Community approaches to improving nutrition in older people

1. Community approaches
to improving nutrition in
older people
DR RACHEL PRYKE

2. 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

3. 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

4. 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

5. Stereotypes misconstrue the
relevance of malnutrition in the UK
 It is still considered a third world problem whilst
we focus on obesity

6. 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?

7.  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

8.  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

9. 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

10. 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

11. 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

12. 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

13. 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

14.  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

15. 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

16. 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

17.  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

18. Conflicting messages
What does
food
labelling
convey?
Who’s job is it to
unpick
misconceptions?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26.  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

27. 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

28. 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

29.  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

30.  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/QuickRefGuid
e/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

31. 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