MUST and Malnutrition Presenter
Housekeeping Northern Devon Healthcare NHS Trust
Confidentiality To respect confidentiality within the group unless it is necessary to address a current concern about the safety of an adult at risk.
Quiz Northern Devon Healthcare NHS Trust
Learning Objectives What is malnutrition What causes malnutrition What are the symptoms of malnutrition What is nutritional screening Why screen patients The MUST tool - what is it? The MUST tool how can it be used?
What is Malnutrition? No universally accepted definition but it can be defined as: A state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome (NICE guideline Nutritional support in adults, February 2006)
Malnutrition Facts and Figures More than 3 Million people in the UK are at risk of malnutrition with the vast majority (93%) living in a community setting. It is estimated that 1 in 10 people over the age of 65 living in the community are malnourished or at risk. Of the 3 million people at risk of malnutrition 150,000 (5% ) are living in residential accommodation. The health and social care costs in the UK directly associated with malnutrition comes to more than 13 billion per annum.
Malnutrition Facts and Figures For most adults a healthy BMI is between 18.5 and 24.9. Body Mass Index (BMI) and weight loss are not the only indicators of malnutrition. A person can be overweight or obese and still be malnourished. This can be due to having a diet consisting of food and drink that is high in fat and sugar and low in essential vitamins and minerals
Consequences of Malnutrition Evidence that malnourished patients: 65% increase in the number and frequency of visits to their GP. Need more prescriptions 82% more hospital admissions and 30% longer stays Have an increased morbidity and mortality Have a reduced quality of life
Causes of Malnutrition Medical conditions A condition that causes a lack of appetite, such as cancer, liver disease, persistent pain or nausea A mental health condition, such as depression or schizophrenia, which may affect your ability to look after yourself A health condition that requires frequent hospital admissions A health condition that disrupts your body s ability to digest food or absorb nutrients, such as Crohn's disease or ulcerative colitis
Causes of Malnutrition Medical Conditions Dementia people with dementia may be unable to communicate their needs when it comes to eating Dysphagia a condition that makes swallowing difficult or painful Persistent vomiting or diarrhoea An eating disorder, such as anorexia nervosa Some types of medication may increase your risk of developing malnutrition. More than 250 types of medicine are known to disrupt the body s ability to absorb and then break down nutrients. You may also be at risk of becoming malnourished if your body has an increased demand for energy for example, if it's trying to heal itself after major surgery, or a serious injury such as a burn.
Causes of Malnutrition Physical factors If your teeth are in a poor condition, or if dentures don't fit properly, eating can be difficult or painful You may lose your appetite as a result of losing your sense of smell and taste You may have a physical disability or other impairment that makes it difficult for you to cook or shop for food yourself
Causes of Malnutrition Social factors Living alone and being socially isolated Having limited knowledge about nutrition or cooking Reduced mobility Alcohol or drug dependency Low income or poverty
Symptoms of Malnutrition Unplanned and unexplained weight loss Feeling tired all the time and lacking energy Taking a long time to recover from infections Delayed wound healing Poor concentration Depression Difficulty keeping warm
Why Screen for Malnutrition? Malnutrition is frequently unrecognised and untreated Effective management of malnutrition reduces the burden on healthcare and care resources Regular screening is the only way that malnourished individuals can be identified and appropriate action taken
When Do We Screen? All hospital inpatients on admission All outpatients at their first appointment All people in care homes on admission All people on registration at GP surgeries And upon clinical concern Clinical concern includes, unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes, or prolonged intercurrent illness
When Do We Screen.. Consider screening at other opportunities ie. health checks, flu injections Repeat screening weekly when there is clinical concern Screening should be carried out by health and social care professionals with appropriate skills and training Screening should assess BMI (Body Mass Index) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this
What is MUST? 5 step tool used to identify adults who are malnourished or a risk of malnutrition A validated tool across various settings including Care Homes, Hospital wards, Outpatient Clinics and General Practice Quick and easy to use and give reproducible results Useful for patients in whom height and weight are difficult to obtain as it includes alternative measures and subjective criteria which are given to obtain BMI ( Body Mass Index ) Provides management guidelines which can be used to develop a care plan
Components of MUST A flow chart showing 5 steps to use for screening and management BMI chart Weight loss tables Alternative measurements
The Five Steps Steps 1 and 2 Gather nutritional measurements (height, weight, BMI, recent unplanned weight loss) Step3 Consider the affects of acute disease Step 4 Determine the overall risk score or category of malnutrition Step 5 Using the management guidelines and / or local policy, form an appropriate care plan
Step 1 - BMI Obtain weight and height Calculate BMI or use BMI chart provided Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained
Step 2: Weight Loss Score (Unplanned weight loss over 3-6 months) Unplanned weight loss over 3-6 months is a more acute risk factor for malnutrition than BMI Ask is there has been any weight loss in the last 3 6 months and if so how much? Deduct current weight from previous weight to calculate amount of eight loss If the subject has not lost weight score 0
Step 3 Acute Disease Effect Patients who have had or are likely to have no nutritional intake for more than 5 days Most likely to apply to patients who are critically ill, those who have swallowing difficulties, or head injuries or are undergoing gastrointestinal surgery
Step 4 Overall Risk of Malnutrition Add up scores from Steps 1, 2 and 3 Document score 0 = Low risk 1 = Medium risk 2 or more = High risk
Step 5 Management Guidelines Record residents overall risk score, agree and document a care plan and any advice given. Residents who fall into the high or medium risk categories typically require some form of intervention Management guidelines are contained within the MUST flowchart.
