Community approaches

to improving nutrition in

older people

DR RACHEL PRYKE

My background

GP and trainer in Redditch

Fellow NICE 2015-2018

RCGP Clinical Advisor on Nutrition and chair of RCGP Nutrition Group

Author Weight Matters for Children and Weight Matters for Young People, Radcliffe Publishing

Author many e-learning sessions on obesity and malnutrition in children and adults

Member of consensus panel that developed Managing Adult Malnutrition in the Community document and pathway

Declaration of interests

I have had funding from Nutricia for speaking

about malnutrition in the past and for helping to

develop the Managing malnutrition in the

community resource.

I have not had any commercial funding to attend

today

Aims of session

To explore how malnutrition is viewed in

primary care

To examine the benefits of improved care

within the community

How does malnutrition link across other

primary care priorities?

To reflect on how primary care can be

supported in improving malnutrition

awareness and management in the future

Stereotypes misconstrue the

relevance of malnutrition in the UK

It is still considered a third world problem whilst

we focus on obesity

Surveys indicate

Up to 10% of people registered with GP surgeries1

46% of patients admitted to hospital from a nursing

home2

41% of patients admitted to hospital from a

residential home2

How big a problem is

malnutrition in the UK?

More than 3 million individuals

are estimated to be at risk of

malnutrition in the UK, of whom about 93% live in the

community1

The number of over 65s set to

increase by 64% over the next

20 years

Malnutrition is a primary care

problem in every sense - But are we in primary care on

board?

A community problem

Poorer clinical outcomes

Impaired immune system

Delayed wound healing

Reduced muscle strength/falls risk

Increased healthcare use (14)

more GP visits (68.8% vs 59.3% with low risk malnutrition)

Increased admission and readmission rate

Longer hospital stay

Costly to health economy

Impact of Malnutrition - both a

cause and consequence of ill

health 3,4,5

Malnutrition is an ‘exemplar

health risk’

Whilst complex co-morbidity management

may dwarf relevance of malnutrition,

prioritising nutritional care can drive

improvements in wider co-morbidities –

skittle effect

Diagnosis involves clinical judgment as tests

are non-specific. No biochemical marker

perfectly assesses general nutritional status

Multiple micronutrient deficiencies are not

uncommon

No ‘Quality and Outcomes Framework’

points exist for malnutrition, but focusing on

malnutrition would benefit other QOF

domains e.g. chronic kidney disease, COPD

Co-morbidity

Malnutrition

Sarcopenic obesity

Risk factors change over time with

multimorbidity : Initial risk is

commonly obesity but disease-

related debility may allow risk of

malnutrition to emerge

Sarcopenia = Loss of muscle mass

and hence reduced physical

strength and function

In Sarcopenic obesity muscle loss

may be veiled behind an

apparently normal BMI

Test informally using gait speed e.g.

time taken to answer the door or to

walk from the waiting room

Malnutrition as prognostic

indicator: COPD

Malnutrition can predate decline in COPD. Addressing malnutrition at all stages of COPD slows predictable decline

Malnutrition in COPD has a poor prognosis (15) because it reduces

resilience to infection

respiratory muscle force

exercise tolerance/quality of life.

Weight loss should always trigger consideration of underlying cancer; around a fifth of patients with COPD will die from lung cancer whilst around half of lung cancer patients will also have COPD

Is there evidence to use weight loss to screen for cancer risk?

Lung cancer

COPD

Around 50% with lung

cancer have COPD :

20% with COPD will

get lung cancer

Current attitudes in

primary care

Weight loss is well recognised as a

red flag of active disease, e.g.

cancer: We ask, we register, we

investigate – but do we treat?

