Preventing and treating malnutrition in care homes Emily Yates, Dietitian

Who am I? Worked as a community Dietitian since 2003. Started working in York in January 2016. Review patients currently prescribed oral nutritional supplements in line with guidelines produced by the Vale of York Clinical Commissioning Group. Seeing patients in surgeries, nursing and residential homes and in their own homes. Project currently in first phase.

Aim of today’s session Introduce you to the guidelines Discuss malnutrition in care homes Screening your residents for malnutrition Food as a treatment for undernutrition Your role in preventing / treating malnutrition Cover CQC standards Interactive session http://www.valeofyorkccg.nhs.uk/rss/index.php?i d=malnutrition-pathway

Guidelines for the appropriate use of Oral Nutritional Supplements (ONS) for adults in the community Identifying adults at risk of malnutrition Assessing underlying causes of malnutrition Setting treatment goals Offering ‘food first’ dietary advice Initiating oral nutritional supplement prescriptions (when food first measures fail) Reviewing and discontinuing oral nutritional supplement prescriptions.

Malnutrition NICE guidelines (CG32) Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome Malnutrition is both a cause and a consequence of ill health. It is common and increases a patient's vulnerability to disease. Methods to improve or maintain nutritional intake are known as nutrition support. NICE guidelines (CG32)

Nutrition support NICE guidelines (CG32) Nutrition support should be considered in people: Who are malnourished At risk of malnutrition Surveys have shown that 30-42% of patients admitted to care homes are at risk of malnutrition NICE guidelines (CG32)

Recognising malnutrition Some of the symptoms and signs to watch out for include: Loss of appetite Weight loss – clothes, rings, jewellery, dentures may become loose Tiredness, loss of energy Reduced ability to perform normal tasks Reduced physical performance – for example, not being able to walk as far or as fast as usual Altered mood – malnutrition can be associated with lethargy and depression Poor concentration BAPEN

Effects of malnutrition Malnutrition affects every system in the body and always results in increased vulnerability to illness, increased complications and in very extreme cases even death. Immune system Muscles Falls Heart failure Kidneys Brain Impaired temperature regulation Micronutrient deficiencies such as anaemia BAPEN

Step 1 - Identifying undernutrition ‘Malnutrition Universal Screening Tool (‘MUST’) MUST calculator MUST charts MUST app for iphone MUST assesses patients as being at low, medium or high risk of malnutrition and guides the user to develop individualised care plans for treatment if required and further monitoring BAPEN

‘MUST’ Body Mass Index (BMI) – less than 18.5kg/m2 suggests a significant risk of malnutrition Recent weight loss - unintentional loss of more than 10% of normal body weight in the last 3 -6 months suggests a significant risk of malnutrition An “acute disease effect” associated with being acutely ill and unable to eat for more than five days. BAPEN

How often should you screen? On admission Monthly Ensure care staff are trained in effective and accurate screening http://www.bapen.org.uk/e-learning-portal/nutritional- screening-using-must/introduction-to-must-e-learning-modules https://www.rcn.org.uk/clinical-topics/nutrition-and- hydration/cpd http://www2.rcn.org.uk/development/practice/cpd_online_lea rning/supporting_peoples_nutritional_needs?_ga=1.187663848.1 728505942.1448621270 Document results Weigh only if safe and able to do so

What about the high risk patients? Start detailed food chart Ensure what was offered and how much was consumed is documented. If food has been offered but refused, document this also. Include snacks and if possible note any food friends or family members give. Record drinks taken as hydration is important and also certain drinks contribute extra nutrients.

What about the high risk patients? Weigh weekly if possible and document Other measurements can be taken if unable to weigh

Step 2 – Assessment Assess for potential causes of weight loss; ? Medication ? Medical condition ? Physical symptoms – vomiting / pain ? Poor oral health / dental issues ? Psychological issues such as depression ? Difficulties swallowing Aim to treat the above if possible

Step 3 – Goal setting Weight gain may not always be achievable Sometimes we can only aim to maintain weight or prevent further loss. Sometimes the aim may be to promote wound healing or to keep hydrated. Families may sometimes have unrealistic expectations which can be challenging.

