Malnutrition in Adults: Guidelines for Identification and Treatment

Transcription

1 Malnutrition in Adults: Guidelines for Identification and Treatment Signatures (e.g. chair of the ratifying committee and lay member) and date Signature...date Designation: Signature...date Designation 1

2 Version: 2 Ratified by: Date ratified: Name of originator/author: Reka Ragubeer Name of responsible committee: Date issued for publication: Review date: July 2013 Expiry date: July 2013 Target audience: GPs, practice nurses, community and district nursing staff, Care Homes, Residential Homes, Nursing Homes and other Health Care Professionals 2

3 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Reka Ragubeer Clinical Community Dietitian Circulated to the following individuals for consultation Name Catherine Humphreys Bharat Patel David Shakespeare Designation Head of Dietetic Services Head of Medicines Management Head of Professional Practice and Risk Changes since previous version: 2 3

4 CONTENTS PAGE 1 Scope 5 2 What is Malnutrition? 6 3 Importance of Nutritional Screening Who should be screened? Which Patients are most at risk? 8 4 Nutritional Screening Tool 9 5 How to screen using MUST 10 6 Malnutrition Universal Screening Tool 11 7 Nutritional Support Flow Chart 12 8 Action to be taken First line dietary advice 13 9 References 17 4

5 Patient Information Leaflets Food fortification Appendix 1 14 Tips to help you make the most of your food Appendix 2 15 Nourishing Snack Ideas Appendix SCOPE This clinical guideline applies to adults within Walsall. These guidelines set out the process for the identification of patients with nutritional problems using a nutritional screening tool and how to proceed with their subsequent management. These guidelines are intended for use by GPs and practice nurses, district nursing staff, Care Homes, and other Health Care Professionals It does not apply to young people under 18 years old. This clinical guideline has been reviewed in accordance with the NICE Clinical Guideline number 32. 5

6 Further copies of the guidelines, including patient and professional advice leaflets, are available from: Nutrition and Dietetic Department, Walsall Manor Hospital, Moat Road, Walsall, WS2 9PS 2. WHAT IS MALNUTRITION? Malnutrition is a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome. For the purposes of this guideline, malnutrition refers to under 6

7 nutrition. This is an insidious condition, often undetected unless very apparent. Symptoms may be multiple and non-specific and may be attributed to underlying disease 1. This means that malnutrition may not be detected or treated. The consequences of malnutrition are: Impaired immune response Reduced muscle strength/fatigue Inactivity leading to pressure sores / thromboembolism Apathy, depression and self-neglect Impaired thermoregulation Impaired wound healing and recovery from illness Weight loss Increased use and cost of healthcare resources This includes: - more GP visits - more new prescriptions 2 - more hospital admissions - increased length of stay in hospital 2 - increased likelihood of transfer from hospital to another healthcare unit rather than patient s own home Early detection by use of a nutrition screening tool and early dietary intervention is essential to highlight those at risk of malnutrition and to improve their health status³. 7

8 3. IMPORTANCE OF NUTRITIONAL SCREENING Nutritional screening should ideally be carried out in all groups at risk of malnutrition, for example, all residents in care homes, community hospitals and prisons, those with chronic diseases, and the elderly WHO SHOULD BE SCREENED? All hospital inpatients on admission including those in community hospitals All outpatients at the first clinic appointment and where there is clinical concern All people in care homes on admission and where there is clinical concern On initial registration at general practice surgeries and where there is clinical concern As part of a medication review. Consider opportunistic screening at, for example, health checks, flu injection. Patients where there is clinical concern (see below). Clinical Concern includes: Unplanned weight loss Fragile skin Poor wound healing Apathy Wasted muscles Poor appetite Altered taste sensation Impaired swallowing Altered bowel habit 8

9 Loose fitting clothes/rings Prolonged intercurrent illness WHICH PATIENTS ARE MOST AT RISK? Patient's Condition Clinical Course of Malnutrition Clinical Implications Cancer Chronic neurological disease, e.g. multiple sclerosis Motor neurone disease Chronic inflammatory bowel disease Chronic respiratory disease Stroke Taste alterations Periods of nausea/vomiting Malabsorption due to chemotherapy/radiotherapy Loss of appetite Increasing problems with swallowing and mouth control, feeding problems Protracted periods of pain and diarrhoea, anorexia Anorexia Feeding problems Swallowing or mouth control problems, reduced taste, reduced understanding Poor response to therapy, pressure sores, extended recovery times Progressive weight loss and muscle weakness, poor response to therapy Dehydration, anorexia, pressur sores Diarrhoea Malabsorption of nutrients and diarrhoea Progressive weight loss and muscle weakness Poor response to therapy, recovery times extended, dehydration Acute/chronic pain e.g. arthritis Sick elderly (especially 70+) Anorexia due to the side effects of analgesic drugs and effects of pain Usually a combination of depression, social and environmental issues, anorexia Rapid and progressive weight loss Increased risk of infection or serious falls Pressure sores 9

