Dignity and Nutrition for Older People

Transcription

1 South Gloucestershire Community Health Services Dignity and Nutrition for Older People Lorraine Norris Nutrition and Dietetic Professional Lead South Gloucestershire Community Health November 9th 2011

2 Aims of Session The Detection & Treatment of Malnutrition The Care Quality commission outcome Meeting Nutritional needs The CQC review of dignity and nutrition in Older people in hospitals The Nutritional Needs of the Care Home Resident Launch of the revised guidelines on Screening for malnutrition and the Appropriate use of sip feeds `

3 Nutrition and Dignity are interlinked

4 Why is nutrition important in the care setting? Maintain Health Monitoring Status Prevent Disease Aid recovery from illness Social Interaction Psychological Need Daily structure

5 Background I Estimated >3 million people malnourished or at risk of being malnourished in the UK* Majority of these (~97%) are in the community* Recent figures estimate the cost of disease related malnutrition for the NHS is 13 billion every year* *Ref: Elia & Russell (2009) Combating Malnutrition: Recommendations for Action, BAPEN

6 Background In South Gloucestershire 2 studies on the use of Oral nutrition supplements 2007 Pilot Study: 2 selected Nursing Homes 25% ONS prescriptions changed to improve compliance & reduce wastage & costs 2009 Medicines Management QOF Audit: Only 23% patients prescribed ONS were taking sufficient scripts to indicate compliance 80% or more. Limited malnutrition screening & only 4% patients received appropriate referral to a dietitian

7 Nutritional Needs of the Care Home Resident Making sure older people have nutritious food and drinks an essential part of good care Mealtimes also add social interaction and structure to the day National Minimum Standards Care Homes for Older People: availability, quality and presentation of food are crucial in ensuring that residents receive a wholesome, appealing and nutritious diet (DoH 2003)

8 Nutritional Needs of the Care Home Resident Nutritional status is a balance between food intake and an individuals nutritional requirements Food Intake Well nourished Weight maintained Nutritional Requirements If there is a shift either side of this balance an individual may be malnourished

9 Nutritional Needs of the Care Home Resident Malnutrition is 'bad' nutrition and therefore the term can encompass wasting (under-nutrition) and/or obesity (over-nutrition) More commonly used to refer to under-nutrition Older adults are more likely to be malnourished than younger individuals Care Home Residents 2-3 times more likely to be underweight than obese (BAPEN 2007)

10 Development of malnutrition Reduced food intake Increased requirements

11 Nutritional Needs of the Care Home Resident Reduced Food Intake Swallowing problems Anxiety & depression Unfamiliar food Reduced taste & smell sensitivity Poor positioning Poor dental health Nausea & vomiting Constipation Pain Gastric upsets No appetite Inadequate staffing to assist residents at meal times Presentation of food Difficulties self feeding Physical disability Inadequate time to finish a meal

12 Nutritional Needs of the Care Home Resident Increased nutritional requirements High temperature/fever Infection Cancer Blood loss Pressure Sores Fractures Wound exudates Diarrhoea & Vomiting Tremors Constant wandering Trauma

13 Malnutrition: Consequences Malnutrition can affect every system in the body Weight loss Weakness & Tiredness Depression & Anxiety Reduced mobility Increased risk of infections e.g. chest infection Increased risk of pressure sores Poor wound healing Loss of muscle power (can lead to increased falls) Vitamin & Mineral deficiencies e.g. Iron-def. anaemia Death

14 Malnutrition: Facts and Figures 30% Care Home residents are estimated to malnourished (BAPEN, 2007) Estimated cost of malnutrition for those in long term care (including care homes) is 2.6 billion per year (BAPEN, 2005) FURTHER READING: BAPEN - Combating Malnutrition: Recommendations for Action BAPEN Improving Nutritional Care & Treatment

15 Malnutrition: Screening Malnutrition is not always obvious Some residents will have a higher risk of malnutrition due to their medical conditions Identifying those residents who are at risk of malnutrition can prevent detrimental effects from occurring

16 Malnutrition: Screening Examples of Medical Conditions Arthritis in the hands Factors that may affect dietary intake Difficulty holding cutlery; cups/mugs; opening packets, sip feeds Pain poor appetite Possible Nutritional Consequences May result in reduced intake of food and drinks malnutrition, unintentional weight loss & dehydration Dementia Memory problems forgetting to eat a meal Distracted at meal times Difficulties with chewing or swallowing Wandering before meal finished Hiding foods rather than eating May result in reduced intake of foods and drinks malnutrition, unintentional weight loss & dehydration Approx 90% pts with Alzheimer's will lose weight Require cues to eat by staff Stroke Requires texture-modified diet e.g. soft or puree meals Difficulties feeding self due to physical disabilities Depression poor appetite May result in reduced intake of foods and drinks malnutrition, unintentional weight loss & dehydration Reduced nutritional intake due to soft/puree meals

17 Malnutrition: Screening Recommendations: All residents should be screened on admission to a care home Screening should be repeated regularly and where there maybe cause for concern (NICE guidance & National Minimum Standards for Care Homes)

18 Malnutrition: Screening The MUST tool: Developed by British Association of Parenteral and Enteral Nutrition (BAPEN) Used to identify adults who are underweight and at risk of malnutrition Prompts looking at BMI, recent weight loss, current intake and effects of illness

