Why Food Matters for Older People Rhonda Smith Minerva Health & Care Communications Ltd
Why Food Matters for Older People • Food as ‘glue’ - vital for society, for all • Food & drink – Preventative: access, services, support – Supports well-being/activities of daily living – Essential part of care – Improves health outcomes • Perfect focus for ‘joining up’ community, care, housing & health • Variable awareness, policy, practice & resources across the UK • Some progress in policy, professions and wider public • However ….. malnutrition is common in the older population
Malnutrition: under-nutrition there’s a lot of it across the UK 3 million in the community at any one time* Incidence of low body weight (BMI < 20) >5% of the ‘healthy’ UK adult population over 65 yrs > 10% of the ‘unwell’ higher for those suffering from cancer, lung disease, GI problems, neurological and psychiatric illness * The ‘MUST’ Report, BAPEN 2003
Malnutrition: under-nutrition there’s a lot of it across the UK 3 million in the community at any one time* Incidence of low body weight (BMI < 20) >5% of the ‘healthy’ UK adult population over 65 yrs > 10% of the ‘unwell’ higher for those suffering from cancer, lung disease, GI problems, neurological and psychiatric illness Malnutrition in hospital and care – tip of the under-nutrition iceberg! * The ‘MUST’ Report, BAPEN 2003
Hospitals – malnutrition on admission Proportion at risk of malnutrition 28% 6% medium risk; 22% high risk (2008) Data on individual patients across the UK • 9722 individual patients • 9460 with ‘MUST’ scores • 9338 with ‘MUST’ scores in patients 18 y and over Number of Hospitals • 175 BAPEN Nutrition Screening Week Report 2008
Care Homes – malnutrition on admission Proportion at risk of malnutrition ~30% 10% medium risk; 20% high risk (2008) Data on individual residents across the UK • 1610 individual residents • 1610 with ‘MUST’ scores • 1610 with ‘MUST’ scores in residents 18 y & over Number of Care Homes • 173 BAPEN Nutrition Screening Week Report 2008
Sheltered Housing (England) Proportion at risk of malnutrition 10-15% half/half medium/high • More people live in sheltered housing than in care homes (~750,000) • More individuals with malnutrition in sheltered housing than in hospitals Screening for Malnutrition in Sheltered Housing BAPEN 2009
The Malnutrition Universal Screening Tool ‘MUST’ (iii) Acute disease effect BMI (kg/m 2 ) (i) (ii) Weight loss in 3-6 months Add a score of 2 if there 0 = >20.0 0 = <5% has been or is likely to be 1 = 18.5-20.0 1 = 5-10% no or very little nutritional 2 = <18.5 2 = >10% intake for >5 days Add scores OVERALL RISK OF UNDERNUTRITION * 0 1 2 or more LOW MEDIUM HIGH ROUTINE CLINICAL OBSERVE TREAT CARE† Repeat screening Hospital – refer to dietitian or implement Hospital - document dietary and fluid Hospital – every week intake for 3 days local policies. Generally food first followed Care homes – every month Care homes (as for hospital) by food fortification and supplements Community – every year for special Community - Repeat screening, e.g. Care homes (as for hospital) groups, e.g. those >75y from <1mo to >6 mo (with dietary Community (as for hospital) advice if necessary) * If height, weight or weight loss cannot be established , use documented or recalled values (if considered reliable). When measured or recalled height cannot be obtained, use knee height as surrogate measure. If neither can be calculated , obtain an overall impression of malnutrition risk (low, medium, high) using the following: (i)Clinical impression (very thin, thin, average, overweight) (ii)aClothes and/or jewellery have become loose fitting (ii)bHistory of decreased food intake, loss of appetite or dysphagia up to 3-6 months (iii)cDisease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss † Involves treatment of underlying condition, and help with food choice and eating when necessary (also applies to other ca tegories).
