MALNUTRITION IN THE ELDERLY: CURRENT CHALLENGES AND INTERVENTIONS
CONDITIONS & DISORDERS
Undernutrition has serious implications for health, recovery from illness or surgery and hospital costs.1 What’s more, malnutrition is estimated to cost £19.6 billion in England annually (2011-12 figures), which is twice as much as obesity.2 A recent report by the British Association for Parenteral and Enteral Nutrition (BAPEN) established that up-front investment in implementing the current National Institute for Health and Clinical Care Excellent (NICE) quality standards on nutritional support in adults, could result in £200 million in savings to the NHS annually, due to reduced healthcare use.2 In the UK, it is estimated that over three million people are malnourished. Of these people, 93% live in the community and 1.3 million are over the age of 65.3 Despite this, malnutrition remains overlooked within the media, the healthcare system and the political agenda. This article will look at current challenges of and interventions for malnutrition in the elderly, whilst showcasing the work of several dietitians. THE PROBLEM WITH NUTRITION RISK SCREENING TOOLS
Numerous studies have reported a lack of recognition and treatment of malnutrition within hospital settings.4 Whilst screening tools do exist, there are not nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables.5 Consequently, it is difficult to make comparisons between studies, which is problematic when estimating global and national prevalence rates of malnutrition. Nutritional screening is recommended in NICE clinical guideline 32 recommendation 1.2.6 for all inpatient hospital admissions in the UK.6 However, definitions of undernutrition and nutritional risk and cut-off values for the nutritional variables measured
must be agreed to allow for consistent and evidence-based practice. Dietitians anecdotally report that the Malnutrition Universal Screening Tool (‘MUST’) score is often calculated incorrectly. This can lead to inappropriate or missed referrals, which can have serious consequences for patients. We need dietitians to collect data, analyse and publish data on incorrect and inadequate nutrition risk screening to allow for changes and improvements to be made. As an evidence-based profession, we need to justify our worth and show that we can make a difference to patient care. INADEQUATE NUTRITION TRAINING
Dietitians play an important role in training allied healthcare professionals to conduct accurate nutritional risk screening. However, the high staff turnover and limited time and resources within the NHS means that not all staff receive adequate training. Interestingly, medical students have recently been campaigning for nutrition training to be embedded within their medical school curriculum. Students state that their five- or six-year medical degrees provide as little as five hours of nutrition training, resulting in them not being confident in giving basic healthy lifestyle advice.7 Elaine MacAninch is a Nutrition Medical Educator and Dietitian. She works closely with Brighton & Sussex Medical School (BSMS) to incorporate nutrition into their degree programme. Elaine says that all BSMS students learn nutritional screening as a clinical skill, which students may be examined on
Harriet Smith Registered Dietitian and Health Writer Harriet is Founder of Surrey Dietitian providing private dietetic consultations and consultancy services, offering evidence-based nutritional advice, backed up by the latest research on food, health and disease. Harriet has written for national, consumer and industry media. www.surrey dietitian.co.uk @SurreyDietitian
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CONDITIONS & DISORDERS during their OSCEs (Objective Structured Clinical Exams). All students complete a ‘MUST’ and are required to interpret the results, discuss how they may use this information within patient management and when to refer on as appropriate. Students are also taught about refeeding risk, deciding on the best route for artificial feeding and ethical issues surrounding feeding. BSMS have included nutrition questions within the single best answer exams and nutrition topics (including nutrition in dementia care) have been incorporated into the recommended reading lists. BSMS have also designed nutrition research projects for students, and Elaine hopes that future projects will look at current practice and the doctor’s role in nutrition support. The student feedback has been overwhelmingly positive, but the challenge remains that nutrition is not always considered in current medical practice and we need to do more to work with current junior doctors. REITERATING A FOOD-FIRST APPROACH
Many allied healthcare professionals are unaware of the importance of a food-first approach in combatting malnutrition. Sophia Sarmiento, an NHS Community Dietitian, is tackling this head on in the London Borough of Waltham Forest. She is working alongside care homes to empower the staff to implement food-first methods daily. Sophia has helped to develop resource packs on nutrition and hydration, which give simple and realistic guidelines, recipes and advice. Her NHS trust found that implementing daily afternoon tea and milkshake rounds in one private care home was so successful in reducing referrals that they are rolling this initiative out in other local care homes. BAPEN completed four national surveys between 2007 and 2011 to establish the prevalence of malnutrition in adults on admission to care in the UK. Their most recent 2011 data found that one in three adults admitted to care homes in the previous six months were malnourished,8 which reiterates why a community-led approach to tackling malnutrition is so important. APPROPRIATE PRESCRIBING OF ONS
Recent audit data indicates that between 57-75% of oral nutrition prescriptions are inappropriate.9
In 2013, Wandsworth CCG released guidelines for healthcare professionals on appropriate prescribing of ONS for adults in the community.10 The guidelines reiterate the importance of a food-first approach and reinforce that ONS should only be prescribed to patients who meet the Advisory Committee for Borderline Substances (ACBS) prescribing criteria and have been screened using a local malnutrition screening tool such as ‘MUST’ and who are deemed to be at nutritional risk. It is encouraging to see that Prescribing Support Dietitians are being employed to work predominantly with GP practices and Medicines Management Teams in Clinical Commissioning Groups (CCGs) to help improve effective and appropriate prescribing of nutritional products. LACK OF AWARENESS OF THE DIETETIC PROFESSION
