Staffordshire Nutrition Support Guidelines

Transcription

1 Staffordshire Nutrition Support Guidelines 6 Steps to Appropriate Nutritional Care for Adults And Make every Mouthful Matter food first tool Guidelines for early identification of malnutrition, first line nutritional support and appropriate use of oral nutritional supplements (ONS). Guidelines/Gateway PP-017 Number: Version Number: V2.2 Name of Ratification Nutrition Effectiveness Group Committee: Safety and Effectiveness Sub Committee Date Ratified: 22 August August May 2017 Title of Guideline Author: SSOTP Steering Group for Managing Malnutrition in the Community Title of Guidelines Lead: Date Issued: December 2017 Next Date of Review: December 2018 Professional Lead Dietetics Date of First Issue: September 2014 Target audience: All staff SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 1

2 CONSULTATION AND RATIFICATION SCHEDULE NAME TITLE DATE CONSULTED Nutrition Effectiveness Staffordshire Nutrition Support 29 May 2014 Group Guidelines V0 Malnutrition Matters Task Staffordshire Nutrition Support 09 June 2014 and Finish Group Guidelines V0 South CCG Area Staffordshire Nutrition Support June 2014 Prescribing Group Guidelines V0.1 Staffordshire and Stoke on Trent Partnership Trust Staffordshire Nutrition Support Guidelines V June -19 July 2014 Patient and Carer Group members Staffordshire Nutrition Support Guidelines V June 19 July 2014 Eat Well Staffordshire Project, Age UK. Staffordshire Nutrition Support Guidelines V June 19 July 2014 Nutrition and Dietetic Service, University Staffordshire Nutrition Support Guidelines V June 19 July 2014 Hospital North Staffordshire SSOTP Quality Staffordshire Nutrition Support 16 July 2014 Governance Committee Guidelines V0.3 Commission Quality Staffordshire Nutrition Support 31 July 2014 Review Meeting Guidelines V0.3 Malnutrition Matters Task Staffordshire Nutrition Support 5 August 2014 and Finish Group Nutrition and Effectiveness Group Guidelines V0.4 Staffordshire Nutrition Support Guidelines V2.0 May 2017 Guidelines APPROVED BY: DATE OF APPROVAL Area Prescribing Group 13 June 2014 Nutrition Effectiveness Group 22 August 2014 Safety and Effectiveness Sub Committee 29 August 2014 Policy Group 12 th May 2017 VERSION CONTROL Guidelines: Staffordshire Nutrition Support Guidelines VERSION VALID FROM VALID TO DOCUMENT PATH/NAME V0.1 January 2014 May 2014 Draft V0.2 June 2014 June 2014 Draft V0.3 June 2014 July 2014 Draft V0.4 July 2014 August 2014 Final V2.0 April 2017 May 2017 Draft V2.1 May 2017 December 2018 Final V2.2 December 2017 December 2018 Final SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 2

3 CONTENTS PAGE 1. Introduction 4 2. Purpose Steps to Appropriate Nutritional Care for Adults. 5 STEP 1- Identification of nutritional risk MUST and refeeding syndrome 5 STEP 2- Assessment of causes of malnutrition. 6 STEP 3- Setting a treatment goal. 6 STEP 4- Offering food first advice MAKE EVERY MOUTHFUL MATTER. 7 STEP 5 - Review - Prescribing Oral Nutritional Supplements (ONS) if no change. 8 STEP 6- Treatment Goal Met? reviewing and discontinuing oral nutritional 9 supplements (ONS). 4. Inappropriate prescribing of oral nutritional supplements (ONS) Over the counter oral nutritional supplements (ONS) Oral nutritional supplements (ONS) to prescribe as first line Oral nutritional supplements (ONS) which should not routinely be initiated in Further reading and resources Acknowledgements Appendices Standard Assessment Forms for Nutrition Quick reference guide 16 6 Steps to appropriate nutritional care for adults 3. Guide to assessing causes of malnutrition Make Every Mouthful Matter resource pack 5. Malnutrition Universal Screening Tool (MUST) SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 3