Deficiencies e.g. iron, B12, folate, vit

D, are commonly viewed

independently of a possible

nutritional component

Weight loss and malnutrition are

accepted as normal parts of

ageing

It remains unclear who is responsible

for managing the social

determinants of malnutrition

Opportunities (and challenges!) to

engage primary care

NICE Multimorbidity guideline –

Sept 2016 encourages holistic care

Assess frailty and falls risk

Identify high risk groups eg those

prescribed over 10 medications

Consider shared risk factors more

than each disease in isolation

Electronic frailty scores on some

GP systems

Enhanced service payments for

admission prevention schemes,

including creating care plans and

risk stratification

Assessment should include biopsychosocial not just

biochemical aspects

Social issues important – Affordability/Availability/Will to

eat/drink

Substantial health gains can arise from addressing the

psychosocial determinants of malnutrition

Red flag: If not managing to eat sufficiently, a person may

also be neglecting other basic aspects of health

Holistic risk

Physical assessment

•BMI /MUST score

•Underlying disease

• Dental check • Swallow • Vision assessment •Drug interactions/side effects

Psychological risks

• Alcohol intake • Mental state examination • Bereavement

• Presence of multi-morbidity

Social factors

• Poverty • Functional ability • Isolation • Family support

Malnutrition

Risk

Nutrition and hydration

are uniquely inter-related

The same patients risk both conditions

The same patients benefit from simple interventions to address both, i.e.

Recognition of risk

Assessment of barriers to self-efficacy, e.g. continence problems that encourage patients to fluid restrict

Help in addressing those barriers, e.g. practical and emotional support at mealtimes, social support to help with food and fluid provision

Addressing hydration protects renal health and reduces risk of acute kidney injury

The healthy eating ‘low-fat’ agenda risks

unintended consequences including

malnourished patients inappropriately

choosing or being given low fat, low calorie

foods by carers

Traffic light food labelling discourages high

fat/high calorie foods but does not indicate

who this information is targeted at

Over-emphasis on lowering cholesterol in

elderly people may be contributing to

malnutrition

Reduced dairy intake risks reducing protein

and fat soluble vitamin intake

‘Healthy eating’ means different

things to different people

Conflicting messages

What does

food

labelling

convey?

Who’s job is it to

unpick

misconceptions?

Calorie contents

Calories per gram

Protein 4

Carbohydrate 4

Fat 9

Alcohol 7

Fibre = carbohydrate but insoluble fibre is poorly absorbed. It helps retain gut moisture and can trigger fullness despite low energy uptake

Cals per 100mls

Full fat milk 64

Semi-skimmed 50

Skimmed 35

Double cream 467

Single cream 194

Groups at risk of malnutrition 3

Chronic disease COPD, cancer, inflammatory bowel

disease, GI disease, renal or liver disease

Chronic progressive

disease

Dementia, neurological conditions

(Parkinson’s disease, MND) arthritis

Acute illness

No food for more than 5 days (e.g. post-

operative)

Debility

Frailty, immobility, old age, depression,

convalescence

Social issues

Poor support, housebound, inability to shop

or cook, poverty, bereavement

Assess malnutrition risk using MUST screening tool

Screening - ‘MUST’ ‘Malnutrition

Universal Screening

Tool’

MUST is validated for

primary and secondary

care settings 6

It asks:

Are you skinny

anyway?

Have you lost weight?

Have you stopped

eating due to illness?

Image - Courtesy of BAPEN

What should GPs do?

First line

Assess causes – isolation, dentures, food availability, intercurrent illness, poverty

Give ‘Food Fortification’ advice for those at low to medium risk and arrange review. Unpick conflicting ‘healthy eating’ ideas

Self-care advice is under-utilised, as shown by low carer confidence (8)

Link printable resources to GP computers

Avoid superficial advice to simply increase calories without addressing essential protein and micronutrient requirements

Evidence shows improvements in muscle mass and hand grip strength with dietary advice10

Food fortification

Increasing energy density: increase nutritional content of meals without a significant increase in food volume, to accommodate poor appetite.

Texture modification, such as softer choices, fork mashable or thick puree foods

Ensuring adequate protein and micronutrient intake, without over-reliance on low-nutrient sugary foods such as cakes and confectionery.

Address potentially conflicting health messages (such as the common health message to eat low fat) do not apply to patients who are malnourished.

Advise about alternative options such as over-the-counter nutritional supplements

Review progress to detect whether prescribed oral nutritional supplements (ONS) are becoming appropriate

Second line community

management – ONS prescribing

Historically, ONS has been haphazardly prescribed without clear goals or appropriate monitoring

Inappropriate prescribing has led to ‘blanket bans’ of ONS prescribing in some CCG localities

Clear pathways improve monitoring and structured care

Consider ONS prescribing according to local pathways or Managing Malnutrition in the Community guidelines7 www.malnutritionpathway.co.uk

