patients. Clin Nutr 2002; 21:499–504.
24 Bales CW, Buhr G. Is obesity bad for older persons? A systematic review of


the pros and cons of weight reduction in later life. J Am Med Dir Assoc 2008;
9:302–312.
This study provides suggestions on how weight status and changes should be
interpreted and managed in elderly people.
25 Omran ML, Morley JE. Assessment of protein energy malnutrition in older
persons, part I: history, examination, body composition, and screening tools.
Nutrition 2000; 16:50–63.
26 Kulminski AM, Arbeev KG, Kulminskaya IV, et al. Body mass index and nine-


year mortality in disabled and nondisabled older U.S. individuals. J Am Geriatr
Soc 2008; 56:105–110.
This study demonstrates that threshold values of ideal weight, overweight
and obesity currently in use for adults are overly restrictive when applied to the
elderly.
27 Gale CR, Martyn CN, Cooper C, et al. Grip strength, body composition, and
mortality. Int J Epidemiol 2007; 36:228–235.
28 Cereda E, Vanotti A. The new Geriatric Nutritional Risk Index is a good
predictor of muscle dysfunction in institutionalized older patients. Clin Nutr
2007; 26:78–83.
29 Cereda E, Vanotti A. Short dietary assessment improves muscle dysfunc-
tion identification by Geriatric Nutritional Risk Index in uncomplicated
institutionalised patients over 70 years old. Clin Nutr 2008; 27:126–
132.
30 Cereda E, Limonta D, Pusani C, et al. The association of geriatric nutritional
risk index and total lymphocyte count with short-term nutrition-related com-
plications in institutionalised elderly. J Am Coll Nutr (in press).
31 Cereda E, Zagami A, Vanotti A, et al. 30th ESPEN Congress. Mortality
prediction in institutionalised elderly by the Mini Nutritional Assessment
and the new Geriatric Nutritional Risk Index: a 3.5-year survival analysis
[abstract]. Clin Nutr 2008; 3 (Suppl 1):157.
32 Cereda E, Limonta D, Pusani C, et al. 30th ESPEN Congress. The attitude of
the Geriatric Nutritional Risk Index in assessing the nutritional state and
predicting the outcome of home-care resident elderly: a comparison with
the Mini Nutritional Assessment [abstract]. Clin Nutr 2008; 3 (Suppl 1):
143.
33 Cereda E, Zagami A, Vanotti A, et al. Geriatric Nutritional Risk Index and
overall-cause mortality prediction in institutionalised elderly: a 3-year survival
analysis. Clin Nutr 2008 [Epub ahead of print].
34 Cereda E, Limonta D, Pusani C, et al. Assessing elderly at risk of malnutrition:
the new Geriatric Nutritional Risk Index versus Nutritional Risk Index. Nutrition
2006; 22:680–682.
35 Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature:
what does it tell us? J Nutr Health Aging 2006; 10:466–485; discussion
485–487.
36 Cereda E, Limonta D, Pusani C, et al. Geriatric nutritional risk index: a possible
indicator of short-term mortality in acutely hospitalized older people. J Am
Geriatr Soc 2006; 54:1011–1012.
37 Cereda E, Valzolgher L, Pedrolli C. Mini Nutritional Assessment is a good
predictor of functional status in institutionalised elderly at risk of malnutrition.
Clin Nutr 2008 [Epub ahead of print].
38 Schram MT, Frijters D, van de Lisdonk EH, et al. Setting and registry
characteristics affect the prevalence and nature of multimorbidity in the
elderly. J Clin Epidemiol 2008 [Epub ahead of print].
39 Suominen M, Muurinen S, Routasalo P, et al. Malnutrition and associated
factors among aged residents in all nursing homes in Helsinki. Eur J Clin Nutr
2005; 59:578–583.
40 Cereda E. Evaluation of the risk factors for short-term mortality after acute
ischemic stroke in the elderly: is there a role for nutritional risk assessment?
Gerontology 2007; 53:61–62.
41 Yamada K, Furuya R, Takita T, et al. Simplified nutritional screening tools
for patients on maintenance hemodialysis. Am J Clin Nutr 2008; 87:106–
113.
42 Omran ML, Morley JE. Assessment of protein energy malnutrition in older
persons, part II: laboratory evaluation. Nutrition 2000; 16:131–140.
 Screening tools for nutritional risk Cereda and Pedrolli 7

43 Stratton RJ, Hackston A, Longmore D, et al. Malnutrition in hospital out-
patients and inpatients: prevalence, concurrent validity and ease of use of the
‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 2004;
92:799–808.
44 Stratton RJ, King CL, Stroud MA, et al. ‘Malnutrition Universal Screening Tool’
predicts mortality and length of hospital stay in acutely ill elderly. Br J Nutr
2006; 95:325–330.
45 Sorensen J, Kondrup J, Prokopowicz J, et al., EuroOOPS study group.
EuroOOPS: an international, multicentre study to implement nutritional
risk screening and evaluate clinical outcome. Clin Nutr 2008; 27:340–
349.
46 Detsky AS, Mc Laughlin JR, Baker JP, et al. What is subjective global
assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987;
11:8–13.

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