4 1. Introduction These guidelines advise on the screening process and intervention to support the nutritional journey of adults at risk of malnutrition within the population we serve. They are based on evidence based guidance as detailed in Managing Adult Malnutrition in the community (2012), including a pathway for the appropriate use of oral nutritional supplements (ONS). 2. Purpose The guidelines aim to assist health and social care professionals and third sector colleagues with the early identification of malnutrition and first line Nutritional support. The guidance also supports value based commissioning through a process which support the appropriate use of oral nutritional supplements (ONS) by prescribers and those responsible for monitoring progress. Other members of the community care team including dietitians, community nurses and matrons, community geriatricians, end of life nurses and other specialist nurses, should also refer to this information in making recommendations to support those identified as requiring nutritional support. These guidelines may not be appropriate for people who are in the final days of life. Please refer to specialist support services for advice. It is the duty of care of those who are using these guidelines to ensure they are competent to adhere to the guidelines. Please contact the Nutrition and Dietetic Service for support if required Advice is also offered within the guidelines on inappropriate prescribing and when it is appropriate to refer to community dietetic services. The Malnutrition Universal Screening Tool (MUST) is a validated screening tool for malnutrition and is used throughout the NHS in primary and secondary care. It was developed by a multi-disciplinary group of healthcare professionals. It includes appropriate care plans and so can influence clinical outcomes. This tool should be used to identify the risk of malnutrition within the pathway. It can be accessed at An app is also available for users of smartphones (search for BAPEN MUST ) which provides a simple to use MUST calculator. Please contact the Nutrition and Dietetic Service for support if required. SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 4

5 3. 6 Steps to Appropriate Nutritional Care for Adults Adapted from 6 Steps to Appropriate Prescribing ONHS, NHS Hertfordshire (June 2010) STEP 1 - IDENTIFICATION OF NUTRITIONAL RISK NICE Clinical Guideline 32, Nutritional Support in Adults, suggests the following criteria are used to identify those who are at nutritional risk or are malnourished. If one of these criteria is identified then implement the pathway: Must Score of 1 or more Body mass index (BMI) less than 18.5kg/m 2 Unintentional weight loss more than 10% in the past 3-6 months Body Mass Index (BMI) less than 20kg/m 2 and an unintentional weight loss more than 5% in the past 3-6 months Those who have eaten little or nothing for more than 5 days Those who have poor absorptive capacity or high nutrient losses Referral to the dietetic service: Refer to the dietitians if one of the following criteria are met: MUST score of 2 with no improvement following the 6 Steps to Appropriate Nutritional Care MUST score of 3 or more Patients for whom supplements are a sole source of nutrition Those who require alternative feeding such as nasogastric (NG) or Percutaneous Endoscopic Gastrostomy (PEG) feeding. Please use standards Dietetic referral forms available from: continue to follow the 6 Steps to Appropriate Nutritional Care offering food first advice as outlined in Step 4. Patients at high risk of developing re-feeding problems should be referred to their GP to ensure adherence of NICE 32. The criteria for determining this is one or more of the following: Body Mass Index (BMI) less than 16kg/m2 Unintentional weight loss greater than 15% within the last 3-6 months Little or no nutritional intake for more than 10 days Low levels of potassium, phosphate or magnesium prior to feeding. Or patient has two of more of the following: Body Mass Index (BMI) less than 18.5 kg/m2 Unintentional weight loss greater than 10% within the last 3-6 months. Little or no nutritional intake for more than 5 days A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 5

6 STEP 2 - ASSESSMENT OF CAUSES OF MALNUTRITION Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Consider: Ability to chew and swallowing issues Impact of medication Physical symptoms e.g. pain, nausea, vomiting, constipation, diarrhoea Medical prognosis Environmental and social issues Psychological issues / low mood Tissue viability / skin integrity Substance or alcohol misuse Review the treatment plan in respect of these issues and if needed make appropriate referrals. See Appendix 3 - A Guide to Assessing Underlying Causes of Malnutrition and Treatment Options. STEP 3 - SETTING A TREATMENT GOAL Clear treatment goals and a care plan should be agreed with patients using a person centered approach. Treatment goals should be documented on the patient record and should include the aim of nutritional support, timescale, be realistic and measurable. This could include: Target weight, or target weight gain, or target Body Mass Index (BMI) over a period of time Wound healing if relevant, e.g. pressure ulcer management Weight maintenance where weight gain is unrealistic or undesirable SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 6