19 Malnutrition: Screening MUST is a step-by step tool resulting in an overall score and guidelines for treatment

20 Case Study Mr Morris is a frail 81yr old gentleman who has just come to live at your care home. In the past few months he had been struggling to live in his own home and has just had a recent stint in hospital due to a recurrent UTI. He has told you he didn t eat well in hospital as he had no appetite and disliked the food. He stays in bed a lot of the time and doesn t seem to eat very much at meal times. His sons report he used to have a good appetite and weighed 62kg about 6 months ago. You have weighed him today and his current weight is 53kg and he is 5 9½ tall

21 Malnutrition: Screening Step 1: Calculating BMI Mr Morris is 53kg and 1.76m tall: BMI: 17 kg/m 2 Low BMI Score of 2

22 Malnutrition: Screening Step 2 : Weight Loss Score Mr Morris previous weight was 62kg. He has lost 8kg over 6 months: Weight loss >6.00 >10% body weight loss Score of 2

23 Malnutrition: Screening Step 3: Acute Disease Score Unaware of any acute illness with Mr Morris Think about what may contribute to this score Step 4: Overall Risk Score Add scores together: BMI: Score 2 + Weight loss: Score 2 = Overall Score of 4 High Risk

24 Screening Difficulties It can be difficult to gain measurements for some residents, especially if they are bed bound Use Alternative measurements (see MUST tool) Use your clinical impression: BMI- Obvious wasting and appear underweight Weight Loss - Clothes and/or jewellery have become loose fitting History of decreased food intake, reduced appetite or dysphagia

25 Malnutrition: Screening Step 5: Treatment Guidelines for Malnutrition Screening and Appropriate Use of Sip Feeds (South Gloucestershire) Based on NICE Guideline 32: Nutrition Support in Adults

26 Malnutrition: Treatment The first line in treatment of malnutrition should always be, wherever possible, the use of normal foods and drinks

27 Little and Often High Calorie Foods & Drinks Snacks inbetween meals Food likes & dislikes Nourishing Drinks Food First Advice Fortifying Foods Avoid diet & low fat options Encouraging to eat with others Identify problems (OT/SALT)

28 Malnutrition: Treatment For some residents the use of Sip Feeds may be indicated to help them improve their nutritional intake and aid weight gain These can either be bought or provided on prescription from the GP

29 Malnutrition: Treatment Practicalities of Using Sip Feeds Various Styles Various Flavours (including neutral) Various Volumes (for use in-between meals) Should be served at correct temperature Can be frozen Can be added to other foods Aim to provide additional energy to current intake (Guidelines: extra 600kcals/d)

30 Summary Nutrition has a vital role in the care of your residents Malnutrition can have huge implications for someone's health and quality of care Detecting malnutrition is key in preventing complications Normal food & drinks should be first line in the treatment of malnutrition Sip feeds can be used to supplement someone s daily intake

31 CQC Outcome 5 : Meeting Nutritional needs Ensure personalised care by providing adequate nutrition, hydration and support Identification of those at risk Action taken when at risk patients are identified Dietary and hydration requirements are known and reviewed Provided in an environment that respect their dignity and ability Nutritional screening is carried out to identify those most at risk

32 The Care Quality commission Dignity and Nutrition Inspection Carried out in Dec 2010 on 100 hospitals All the inspections were on a single day 9-4pm they looked at outcome 1- respecting and involving people who use the service Outcome 5 Meeting Nutritional needs

33 The Care Quality commission Dignity and Nutrition Inspection Outcome 5: 51 hospitals were fully compliant 32 compliant but needed improvement 15 not compliant 2 were a major cause for concern

34 The Care Quality commission Dignity and Nutrition Inspection Outcome 5: patients were not given the help they needed to eat Patients were interrupted during meal times The needs of patients were not always assessed properly and they didn t get the care they needed e.g. special diets records of food and drink were not accurate so progress was not monitored Many patients were not able to wash their hands before meals

35 The Care Quality commission Dignity and Nutrition Inspection Common themes in the 17 hospitals failing in Outcome 5 Was the record of food and drink accurate? 12 hospitals had significant failings: A record was kept of food offered but what they had actually eaten

36 The Care Quality commission Dignity and Nutrition Inspection Common themes in the 17 hospitals failing in Outcome 5 were patients offered the chance to wash their hands? 15 of the failing hospitals were checked 13 of these did not offer hand washing before or after a meal

37 The Care Quality commission Dignity and Nutrition Inspection Common themes in the 17 hospitals failing in Outcome 5 Did staff have time to support patients? 15 hospitals were checked 11 were found to have failings Staff were trying to help patients sit up and serve lunch whilst a medication round was conducted There was not enough staff to support patients in feeding

38 The Care Quality commission Dignity and Nutrition Inspection Good practice Patients were helped to sit comfortably to eat their meals Food was cut up if needed Staff sat with patients whilst they ate meals Mealtimes was unrushed Patients at risk were identified by using coloured trays or jugs 77 of the hospitals met the standard for food quality 2/3 of hospitals offered a choice of foods There was a good availability of dietitians NB food quality was determined by patient feedback

39 References Guidelines for Malnutrition Screening and the Appropriate Use of Commercial Sip Feeds in South Gloucestershire NHS (2009). Available from National Institute for Health and Clinical Excellence (NICE), Clinical Guideline 32, Nutrition Support in Adults (2006). Available from Elia M, Russell CA (eds) (2009) Combating Malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition. Available from Care homes for older people: national minimum standards and The Care Homes Regulations - third edition Available from Department of Health MUST Information and downloadable tools. Available from