Step 4 – Food First First line treatment for nutrition support. Every mouthful counts if someone has a poor appetite so ensure that foods and drinks are packed full of nourishment. Weight loss can potentially be prevented even if someone is only eating small amounts.

Nourishing snacks Offered at least twice daily between meals; Cheese and biscuits / pork pie / sausage roll Malt loaf / crumpet / teacake / scone with butter Piece of cake / Doughnut / Bakewell tart 2 chocolate biscuits Flapjack / cream bun / chocolate / sweets Creamy yoghurt / trifle / rice pudding / custard pot / mousse

Nourishing drinks Encouraged throughout the day – aim to replace lower calorie drinks like tea; Whole milk / cream added to coffee, made into hot chocolate, Ovaltine, Horlicks, Nesquik etc. Fresh fruit juice, smoothies – especially if home made as cream / yoghurt / ice-cream / milk powder / fresh fruit can be added to them. Fizzy drinks and alcohol contain calories if allowed / tolerated.

Fortified diet Extra calories / nutrients are added to everyday foods / meals Cream can be added to porridge, puddings, mashed potato, soup etc. Butter can be added to bread, toast, vegetables, potatoes etc. Cheese can be grated into potato and onto many meals. Milk powder can be added to milk

Step 5 – Oral Nutritional Supplements If food first measures has failed to progress towards agreed goals after 4-6 weeks then supplements may be considered. Input from a Doctor will be needed at this point. There are certain criteria that need to be met prior to supplements being started. Over the counter supplements such as Complan are available if patients don’t meet prescribing criteria.

Which supplement to use? Numerous types and brands available. In Vale of York, 1st line is powdered – Aymes shake. Made with fresh milk = more palatable. 2nd line are ready made milkshakes – Altraplen (125mls) or Aymes complete (200ml) 3rd line is juice based – Fresubin Jucy All come in a variety of flavours.

Which supplement to use? Supplements should be taken between meals and not as a meal replacement. Choose a time that isn’t going to fill them up and prevent them eating their meal. Do they prefer the supplement cold or at room temperature? Are there certain flavours that they like / dislike? Do they need it pouring into a beaker or can they drink it out of the bottle.

Please…. If your resident dislikes the supplement or isn’t taking it for whatever reason, please contact the Doctor / Dietitian to review as it isn’t beneficial to them and they could be on an alternative. Patients are frequently discharged from hospital on supplements – do they need them? Ensure your scales are frequently serviced and calibrated for accuracy.

= Which would you rather? Forticreme complete = 200 calories A crumpet ½ buttered teacake Slice of fruit/sponge cake Mini pork pie Pot of trifle Pot of thick and creamy yoghurt Pot of rich chocolate mousse =

= Which would you rather? Fortisip / Ensure / Fresubin = 300 calories Slice of flapjack 2 slices of buttered malt loaf ½ scone jam and cream Chocolate bar Handful of peanuts 2-3 scoops of ice cream 2 crackers with butter and cheese 2 slices of buttered toast =

Recipe boosters

Care Quality Commission Regulation 14: Meeting nutritional and hydration needs. Key points; Suitable, nutritious and appetising food and hydration Needs should be regularly reviewed Prompts, encouragement and aid Intake should be monitored and recorded Take action if concern Drinks available day and night Snacks to be available

Any questions? Caroline Walker Trust - www.cwt.org.uk have some fantastic resources; Eating Well for Older People: Practical and Nutritional Guidelines for Food in Residential and Community care (2004) Eating Well: Supporting Older People and Older People with Dementia (2011) Food First leaflets http://www.yorkhospitals.nhs.uk/your_visit/patient_information _leaflets/nutrition_and_dietetics/ https://www.bda.uk.com/foodfacts/MalnutritionFactSheet.pdf