7 STEP 4 - MAKE EVERY MOUTHFUL MATTER offering food first advice (Please refer appendix 4) Oral nutritional supplements (ONS) should not be used as first line treatment. A food first approach should be used initially. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements for those with a small appetite. Please follow the DAILY MEAL PLANNER advice 3 Aim for 3 fortified meals a day ie. breakfast, lunch and evening meal. These meals should be fortified by adding extra goodness Add full fat milk to porridge and breakfast cereal* Add sugar to drinks and cereals* Add jam to cereal / porridge / toast* Add butter to bread, potatoes and vegetables* Add full fat mayonnaise/salad cream to sandwich fillings/salads* Add cheese to soups and potatoes* 2 At least 2 high energy snacks each day Cheese and crackers with butter* Full fat yoghurt* Crisps* Custard pots* Cake* Milky drinks* Biscuits (not plain), chocolate covered, flapjacks, cake* Toast with butter and jam / peanut butter / chocolate spread /cheese / full fat cheese spread. Scone or bun or teacake with butter Sandwich with butter and meat / fish / cheese/ peanut butter Mini pork pie, sausage roll, cocktail sausage, mini scotch egg, quiche Any nuts *Available in our Community Hospitals 1 USE 1 PINT of fortified milk daily To make fortified milk add 4 heaped tablespoons of dried skimmed milk powder to 1 pint of whole (full fat) milk, stir well or whisk to dissolve. Use this on cereal, in tea/coffee, in milky drinks ie milkshake, hot chocolate, coffee, Horlicks, in puddings, in milk based soups and sauces. In community hospitals where milk powder may not always be available use full fat milk. Encourage Meritene Soups and milkshakes available from Catering/Sodexo. If patients prefer, they can purchase over the counter products such as Meritene Complan Nurishment Extra, Aymes milkshakes or soups. Nutritional content of these products are shown on page 11. SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 7

8 STEP 5 REVIEW PRESCRIBING ORAL NUTRITIONAL SUPPLEMENTS (ONS) IF NO CHANGE. Patients MUST care plan and treatment goal should be reviewed within one month in the community and after one week in community hospitals, ideally by the person who initiated assessment. If there is a positive change towards meeting goals, the changes should be encouraged and maintained and a further review arranged until goals are met. If a food first approach has failed to achieve a positive change towards meeting goals after one month, one week for those in community hospitals and there is clear evidence that all attempts have been made to optimize this approach consider prescribing oral nutritional supplements (ONS) in addition to the food first changes which should be maintained. Patients must meet at least one of the Advisory Committee for Borderline Substances (ACBS)* criteria below to be eligible for prescribed oral nutritional supplements (ONS): Short bowel syndrome Intractable malabsorption Pre-operative preparation of patients who are undernourished Proven inflammatory bowel disease Following total gastrectomy Dysphagia Bowel fistulae Disease related malnutrition Patients who do not meet ACBS prescribing criteria can also be advised to purchase supplements over the counter or prepare homemade nourishing drinks. Advice on starting prescribed ONS To maximise their effectiveness and avoid spoiling appetite, patients should be advised to take oral nutritional supplements (ONS) between or after meals and not before meals or as a meal replacement To be clinically effective it is recommended that oral nutritional supplements (ONS) are prescribed twice daily. This ensures that calorie and protein intake is sufficient to achieve weight gain A one week prescription or starter pack should always be prescribed initially to avoid wastage in case products are not well tolerated. In community hospitals patients should only be offered the exact ons prescribed for that patient. If a patient is refusing their supplements they should be reviewed by the Dietitian/prescriber. Please follow Community Hospitals Care Management Pathway for Declined Prescribed ONS. Avoid adding prescriptions for oral nutritional supplements (ONS) to the repeat template unless a short review date is included to ensure review against goals *NHS England and Wales Drug tariff List in section XV of the drug tariff refers to Advisory Committee Borderline Substances (ACBS). SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 8

