Nutricia Screening for malnutrition using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) Training Slides
Aims and Objectives By the end of this training session you will be able to : • Define malnutrition (undernutrition), and understand its causes and consequences in the clinical setting • Understand the problem of malnutrition, its economic impact and the prevalence across care settings • Understand the need for nutritional screening, and what makes a good screening tool • Understand the stages involved in nutritional screening using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) • Use ‘MUST’ to screen individuals for malnutrition • Implement appropriate management guidelines linked to malnutrition risk category using nutrition care plans • Understand the different options available to treat malnutrition appropriately
1 Overview of Malnutrition
Definition of Malnutrition “A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients (e.g. vitamins) causes measureable adverse effects on tissue/body form and function and clinical outcome.” Source: Elia. http://www.bapen.org.uk/information-and-resources/publications-and-resources/bapen-reports [01.07.2016]
Prevalence of Malnutrition 3 million people in the UK are malnourished 1 93% of these are in 5% of these are in 2% of these are in the community care homes hospitals • The prevalence of Malnutrition is higher within 2 : Older people 65 years and over (28% vs 21%) Those in care homes (41%) and hospitals (25%) 1. Elia M. http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf [19.05.16]. 2. Russell CA. http://www.bapen.org.uk/pdfs/nsw/nsw-2011-report.pdf [19.05.16].
Causes of Malnutrition Decreased intake Increased nutritional needs Increased nutrient losses
Causes of Malnutrition Decreased intake • • Poor food provision Availability of food • • Finances Lack of interest in food • • Oral problems e.g. ill fitting dentures, Reduced ability to cook dry mouth • Changes to sensory perception e.g. • taste and smell Needing assistance with food • • Bad mealtime experience Health issues • • Social isolation Depression/anxiety Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014
Causes of Malnutrition Increased nutritional needs • Involuntary movements e.g. Parkinson’s Disease or wandering in dementia • Drug-nutrient interactions • Illness/disease e.g. COPD, cancer, pneumonia Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014
Causes of Malnutrition Increased nutrient losses • Drug-nutrient interactions • Polypharmacy • Bacterial overgrowth • GI losses e.g. vomiting, diarrhoea, fistulae, exudate from wounds or pressure sores Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014
Groups at Risk of Malnutrition Group Example Older people Frail elderly, prone to falls, less mobile, wounds/pressure ulcers Acute and chronic conditions Cancer, COPD, gastrointestinal illness, renal disease, liver disease, neurological disease Chronic, progressive conditions Dementia, neurological conditions (Parkinson’s Disease, MND) Inpatients Those in hospital but also those recently discharged, those at high risk of being admitted, and those at high risk of being readmitted
Consequences of Malnutrition Malnutrition ↑ Morbidity ↑ Mortality ↓ Wound healing ↑ Treatment ↑ Infections ↑ Length of stay in hospital ↑ Complications ↑ GP visits ↑ Hospital admissions ↓ Convalescence and readmissions ↓ QOL and ↑ COST Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014
The Cost of Malnutrition Malnutrition £19.6 billion per annum 1 Obesity £3.5 billion per annum Source: Elia M. http://www.bapen.org.uk/pdfs/economic-report-full.pdf [01.06.16]
2. Identifying Malnutrition
Identifying Malnutrition • NICE Clinical Guideline 32 - Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (NICE CG32) is the NICE guideline providing recommendations for identifying and managing malnutrition • This guideline is the basis of NICE Quality Standard 24 (QS24) • It recommends: ‒ Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training. ‒ Screening of hospital inpatients on admission, and outpatients at their first appointment ‒ Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients. ‒ People in care homes should be screened on admission and when there is clinical concern. Source: NICE CG32 2006.
What is Nutritional Screening and Assessment? Nutritional screening: Rapid, general, often initial evaluation undertaken by nurses, medical staff or any healthcare workers, to detect significant risk of malnutrition and to implement a clear plan of action (Elia 2003). Nutritional assessment: More detailed, more specific and more in depth evaluation of nutritional status by an expert, so that specific plans can be implemented, often for more complicated nutritional problems. Not everybody requires a nutritional assessment (Elia 2003).
What Makes a Good Screening Tool ? Quick & simple to use Reliable Practical Use of same screening Good Can be used for reproducibility everyone between users tool avoids confusion and Good establishes continuity of screening nutritional care for tool patients moving across Has a range of alternative Concurrent measures if care settings. validity with weight & other tools height can’t be obtained Linked to a Evidence based care plan Suitable for use across disciplines Source: NICE CG32 2006.
What Makes a Good Screening Tool ? NICE Clinical Guideline 32, 2006 Screening should: • assess BMI • assess percentage unintentional weight loss • consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. ‘MUST’ may be used to do this. MUST is a reliable and validated screening tool (Elia 2003) Source: NICE CG32 2006.
3. Interactive explanation of the ‘MUST’
Malnutrition Universal Screening Tool (‘MUST’) • The ‘MUST’ is a five step tool used to identify individuals who are malnourished or at risk of malnutrition • It gives a score that indicates malnutrition risk using: • BMI • Weight loss over the last 3-6 months • Acute disease effect • It also has suggested management guidelines based on the ‘MUST’ score • For more information visit the ‘MUST’ website - http://www.bapen.org.uk/screening-and-must/must/introducing-must Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].
Malnutrition Universal Screening Tool (‘MUST’) Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].
‘MUST’ Step 1: Body Mass Index (BMI) Score • Height and weight are required to obtain BMI score • You can use the ‘Step 1: BMI score chart’ to obtain the BMI score (see next page for an explanation of how it can be used) Practical Tips • The BMI score chart is set up as a traffic light system green score = 0, amber score = 1 and red score = 2 • If the individuals weight is a decimal round up or down to the nearest kilogram • Actual BMI can be calculated using the following equation however this is not necessary to complete nutrition screening For your information BMI (kg/m 2 ) = Weight (kg) BMI 18.5-20kg/m 2 BMI greater than BMI less than Height 20kg/m 2 = Score 1 18.5kg/m 2 (m 2 ) = Score 0 = Score 2
‘MUST’ Step 1: Body Mass Index (BMI) Score • Locate the individual’s weight on the left or right of then chart and read along the row to line up with their height at the top or bottom of the chart • Use the colour in the chart to identify the BMI score: Green score = 0 Amber score = 1 Red score = 2
How Can I Obtain a Persons Weight ? Weigh the individual on standing/sitting scales Can’t weigh because unable to stand or transfer to sitting scales Use hoist scales Use recently documented weight Ask person/family (recalled) Clinical impression (obvious wasting, loose clothing/jewellery/dentures
What Type of Scales Should I Use ? • Digital grade III medical scales • Calibrated regularly Tips Ensure scales are balanced on flat ground (avoid uneven surfaces e.g. Chair scales: ensure the person’s carpet), with zero displayed before feet are not touching the floor weighing Standing scales: ensure person has nothing heavy in their pockets and weigh without shoes
How Can I Obtain a Persons Height ? • Height only needs to be obtained once • Height can be measured using a stadiometer • Height can be recalled • Height can be estimated using alternative measures e.g. ulna length Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].
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