Issue ‘starter pack’ to check taste preferences

ONS prescribing goals

in community

Consider ONS prescribing for high risk patients especially if disease-

related or prior to surgery

Consider changing energy requirements - may increase during

rehabilitation programmes due to increased physical activity

Ensure social and practical barriers have been addressed

Agree goals with patient and or carer E.g. Improve weight, function,

quality of life (e.g. strength), reduce exacerbations, risk of admission

Plan review to ensure appropriate prescribing – including when to

start and stop ONS

Evidence demonstrates a range of clinical and health economic

benefits11, 13

Improved nutrition helps wound healing,

reduces length of hospital stay and rates

of hospital readmission3,4,5,14, plus quality of

life measures

Uncertainties around addressing

malnutrition are heightened when

patients are dying. Withdraw ONS once

symptomatic benefits cease

Whilst malnutrition should not be

considered a normal part of ageing, it is

commonly an acceptable part of dying

Guidance re: nutritional support in lung

cancer is at

www.lungcancernutrition.com

Review aims of nutritional

interventions over time

ACBS – prescribable

indications

Disease related malnutrition

Short bowel syndrome

Intractable malabsorption

Pre-operative preparation of

undernourished patients

Inflammatory bowel disease

Total gastrectomy

Dysphagia

Bowel fistulae

Caution in:

Alcoholics

Substance misuse

Eating disorders require

psychiatric assessment

Refer to dietitian if:

Complex nutritional needs

– renal disease, poorly

controlled DM, GI disorder

Recommendations for

ONS Prescribing

Acute illness/recent hospital discharge?

Short term prescribing may be required – 1-3 ONS per day in addition to oral intake7

Chronic conditions ?

2 ONS per day in addition to oral intake with regular review7

Terminal conditions – palliative care, progressive neurological conditions, advance illness; consider whether ONS would give symptomatic support and slow down weight loss and functional decline

Consider malnutrition in the context of multimorbidity and as a shared risk factor across an array of conditions

Inquire, investigate AND treat malnutrition

Use a validated screening tool – ‘MUST’

Malnutrition is not a normal part of ageing, but may be an accepted part of dying

Assess hydration in addition to malnutrition

Ensure that malnutrition treatment in the elderly is driven by genuine goals to promote quality of life rather than just to postpone death

Follow your local malnutrition pathway re food fortification and prescribing

Visit www.malnutritionpathway.co.uk for evidence based guidance

Summary points for

primary care

For guidance on screening, (including use of ‘Malnutrition Universal Screening Tool’), dietary advice and appropriate community prescribing of ONS www.malnutritionpathway.co.uk

CG32 Nutrition support in adults: quick reference guide, 20 February 2006. http://guidance.nice.org.uk/CG32/QuickRefGuide/pdf/English

RCGP Nutrition webpages - search on ‘RCGP Nutrition’ http://www.rcgp.org.uk/clinical-and-research/clinical-resources/nutrition.aspx

RCGP Obesity and malnutrition e-learning modules http://elearning.rcgp.org.uk/course/info.php?id=147&popup=0

Resources

1. Elia M, Russell C. Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009.

2. Russell CA and Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. A report by BAPEN. 2012.

3. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing; 2003.

4. Elia M. Nutrition and health economics. Nutrition 2006; 22(5):576-578.

5. Guest JF et al. Health Economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr 2011; 30(4): 422-429.

6. The "MUST" report. Nutritional screening for adults: a multidisciplinary responsibility. Elia M, editor. 2003. Redditch, UK, BAPEN.

7. Multi-professional consensus panel. Managing Adult Malnutrition in the Community. 2012.

8. http://www.bapen.org.uk/pdfs/nutritional-care-and-the-patient-voice.pdf 9. Manual of Dietetic Practice. 5th ed. Wiley Blackwell; 2014.

10. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease related malnutrition in adults (review). Cochrane Database of Systematic Reviews. 2011.

11. National Institute for Health and Clinical Excellence (NICE). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2006.

12. BMJ Group And Royal Pharmaceutical Society of Great Britain. British National Formulary; 2011.

13. Stratton RJ, Elia M. A review of reviews: a look at the evidence for oral nutritional supplements. Clin Nutr Supp 2007; 2, 5-23.

14. McGurk P, Cawood A, Walters E et al. The burden of malnutrition in general practice http://gut.bmj.com/content/61/Suppl_2/A18.2

15. A study of correlation between body mass index and GOLD staging of chronic obstructive pulmonary disease patients. Mrinmoy Mitra et al. DOI: 10.4103/2320-8775.123217

References