Dietetics is a relatively small profession in the UK and, unfortunately, this means that not all allied healthcare professionals are aware of the important work that dietitians do. Recent headlines announced that GP surgeries will be hiring 20,000 support staff as part of a major overhaul, with soon-to-be recruits including pharmacists, physiotherapists, paramedics and social workers. They failed to mention dietitians. The BDA remarked, “It is very positive to see this commitment to expanding the primary care workforce, but disappointing not to see dietitians forming a key part of these plans.” Dietitians can play a crucial role in addressing malnutrition in the community setting, which places a significant strain on primary care services. Yet our voice isn’t (yet) loud enough. A MULTIDISCIPLINARY TEAM APPROACH
Physical symptoms can affect someone’s ability to eat.11 Simple interventions, such as asking doctors to switch timings of medications and manage pain levels and asking healthcare assistants to provide appropriate menus and mealtime assistance, can help when addressing these potential barriers. This requires a multidisciplinary team approach. Additionally, attitudes of staff towards nutrition can influence whether a patient finishes their meal.12 Small changes to ward culture, such as providing www.NHDmag.com March 2019 - Issue 142
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CONDITIONS & DISORDERS mealtime assistance as already mentioned, and ensuring food is within easy reach, can have a big impact. Dietitians play an important role in educating staff about the importance of nutrition and hydration and changing ward culture. SOCIAL AND ECONOMIC HURDLES
Wider socio and economic factors can also play a role in the aetiology of malnutrition. For example, widows are at increased risk of social isolation and socioeconomic vulnerability, which may affect food choices and willingness to cook.13 Those with severe comorbidities, or who are mobility-impaired, may experience difficulties accessing and preparing food, as well as being less likely to partake in social food activities.14 A review by Age UK in 2014 found that 1.6 million pensioners are in relative poverty, defined as having incomes below 60% median income after housing costs (AHC) in 2011/12. Moreover, 900,000 pensioners are in severe poverty (incomes below 50% median income in 2011/12).15 We need to ensure that these wider socioeconomical factors are prioritised in the politic agenda when tackling malnutrition. Additionally, dietitians must consider these socioeconomic hurdles when providing individualised dietary advice. IMPROVING HOSPITAL FOOD
Data compiled by Sustain, a group campaigning for better food in hospitals, found that some NHS hospitals spend as little as £2.94 per patient per day for meals and snacks.16 It’s perhaps unsurprising that some of these NHS trusts received extremely low patient satisfaction ratings for the hospital food. In 2014, the Hospital Food Standards Panel produced a set of recommended hospital food standards, which are hoped will become routine practice across NHS hospitals.17 Andy Jones, the Co-Lead for Nutrition and Hydration Week and Chair of the PS100 Group (a lobbying voice that aims to drive government legislation) believes that tackling malnutrition requires a new way of thinking in terms of nutritional guidelines. He says that the UK Eatwell Guide, which has been in place for several years, focuses on fighting obesity and reducing calories, despite malnutrition costing the UK twice as much as obesity. 24
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The Eatwell model neglects the fact that malnourished individuals need to eat more calories and energy-dense foods. Andy believes that Public Health England should take note from Canada’s Eatwell Plate, which puts the focus on all foods being healthy and that proportions and intake vary for different people’s nutritional needs. DIETETIC INTERVENTIONS
Oral nutritional interventions are indicated when any patient is taking inadequate food and fluid to meet their requirements.1 The three main approaches include food-based, ONS and organisational. This article has highlighted how a food-first approach is usually the first step when addressing malnutrition. Food-based approaches could include encouraging patients to order energy and protein dense options from the hospital menu, increasing portion sizes, offering additional snacks and puddings and encouraging patients or staff to fortify foods with high sugar or high fat foods such as butter, jam and sugar. Studies have shown that dietary counselling given with or without ONS is effective in increasing nutritional intake and weight.18 Therefore, ONS and a food-first approach are often used in combination. ONS, as already discussed, must be appropriately prescribed. It is important that dietitians work closely with patients and/or staff to ensure that ONS does not impact on appetite (ie, avoid 30 minutes before a meal) and that a patient is compliant. Compliance rates are highly variable, with one systematic review reporting compliance rates of 37 to 100%, the highest compliance being with high-energy sip feeds.19 Patients taking ONS should be regularly reviewed to maximise compliance and ONS should be discontinued if no longer indicated.10 Organisational approaches could include providing mealtime assistance, improving the eating environment and implementing protected mealtimes.20 These are all interventions that dietitians can be involved with. However, there is limited evidence to support their efficacy. Finally, enteral tube feeding may be indicated in patients who cannot achieve an adequate oral intake from food and/or ONS, or in those who cannot eat or drink safely. Parenteral feeding is indicated in individuals whose GI tract is unable to absorb sufficient nutrients, or in those who are unable to tolerate enteral tube feeding.1