9 STEP 6 TREATMENT GOAL MET? REVIEWING AND DISCONTINUING ORAL NUTRITIONAL SUPPLEMENTS (ONS) Patients on oral nutritional supplements (ONS) should be reviewed regularly following the advice in these guidelines, to assess progress towards goals and whether there is a continued need for oral nutritional supplements (ONS) on prescription. The following parameters should be monitored: Weight/Body Mass Index (BMI)/wound healing depending on goal set if unable to weigh patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, clothes/rings/watch looser or tighter, visual assessment Changes in food intake and / or appetite Compliance with oral nutritional supplements (ONS) and stock levels at home/care home When conducting general medication reviews, oral nutritional supplements (ONS) should be included as above. Advice on discontinuing prescriptions When treatment goals are met, discontinue prescriptions Review three months after discontinuation of oral nutritional supplements (ONS) or sooner dependent on need to ensure that there is no recurrence of the precipitating problem If the patient no longer meets Advisory Committee for Borderline Substances (ACBS) criteria, or goals are met, but still wishes to take oral nutritional supplements (ONS), suggest over the counter products e.g. Aymes, Meritene, Complan or Nurishment Extra. Information regarding nutritional content are shown on page 11. SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 9

10 4. Inappropriate Prescribing of Oral Nutritional Supplements (ONS) Care homes should provide adequate quantities of good quality food to avoid unnecessary nutrition support. Oral nutritional supplements should not be used as a substitute for the provision of food. Suitable snacks, food fortification as well as homemade milkshakes and smoothies and over the counter products can be used to improve the nutritional intake of those at risk of malnutrition. Patients who are discharged from hospital on oral nutritional supplements with no ongoing dietetic review process in place will not automatically require oral nutritional supplements on prescription once home. They may have required oral nutritional supplements whilst acutely unwell or recovering, but once home and eating normally the need is negated. Therefore it is recommended that oral nutritional supplements are not prescribed following hospital discharge without first assessing need in line with the 6 steps to appropriate nutritional care. Where oral nutritional supplements are still required, a switch to first line community products is recommended following locally agreed prescribing guidelines unless specific recommendations in a discharging letter have been made by Hospital Dietitian. The ons recommended and treatment plan should then be prescribed and followed. Avoid prescribing less than the clinically effective dose of 2 sachets/bottles daily which will provide kcals/day. Once daily prescribing provides amounts which can be met with food fortification alone and will delay resolution of the problem. Patients with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes and gastrointestinal disorders may require specialist products and should be referred to local community dietetic services. Patients with swallowing problems will require assessment by a Speech and Language Therapist before dietetic input. Patients with diabetes should not routinely be prescribed fruit juice based oral nutritional supplements i.e. Fresubin Jucy, Resource Fruit, Fortijuce, Ensure Plus Juce. These products have a higher glycaemic index, and blood glucose levels will need monitoring, with possible changes required to medication. Patients in the final days or weeks of life are unlikely to benefit from oral nutritional supplements. Over the counter products can be recommended if required. SSOTP Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2 10

11 5. Over The Counter Oral Nutritional Supplements If patients prefer and or do not meet the ACBS criteria and cannot meet their additional nutritional requirements through a food first approach alone, they can purchase over the counter nutritional supplements such as Complan milkshakes or soups, Aymes, Meritene, Nurishment milkshakes or soups, or unless contraindicated (i.e. Poorly controlled diabetes, chronic kidney disease stage 3-4, liver disease (Seek advice from a dietitian). Over the counter products can also be useful store cupboard items for those who have variable appetites and oral intakes to stop them becoming nutritionally compromised. These products are available from some supermarkets, pharmacies and also from online pharmacies. These products are not suitable as sole source of nutrition and should not be used as tube feeds. Powdered Products Meritene Complan Presentation 270g tin and 30 g sachets Vanilla, banana, strawberry, and chocolate flavours Not available routinely in Pharmacies but can be ordered in if requested by patients 4 x 57g sachets Vanilla, banana, strawberry, chocolate and neutral flavours Nutritional content Per sachet mixed with 200ml full fat milk 200kcals 16g protein when mixed with 200ml semi skimmed milk kcals 8.5g protein when mixed with water Aymes 4 x 38 g sachets Vanilla, strawberry, chocolate, banana. 265 Kcals 15g protein when mixed with whole milk Powdered Products Complan stir in Presentation Nutritional content per 100g powder 1 box of 450g neutral flavour 438kcals 15.3g protein 11

