Older People’s Essential Nutrition (OPEN) Eastleigh Launch 19 th March 2015
Agenda Topic Speaker Welcome Martin Stephens, CEO, Wessex Academic Introduction to OPEN Dr Dina Foy, Locality Lead, ENTVS Why identifying and caring for Dr Emma Parsons, Lead Dietitian, Wessex malnutrition is important AHSN Why we need joined up care for All malnutrition Eastleigh OPEN Nutritional Care Pathways Dr Emma Parsons, Lead Dietitian, Wessex AHSN OPEN Training Plan Rhiannon Jones, Dietitian, Wessex AHSN Raising awareness of good nutrition for Jean Roberts Jones, CEO, One Community older people in Eastleigh Questions and Answers All
Why identifying and treating malnutrition is important Dr Emma Parsons Lead Dietitian, Wessex AHSN
Overview • Identification and treatment of malnutrition • Development of the nutritional care pathways
Why focus on older people’s nutritional care? • Increasing population of older people – Expected to rise from 16% to 25% over the next 45 years. • Nutrition plays an important role in maintaining the health and independence of older people. • It is just as important to ensure people remain in good health, as well as treating those who become nutritionally compromised.
Maintaining independence in older age • 90% of older people live independently in the UK. • 10% require care in the community Care Homes Homes Places Residential 13,134 247,824 Nursing 4,672 215,463 • The independent sector now accounts for around 96% of council-supported placements.
Nutritional inadequacies • Vulnerability to nutritional inadequacies associated with: – Increasing age, – worsening health conditions – Levels of dependency. • Definition of malnutrition: – ‘A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients (e.g. vitamins) causes measurable adverse effects on tissue/body form and function and clinical outcome’ Elia 2000.
Malnutrition – Does it matter? COSTLY - Disease related malnutrition in the UK costs in excess of £13billion (Elia 2009). Under-recognised and under-treated across care settings (Elia 2003)
Malnutrition in community • 93% of malnourished individuals live in the community – Affects ~3 million people • Prevalence varies according to setting 16% 30-42% 5% Hospital Care Homes GP practices Outpatients (NICE, 2006) (BAPEN) (Rust, 2009) • Vulnerable groups are at higher risk Socially Chronic Children Elderly Isolated Disease
Malnutrition: A common problem ‘Malnutrition’ was found to affect : • 25% of adults on admission to hospitals • 41% of adults admitted to care homes in the previous 6 months • 19% of adults on admission to mental health units in the UK Most of those affected were in the high risk category. (171 hospitals, 78 care homes and 67 mental health units)
Causes of malnutrition • Chronic disease • Anxiety • Depression • Physical disability • Loss of senses • Bereavement (sight, smell etc.) • Changes in gastric signalling pathways Physiological Psychological • Sarcopenia Poly- Social pharmacy • Social isolation • Adaptation to new • Drug-nutrient surroundings interactions • Social networks • Dining environments This may then result in a reduction of food intake and weight loss, which can lead to a range of clinical and economic consequences.
Outcomes for malnourished outpatients • Risk of malnutrition in general outpatients was associated with; – Increased hospital admissions – Increased healthcare use (Cawood et al, 2011) • Malnourished outpatients with COPD – Twice the number of hospital admissions – Three times more likely to die in 6 months (Collins et al, 2010)
Nutritional care pathway Identification of malnutrition with screening Treatment of malnutrition Opportunity for HCP’s to Compliance improve outcomes Maximise nutritional intake Clinical benefits
The need for screening Many reports since 1992 have specified the need for screening. NICE 2006 – Screening should take place on initial registration at general practice surgeries and when there is clinical concern (1.2.5) Nutrition Action Plan DH 2007 – Five key priorities for action – Point 3 of the plan encourages nutritional screening for all people using health and social care services Care Quality Commission – Essential standards of quality and safety (2010) – ‘Nutritional screening is carried out to identify where they are at risk of poor nutrition and hydration when they first begin to use the service and at regular intervals’
“MUST” - Malnutrition Universal Screening Tool
‘MUST’: Use in all settings Primary Care Home Acute care home visits Emergency Routine On New admission assessment admission assessment Routine Health admission checks Monthly Monitoring Monitoring New patient monitoring and review checks
NICE QS24: Nutrition Support • People in care settings are screened for the risk of malnutrition using a validated screening tool. 1. • People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements. 2. • All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented 3. and communicated in writing within and between settings. • People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their 4. wellbeing . • People receiving nutrition support are offered a review of the indications, route, risks, benefits and goals of nutrition support at planned intervals. 5.
Nutritional care in the community Cawood et al 2008, 2009; Parsons et al 2009, 2010 • Currently there is a lack of: – Screening for malnutrition – Documentation of nutritional status – Use of appropriate equipment and care plans – Monitoring and review – Implementation of nutrition support
Barriers to identifying malnutrition • Awareness of the need to identify and treat malnutrition • Staff require training in nutritional screening • Access to people at risk of malnutrition may vary – Those accessing community services may be identified and monitored more easily than those not accessing services (e.g. outpatients, GP surgeries, district nurses) • Funding for nutritional screening within community services
Oral nutrition support strategies Support for people unable to feed themselves (e.g. modified feeding aids) Dietary advice from a Dietitian Altered meal patterns Fortified food with protein, carbohydrate, fat, vitamins, minerals Oral nutritional supplements (ONS) • (NICE 2006)
Oral Nutritional Supplements • Palatable drinks containing calories, protein, vitamins and minerals • Available as milkshakes, juices, puddings and soups • Over the counter: – Build Up, Complan, Boots Recovery • Via prescription: – Fortisip, Ensure, Fresubin • May be used in association with dietary advice
NICE review of the evidence for ONS use • Proprietary oral nutritional supplements: • Significantly reduce mortality • Significantly reduce complications • Significantly improve weight • Functional benefits • Better energy and protein intakes in supplemented • patients in all trials • Acceptable to patients
Evidence base for dietary advice in the community • A Cochrane review (35 trials, n 2468, Baldwin et al 2007) • Dietary advice vs. no advice – insufficient studies in the community for meta-analysis • Supplemented patients had significantly greater weight gain (or less loss) and significantly greater energy intakes than patients given dietary advice, over 3 months • ‘lack of evidence for the provision of dietary advice in managing illness- related malnutrition’
Summary Malnutrition is common and costly. Screening for malnutrition and monitoring should take place at regular intervals. Peoples nutritional needs and preferences should be identified. Nutrition care plans should be implemented and reviewed. ALL staff should receive training on nutritional care.
Eastleigh Nutritional Care Pathways Dr Emma Parsons Lead Dietitian, Wessex AHSN
Wessex AHSN Nutrition programme Aims to: • Develop and implement an approach(es) for reducing malnutrition in older people. • Develop and test a toolkit that develops capability to improve nutritional care in the elderly. • Facilitate and lead learning workshops across Wessex to encourage the adoption of the evidence based approaches to reducing malnutrition in the elderly. • Develop and apply an evaluation framework. • Develop and co-ordinate communication through appropriate channels to facilitate the sharing of good practice
OPEN Older People’s Essential Nutrition • To reduce the number of older people who are Aim malnourished and the associated health and social care use. • Eastleigh, Hampshire Location • Plans to spread wider across Hampshire. • It is estimated that malnutrition costs for Wessex are at Rationale least £520 million (approx. 4% of total UK costs).
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