Why Food Matters...Why Food Matters for Older People •Food as ‘glue’ - vital for society, for...
Transcript of Why Food Matters...Why Food Matters for Older People •Food as ‘glue’ - vital for society, for...
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-nutritionthere’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-nutritionthere’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
• More people live in sheltered housing
than in care homes (~750,000)
• More individuals with malnutrition in
sheltered housing than in hospitals
Sheltered Housing (England)
Proportion at risk of malnutrition
10-15% half/half medium/high
Screening for Malnutrition in Sheltered Housing BAPEN 2009
* 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 categories).
OVERALL RISK OF UNDERNUTRITION *
(i) BMI (kg/m2)
0 = >20.0
1 = 18.5-20.0
2 = <18.5
(ii) Weight loss in 3-6 months
0 = <5%
1 = 5-10%
2 = >10%
(iii) Acute disease effect
Add a score of 2 if there
has been or is likely to be
no or very little nutritional
intake for >5 days
0
LOW
ROUTINE CLINICAL
CARE†Repeat screening
Hospital – every week
Care homes – every month
Community – every year for special
groups, e.g. those >75y
1
MEDIUM
OBSERVE
Hospital - document dietary and fluid
intake for 3 days
Care homes (as for hospital)
Community - Repeat screening, e.g.
from <1mo to >6 mo (with dietary
advice if necessary)
2 or more
HIGH
TREAT
Hospital – refer to dietitian or implement
local policies. Generally food first followed
by food fortification and supplements
Care homes (as for hospital)
Community (as for hospital)
Add scores
The Malnutrition Universal Screening Tool ‘MUST’
Malnutrition: under-nutritionMultiple adverse effects on the individual
Immunity - low WBCs,
CMI, globulin & SIR
HypothermiaImpaired gut
integrity and
immunity
Renal function - loss of
ability to excrete
Na & H2O
Decreased Cardiac output
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Anorexia
Micronutrient deficiency
Loss of strength
Liver fatty change,
functional decline
necrosis, fibrosis
Impaired wound
healing
Slide courtesy of Dr Mike Stroud, Chair, BAPEN
Prevalence & consequences
of malnutrition in the UK
SECONDARY CARE
complications
length of stay
readmissions
mortality
CARE HOMES
30-42% of recently
admitted residents
HOSPITAL
28% of admissions
PRIMARY CARE
hospital
dependency
GP visits
prescription costs
SHELTERED HOUSING
10-14% of tenants
HOME
General population (adults)
BMI <20kg/m2 : 5%
BMI <18.5kg/m2 : 1.8%
Elderly: 14%
Prevalence of
malnutrition
Source: BAPEN Toolkit, 2010
The Malnutrition Carousel
15-60% of patients
admitted to hospital
are already malnourished
Up to 70% of patients
discharged from hospital
weigh less than on admission
More GP visits
Home Hospital
More hospital
admissions
Longer stay
More support
post- discharge
Professor Marinos Elia, Chair, Malnutrition Action Group (MAG), BAPEN
BAPEN – UK Cost of Malnutrition – health & social care
2006 - £7.3 billion 2009 - £13 billion
Obesity 2007 - £4.7 billion
Treating Malnutrition Works – 1
COPD Elderly HIV / AIDS Liver
disease
Surgery
improved respiratory function
increased hand-grip strength
increased walking distance
reduced number of falls
increased activities of daily living and mobility
improved immune function
increased well being
improved cognitive function
immune function changes
lower incidence of severe infections
improved liver function
greater wound healing
less fatigue
less loss of muscle strength
Treating Malnutrition Works – 2
0 10 20 30 40 500 5 10 15 20 25 30
30 RCT, n = 3258
RR 0.59 (CI 0.48 to 0.72) 10 RCT, n = 494;
RR 0.29 (CI 0.18 to 0.47)
Decreased complications % Decreased mortality %
Controls Controls
Treatment Treatment
Southampton meta-analysis of oral and
enteral feeding in malnourished patients
Slides courtesy of Dr Mike Stroud, BAPEN/Southampton
hospital
community
Distribution of under-nutrition
in the UK
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 – 4th 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
Europe & Malnutrition
• Council of Europe – human rights focus
• Studies across Europe reveal same prevalence rates as UK in hospital & care
• European Nutrition Day in hospitals – record how much food is eaten not given
• Annual prize for European country tackling malnutrition most effectively – won by BAPEN 2008!
• Malnutrition included alongside obesity in health declarations
• EC - ENVI Committee upcoming debate on screening & mandatory action
Continuum of Nutritional Care
Prevent – Identify – Treat – Support
from Food to Specialist Feeding
Community - Care - Hospital
Making the ‘Business Case’
for nutritional care together
and working together are the keys
to preventing & effectively treating
avoidable malnutrition