12 Soups Presentation Nutritional content Per sachet mixed with 200mls water Meritene soup 1 box of 4 x 50g sachets Chicken, vegetable 207kcals 7g protein mixed with water Complan soup 1 box of 4 x 57g sachets of chicken flavour. 243kcals 8.7g protein mixed with water Aymes 4 x 49 g sachets Chicken flavour 207 kcals 7.7g protein mixed with water Liquid Presentation Products Nurishment 400g tin original Vanilla, banana, strawberry, raspberry, cherry and chocolate flavours Nurishment Extra 310ml bottle Vanilla, banana, strawberry and chocolate flavours Nutritional content per unit Per 400g can kcals 20g protein Per 310 bottle kcals 12g protein Complan Smoothie 250ml tetrapak Tropical and berry flavours Milkshakes ml chocolate and strawberry flavors Per 250 ml - 272kcals g protein Per 250 ml Kcal 8.9 g protein 6. Oral Nutritional Supplements to be Prescribed as First Line Please refer to local prescribing agreements. Prescribe supplements which have a minimum 1.5kcal/ml or above. 7. Oral Nutritional Supplements Which Should Not Routinely Be Initiated In Primary Care. Dietitians may make clinical decisions to use other oral nutritional supplements where first line products are not sufficient to meet individual patients nutritional needs. However these patients should always be under review by the dietitians. The list includes: Low calorie products i.e. 1kcal/ml since these are not cost effective Milkshake style oral nutritional supplements which are not first or second line products in primary care Modular supplements which do not provide a balance of nutrients Specialist products which may be required for particular patient groups e.g. renal patients, or those with bowel disorders, those with 12

13 pressure ulcers, or those with dysphagia Puddings or soups as it should usually be possible for suitable homemade products to be fortified It is not a fully comprehensive list. Please discuss with your local Dietitian for further advice. 8. Further Reading And Resources British National Formulary. Cochrane Collaboration (2007). Dietary advice for illness-related malnutrition in adults (review), The Cochrane Library. Elia M. (Chairman and Ed 2003) MUST Report : Nutritional screening of adults : a multi-disciplinary approach. Elia M., Stratton,R.J., Russell et al (2005). The cost of malnutrition in the UK and the economic case for the use of oral nutritional supplements (ONS) in adults. British Association Parenteral and Enteral Nutrition (BAPEN) Elia M., and Russell CA (Eds). Combating Malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN (2009). London Procurement Programme: A guide to prescribing oral nutritional supplements in nursing and care homes (2011). Malnutrition Universal Screening Tool (MUST). Managing Adult Malnutrition in the Community (including a pathway for the appropriate use of oral nutritional supplements (ONS). Produced by a multi-professional consensus panel including the RCGP, RCN, BDA, BAPEN, PCPA. (2012) Manual of Dietetic Practice.5 th ed. Blackwell Publishing Ltd. (2014) MIMS monthly prescribing guide. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 32 Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition updated in August National Institute for Health and Clinical Excellence (NICE). Cost saving guidance. ce.jsp 13