Alternative measurements Estimating Height from ulna length Ask resident to bend arm (left if possible), palm across chest, fingers pointing to opposite shoulder. Using a tape measure, measure the length in centimeters to the nearest 0.5cm between the point of the elbow and the mid point of the prominent bone of the wrist. Use the table to convert the ulna length to height.
Estimating BMI from mid upper arm circumference (MUAC) If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2 If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2
Estimating BMI The resident should be standing or sitting Use the left arm if possible, ask resident to remove clothing so arm is bare Locate the top of the shoulder and the point of the elbow Measure the distance between the two points and mark the arm Ask the resident to let the arm hang loose and with tape measure, measure the circumference of arm at mid point.
MUST Screening Tool How do we use it?
Activity Group work Undertaking MUST Measurements Case Studies Discussion
Case Study A Mr A is 69 year old man living in a residential home, has rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea. Height: 1.73m Previous weight: 71kg (2 months ago when weighed at GP Surgery) Current weight: 69kg Is patient at low, medium or high risk of malnutrition? What would be your action plan?
Case Study A - Answer 69 year old man living in a residential home, has rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea Height: 1.73m Previous weight: 71kg (2 months ago when weighed at GP Surgery) Current weight: 69kg Is patient at low, medium or high risk of malnutrition? Answer = Low Risk What would be your action plan? Repeat MUST monthly due to constipation, nausea and some weight loss Ensure balanced diet is advised, for a regular meal pattern and adequate fibre intake Give and discuss fluid advice sheet
Case Study B Miss B is a 38 year old lady living at home with regular visits during the day from Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less Height: ulna length 24.0cm Previous weight: 62kg (6 months ago at OP clinic) Current weight: 57kg Is patient at low, medium or high risk of malnutrition? What would be your Action Plan?
Case Study B - Answer 38 year old lady living at home with regular visits during the day from Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less Height: ulna length 24.0cm Previous weight: 62kg (6 months ago at OP clinic) Current weight: 57kg Is patient at low, medium or high risk of malnutrition? Answer = Medium risk What would be your Action Plan? Repeat MUST monthly due to weight loss Refer to Speech and Language therapist Food and fluid chart
Case Study C Mr C is a 89 year old man admitted to hospital after a fall at home and whilst an inpatient he contracted c.diff infection. Two months later he has been discharged to your care home, he still has diarrhoea but it is improving with treatment. Height: 6 0 (estimated) Weight: 56kg (estimated) Previous weight: 65kg (before admission) Is patient at low, medium or high risk of malnutrition? What would be your Action Plan?
Case Study C - Answer 89 year old man admitted to hospital after a fall at home and whilst an inpatient he contracted c.diff infection. Two months later he has been discharged to your care home, he still has diarrhoea but it is improving with treatment. Height: 6 0 (estimated) Weight: 56kg (estimated) Previous weight: 65kg (before admission to hospital) Is patient at low, medium or high risk of malnutrition? Answer = High Risk What would be your Action Plan? Start food and fluid chart Discuss weight loss with GP Consider referral to Dietician
What will you do differently after today?
Questions? Northern Devon Healthcare NHS Trust
QUIZ Northern Devon Healthcare NHS Trust
References NICE guideline Nutritional support in adults, February 2006 Malnutrition Universal Screening Tool, Bapen, November 2011 Dietician Key Facts Malnutrition British Dietetic Association 2014
Contacting the Care Homes Team Becky Young: RN, Barnstaple care homes Martine Butler: RN, BLIS care homes Bridget Tait: RN, Torridge care homes Sarah Bishop: Paramedic Educator, Torridge care homes Meg Hill: Occupational therapist, North Devon care homes Sarah Winfield-Davies: RN, Safeguarding Nurse, North Devon care homes e-mail: ndht.northerncarehomesteam@nhs.net