Malnutrition: under-nutrition Multiple adverse effects on the individual Psychology – Ventilation - loss of depression & apathy muscle & hypoxic responses Immunity - low WBCs, CMI, globulin & SIR Liver fatty change, functional decline necrosis, fibrosis Decreased Cardiac output Impaired wound Renal function - loss of healing ability to excrete Na & H2O Impaired gut Hypothermia integrity and immunity Loss of strength Anorexia Micronutrient deficiency Slide courtesy of Dr Mike Stroud, Chair, BAPEN
Prevalence & consequences PRIMARY CARE of malnutrition in the UK hospital dependency GP visits prescription costs HOME General population(adults) BMI <20kg/m 2 : 5% SHELTERED HOUSING BMI <18.5kg/m 2 : 1.8% 10-14% of tenants Elderly: 14% Prevalence of malnutrition HOSPITAL CARE HOMES 28% of admissions 30-42% of recently admitted residents SECONDARY CARE complications length of stay readmissions mortality Source: BAPEN Toolkit, 2010
The Malnutrition Carousel 15-60% of patients admitted to hospital are already malnourished Hospital Home More GP visits Longer stay More hospital More support admissions post- discharge Up to 70% of patients discharged from hospital weigh less than on admission Professor Marinos Elia, Chair, Malnutrition Action Group (MAG), BAPEN
BAPEN – UK Cost of Malnutrition – health & social care 2009 - £13 billion 2006 - £7.3 billion Obesity 2007 - £4.7 billion
Treating Malnutrition Works – 1 COPD Elderly HIV / AIDS Liver Surgery disease improved reduced improved lower greater respiratory number of cognitive incidence wound function falls function of severe healing infections increased increased immune less improved hand-grip activities of function fatigue strength daily living changes liver less loss and mobility function increased of improved walking muscle distance immune strength function increased well being
Treating Malnutrition Works – 2 Southampton meta-analysis of oral and enteral feeding in malnourished patients 30 RCT, n = 3258 10 RCT, n = 494; RR 0.59 (CI 0.48 to 0.72) RR 0.29 (CI 0.18 to 0.47) Controls Controls Treatment Treatment 0 10 20 30 40 50 0 5 10 15 20 25 30 Decreased complications % Decreased mortality % Slides courtesy of Dr Mike Stroud, BAPEN/Southampton
Distribution of under-nutrition in the UK hospital community hospital community Proportion of illness spent in hospital from onset to complete recovery Adapted from slides provided by Prof Elia/Dr Stroud, BAPEN
Malnutrition in the Community • Prevent in first place • Identify where there is risk or where it exists already • Inform/support individuals/families • Provide resources to implement action • Ensure information flow between settings – GP, hospital, sheltered housing, care • Greatest risk at transition
Progress – Scotland leading the way • 2003 screening on admission to hospital mandatory (e.g. BAPEN’s ‘MUST’) • Training – development & use of e-learning • NHS Scotland – Nutrition Quality standard • Nutrition Ambassadors – outreach to care and community (2 year funding ends) • Nutrition Clinical Network for Hospital staff (future?) • Community meals provision valued – protected?
Progress – across the UK • NICE: nutrition support for adults: hospital, care & community - implementation slow • Nutrition summit – Nutrition Action Plan & Governance Board – findings ignored • BAPEN – Nutrition Screening Weeks: size of problem • Age UK – Hungry to be Heard: public feedback • RCN – Essence of Care: nutrition/hydration benchmark • Quality Board – value not simply cost: focus on outcomes • Nutritional care – 4 th most cost effective initiative (NICE) • Chief Nurses – nutrition ‘high impact action’ • Guidance galore: care catering, nutrition standards, diets, meal planning for care homes
Reaching the ‘Tipping Point’ • NHS England: Care Quality Commission Hospitals, care homes and all clinics – legal requirement Outcome 5: Food and drink should meet people’s individual dietary requirements • Health & Well-being Boards: Public Health responsibility – prevention/promotion – all programmes • Commissioners – GPs & other clinical stakeholders: nutrition as cross-cutting theme – across all care and disease pathways • NICE – nutrition as a Quality Standard
Where does nutrition fit in the quality improvement framework..... Slide courtesy of DH/Ailsa Brotherton
The Big BAPEN Push • Westminster All Party Parliamentary Group – Nutrition & Hydration • Focused Clinical Guidance • Partnership working across sectors and professions – can’t do it alone • Collaboration across all UK nations • Europe has woken up to malnutrition
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