New Tools to Identify Malnutrition Annemarie Aburrow RD Consultant Dietitian for Wessex AHSN
Tonight’s webinar will cover: • Wessex AHSN: Who we are and what we do • The Nutrition in Older People Programme (2014-18): key achievements • Wessex AHSN Healthy Ageing Programme • The problem of malnutrition in the community and the need for new tools • Need for new validated approaches in the community to help identify risk of malnutrition, provide signposting & advice, that can be used by the wider workforce and volunteers
Wessex Academic Health Science Network (AHSN): Who we are & what we do • Wessex AHSN is one of 15 AHSNs in England • Hampshire, Dorset, the Isle of Wight and South Wiltshire • Speed innovation across the region’s health system to create a healthier population and thriving economy • Programmes drive research into practice to address local health and social care priorities through partnership, collaboration, investment and support e.g. Healthy Ageing, Nutrition in Older People Programme, Medicines Optimisation, Mental Health
Nutrition in Older People Programme: 2014 – 2018 A focus on improving screening and care of those 1. Nutritional screening and care planning most at most at risk and causing the greatest cost – i.e. people living in the community receiving by integrated teams (health and social community health & social care care) in the community To help identify people as risk in the community leading to appropriate signposting, advice, or 2. Innovative approaches for increasing triage those who need formal screening awareness & identification of people at risk of malnutrition by volunteers and carers To improve awareness and training around malnutrition To provide resources for wider spread, to minimise 3. Resource development duplication of effort
Key achievements of the Programme Innovative approaches Resource development Research to show Developed simple tools to identify the Nutrition malnutrition and Checklist picks up enable signposting / those ‘at risk’ according advice - Nutrition to ‘MUST’ (clinical Checklist & Wheel screening tool) Screening, signposting & care planning
https://wessexahsn.org.uk/img/pr ogrammes/NutritionReportExecuti veSummary.pdf
Healthy Ageing Programme: 2018 - 2023 Purpose: • Add value to the Frailty agenda and activities in Wessex • Retain focus on innovation and spread Three streams of work: Hydration and Nutrition Evaluation / evidence Spread • • • Nutrition Checklist Red Bags Healthy Ageing • • Nutrition Wheel Wessex Acute Frailty Timeline • • OPEN Toolkit Audit ESCAPE Pain • • Hydration in Care Homes Community of Practice • Hydration in Domiciliary Care
The problem of malnutrition in the community • The majority of people with or at risk of malnutrition are living in the community: 1 in 10 older people and ageing population • Malnutrition still remains under-detected and under-treated, despite NICE guidance and quality standards recommending nutritional screening using validated tools such as ‘MUST’ • Malnutrition results from disease-related, physical and social factors – social risk factors are an important consideration in the community • £££ - Malnutrition in the UK costs > £19 billion (BAPEN/NIHR 2015) • Need for new validated approaches in the community to help identify risk of malnutrition, provide signposting & advice, that can be used by the wider workforce and volunteers
Tools to identify malnutrition Development of the Patients Association Nutrition Checklist Original checklist Adaptation of the Adaptation of the developed & piloted checklist by Wessex checklist by Wessex by The Patients AHSN for use in AHSN for use with Fire Association domiciliary care Service & Age UK Dec 2018: Finalisation Future plans: Research to validate and launch of the evaluation of tool the questions on the Nutrition Checklist Checklist ? App development and toolkit
Patients Association Nutrition Checklist Launched December 2018 https://www.patients-association.org.uk/blog/patients- association-nutrition-checklist
What is the Patients Association Nutrition Checklist? • A simple tool designed to identify potential malnutrition risk • Involves asking an older person 4 key questions to focus discussions around weight loss and nutrition, to identify potential risk of malnutrition (Section A) • For those likely to be an increased risk, guidance on the provision of basic advice and signposting is provided (Section B) • Initial testing has been carried out in domiciliary care, Hampshire Fire & Rescue Service, Age UK Southampton