10 Pre and post operative Anorexia, increased nutritional requirements Rapid and progressive weight loss. Decreased immune function. Increasing risk of further infection. Wound breakdown HIV/AIDS Malabsorption as result of infection Rapid and progressive weight loss 4. NUTRITIONAL SCREENING TOOL The Malnutrition Universal Screening Tool ( MUST ) is a five step screening tool to identity adults, who are malnourished, at risk of malnutrition (under-nutrition), or obese. It has not been designed to detect deficiencies in or excessive intakes of vitamins and minerals. If a patient is identified as obese please refer to NICE guidelines on the use of anti-obesity medicines, and the Health Select Committee Report on Obesity. MUST has been validated across various settings such as hospital wards, outpatient clinics, general practice, community settings and care homes. It was found that MUST was quick and easy to use, and gave reproducible results. It can be used for patients in whom height and weight are difficult to obtain, as a range of alternative measures and subjective criteria are given to obtain the Body Mass Index (BMI). The evidence base for MUST is summarised in The MUST Report and Explanatory Booklet, copies of both are available from BAPEN (British Association for Parenteral and Enteral Nutrition). The MUST was developed by the Malnutrition Advisory Group (MAG), a Standing Committee of BAPEN 4. A copy of the MUST can be found in Appendix V. Further details can be found on the BAPEN website at and copies of MUST can be downloaded and printed from this site. 10

11 This document acts as the local policy referred to throughout the MUST document. The Nutritional Support Flow chart (p 10) should be followed once a patient has been identified as at risk of malnutrition. 5. HOW TO SCREEN USING MUST There are five steps to follow:- 11

12 6. 'MALNUTRITION UNIVERSAL SCREEENING TOOL' ( MUST ) 12

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14 7. NUTRITIONAL SUPPORT FLOW CHART FOR MEDIUM AND HIGH RISK PATIENTS Patient identified at risk of malnutrition using MUST Give first line dietary advice and information to boost nutritional intake, (see appendix) If in care home, document/monitor dietary intake. Reassess using MUST and document weight At 4 weeks for medium risk patients At 1 week for high risk patients Assess dietary changes made IMPROVEMENT NO IMPROVEMENT Still losing weight/not eating better Reinforce dietary advice Reassess underlying problems and treat where possible Introduce sip feeds 1-2 per day in addition to normal foods. Patients unable to take normal food may require more. Weight stable or increasing/eating increased Reinforce advice Monitor compliance with nutritional support. Continue to reassess every 4 weeks using MUST, until desired outcomes are achieved Reassess using MUST Weekly if hospital setting Within 4 weeks in community or care home. Use professional judgement to set date of reassessment. When aim of therapy is achieved e.g. agreed weight reached/eating returned to normal If on sip feeds, withdraw under supervision. Weigh every month for at least 3 months If problems recur start at the Weight/eating continues to deteriorate Consider GP referral to dietitian or appropriate health care professions e.g. Speech and Language Therapy, Medical referral Or if patient is for palliative care consider appetite stimulants (contact palliative care team for further advice) 14

15 8. ACTION TO BE TAKEN 8. ACTION TO BE TAKEN 8.1. FIRST LINE DIETARY ADVICE In the first instance patients who have unplanned weight loss should be encouraged to increase their food intake, by having regular meals and extra snacks. See appendices 1, 2 and 3 for details of the leaflets for patients, Food fortification, Tips to help you make the most of your food and Nourishing Snack Ideas. Fortifying ordinary food with high calorie foods such as butter or cream and presenting food in alternative ways is often more effective and more palatable than prescribing sip feeds. Dietary advice regarding food fortification is likely to contradict healthy eating messages of low fat & low sugar. However, the fact that a patient requires this type of dietary advice means that healthy eating messages are not appropriate for them at this time. Leaflets for patients are available giving suggestions on how to maximise calories and protein from everyday foods (See appendices 1-3). It is essential that the patients overall nutrient intake contains a balanced mixture of protein, energy, fibre, electrolytes, vitamins and minerals. A dietary record may help to determine this. For patients with specific dietary requirements e.g. coeliac disease, diabetes, food allergy to milk or vegan diet, please consult a dietitian. 15

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17 Appendix 2 17

18 Appendix 3 18

19 REFERENCES 1 MAG June 2000 Brief prepared for the Health Select Committee 2 Edington et al.prevalence of malnutrition on admission to four hospitals in England. Clinical Nutrition 2000; 19: ³ National Institute for Health and Clinical Excellence (2006).Nutrition support in adult. Oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32 4 BAPEN (2003) The MUST explanatory booklet: A guide to the MalnutritionUniversal screening tool ( MUST ) for adults. BAPEN 19