14 National Institute for Health and Clinical Excellence (NICE) Quality standard for nutrition support in adults. NICE QS24 Nov National Minimum Standards for Care Homes for Older People. Dept of Health (2003). National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding principles for improving the systems and processes for ONS use. Prescribing Toolkit provided by NHS Prescription Services. Information provided by the Information Centre for Health and Social Care, October 2011 PrescQIPP NHS Midlands and East. Fabulous Fortified Feasts (2012) a collection of fortified recipes. Royal College of General Practitioners (2006). Prescribing in Primary Care Accessed online: Stratton RJ, and Elia M. Encouraging appropriate, evidence based use of oral nutritional supplements. Proc Nut Soc 2010; 69(4): Acknowledgements 6 Steps to Appropriate Nutritional Care for Adults - Care Pathway has been adapted from 6 Steps to Appropriate Prescribing ONHS, NHS Hertfordshire (June 2010) The following healthcare professionals contributed to the original development of this document as part of the Steering Group: o Dr Joanne Fillingham, Professional Head of Allied Health Professions, SSOTP o Gillian Rudge, Prescribing Support Lead Dietitian, ESCCG and SSOTP o Charlotte Jackson, Specialist Dietitian, SSOTP o Laura Hill, Specialist Dietitian, SSOTP o Marie Skerry, Advanced Dietitian, SSOTP o Cath Babington, Dietetic Assistant SSOTP 14

15 10. Appendices Appendix 1 Standard Assessment Forms Community MUST Nutrition Screening Form: DTC%20DIT%20Community%20Must%20Nutrition%20Screen%20V2.0.pdf Community MUST monitoring Form: DTC%20DIT%20Community%20Must%20Nutritional%20Assessment%20Mo nitoring.pdf Community Hospital Nutritional Assessment Form: Community Hospital Food Diary: CH%20Food%20Diary%20Chart%20V2.0.pdf Make Every Mouthful Matter Leaflet: DTC%20Make%20Every%20Mouthful%20Matter.pdf 15

16 Appendix 2 Quick Reference Guide 6 Steps to Appropriate Nutritional Care for Adults - Care Pathway STEP 1 Identification of Nutritional Risk if there is a MUST score of 1 move to STEP 2 Refer to Dietetic service (and also commence pathway) if: MUST score of 2 or more with no improvement following 6 Steps to Appropriate Nutritional Care On ONS as their sole source of nutrition Require artificial nutritional support eg Nasogastric/Percutaneous Endoscopic Gastrostomy Patients at high risk of developing re-feeding problems should be referred to their GP to ensure adherence of NICE 32 see pg. 5 STEP 2 Assess underlying causes of malnutrition and availability of adequate diet Make changes to treatment plan and refer to other services as needed. STEP 3 Set a treatment goal and devise a nutrition care plan STEP 4 MAKE EVERY MOUTHFUL MATTER - offer food first advice DAILY MEAL PLANNER advice STEP 5 Review after 1 month in community and 1 week in community hospital. Has there been progress towards goal set? Yes, there is progress towards goal set: Reinforce advice Reassess after 1-3 months in community and 1 week community hospital. Continued progress or improvement: Reinforce advice Reassess after 1-3 months in community and 1-2 weeks community hospital, until goal met. STEP 6 Treatment goal met Discontinue ONS if prescribed on a phased approach Review after 3 months If problems reoccur return to start of flow chart. No progress towards goal set: Reinforce Make Every Mouthful Matter food first advice. Reassess underlying problems and treat/refer on as appropriate. Prescribe ONS as per guideline (if meets ACBS criteria) in addition to fortified foods. If does not meet ACBS criteria recommend over the counter supplements Reassess after 1 week trial of first line ONS and prescribe preferred flavour bd for 1-3 months then review. No progress or improvement refer to dietetic services 16

17 Appendix 3 Guide to assessing causes of malnutrition A guide to assessing underlying causes of malnutrition and possible actions/solutions Medical conditions causing poor appetite, nausea etc e.g. cancer, COPD, diarrhoea, constipation GP and/or Community Matron and/or District Nursing management, consider appropriate medication Poor emotional or mental health e.g. depression, isolation, bereavement GP management, counselling, social clubs, day centres, mental health team PP Poor dentation Refer to dentist and advise patient on appropriate /soft diet Difficulties with swallowing or unable to swallow Refer to Speech and Language Therapy Unable to do own shopping and/or cook and/or feed self Suggest home delivery of food and or refer to social service/casserole club and EatWell Experiencing financial difficulties Refer to social services Alcohol or other substance misuse Refer to Community Drug and alcohol services 17

18 Appendix 4 Make Every Mouthful Matter Leaflet 18

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21 Appendix 5 MUST Screening Tool 25

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