Patients Association Nutrition Checklist
Research Project Aim: A cross-sectional study to investigate the concurrent validity of the Patients Association Nutrition Checklist to identify the risk of malnutrition in older people living in the community against ‘MUST’
Methods Local organisations offering lunch, social and activity clubs across Hampshire and Dorset were attended by a dietitian and researcher between January and May 2018 All participants were aged 65 and over and were recruited on the day and gave informed written consent Participants asked the questions from Section A of the Patients Association Nutrition Checklist and were then screened using ‘MUST’ (Elia, 2003) Agreement and chance-corrected agreement (ĸ) between ‘MUST’ and the Patients Association Nutrition Checklist were assessed (Landis & Koch, 1977)
Results: Participants • 312 older people were recruited from 21 lunch and activity clubs across Dorset (n=140) and Hampshire (n=172) • Mean age was 79.6 years (SD 8.3) • Mean BMI was 27.8 kg/m 2 (SD 5.6) • 197 older people (63%) were living alone
Results: Risk of malnutrition according to ‘MUST’ % at risk % at medium risk % at high risk 9.9% (n=31) 6.7% (n=21) 3.2% (n=10)
Results: Risk of malnutrition according to the Checklist No. participants answering ‘yes’ or ‘don’t know’ to each question (denoting risk) Q1 “are you or your family concerned you may be n=23 (34%) underweight or need nutritional advice?” Q2 “Have you lost a lot of weight unintentionally in n=30 (44%) the past 3- 6 months?” Q4 “Have you noticed that your clothes or rings n=37 (54%) have become loose recently?” Q4 “Have you recently found that you have lost n=38 (56%) your appetite and/or interest in eating?” Total ‘at risk’ 21.8% (n=68)
Results: Agreement between the tools • Moderate level of agreement between the two tools (sensitivity 85.4%, specificity 87.1%; ĸ= 0.47 (SE = 0.064), 95% CI [0.349, 0.599], P < 0.001) • There were 4 people at risk according to ‘MUST’ but not identified by the Patients Association Nutrition Checklist – these participants reported no change in weight and that they had always been slim • The Patients Association Nutrition Checklist identified more people at risk than ‘MUST’ – as it included people in the earlier stages of weight loss and with appetite changes
Conclusions The Patients Association Nutrition Checklist has: ✓ Acceptable sensitivity and specificity when compared with ‘MUST’ ✓ Potential for early identification of malnutrition risk and includes signposting to basic dietary advice and appropriate health and social care support
Tools to identify malnutrition: Development of the Nutrition Wheel 1. Results of a project we ran with Age Concern Hampshire in 2016 piloting the use of the PaperWeight Nutrition Armbands highlighted the need for an interactive tool to act as a conversation starter that includes the importance of asking questions to determine unintentional weight loss 2. In 2017, a group of 7 students from BU agreed to develop the questions and signposting / advice from the checklist into an initial prototype as part of their ‘Service Improvement Project’ 3. The students obtained some initial feedback from 7 volunteers in lunch clubs and 12 service users
Prototype developed by students
Tools to identify malnutrition: Development of the Nutrition Wheel 4. The students obtained some initial feedback from 7 volunteers in lunch clubs and 12 service users – feedback included: Design easy to understand and straightforward to use – with or without volunteer Provision of national helpline numbers helpful A ‘friendly’ way to have the conversation Liked the signposting advice on the information sheet 5. The Nutrition Wheel was further amended and 100 were printed for piloting purposes. A tear-off information/advice sheet produced
Tools to identify malnutrition: Development of the Nutrition Wheel 6. Ethics approval for research project to pilot the Nutrition Wheel - piloted by 17 volunteers All volunteers felt the Wheel was an excellent conversation starter Changes were required to address repetition in questions and make wording less ‘clinical’; also to simplify the advice sheet Design changes required to add in question numbering, use alternative colours
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