Nutrition for the Older Persons Empowering staff to look at practice Gráinne Flanagan Clinical Specialist Community Dietitian HSE, Midland Area, Ireland

Under-nutrition in Residential Care The evidence: National Diet and Nutrition Survey carried out on the over 65-age group found that 1 in 6 residents of residential homes were malnourished (16% men & 15 % women). This compared with 3% men and 6% women of similar age in the community (at home). (Copeman, 2000 UK)

The prevalence of malnutrition: is consistently higher in health care settings, including nursing homes & hospitals than in patients living at home is up to 36% in older patients with a variety of conditions is up to 31% in patients with CVA/Stroke (Stratton & Elia 2002)

‘Nutritional status shows progressive deterioration during hospitalisation - up to 78%.’ Hamilton et al, 2002; McWhiter and Pennington, 1994

Consequences of malnutrition in Older persons body wasting reduced muscle mass reduced heart volume reduced respiratory muscle strength changes in intestinal permeability impaired immune function impaired Thermo-regulation changes in psychological function Quality of Life Health care Costs (Stratton & Elia 2002)

Survival beyond 50% weight loss is unlikely A rapid weight loss of between 35 & 40% is associated with a 30% risk of death. Survival beyond 50% weight loss is unlikely (Allison 1992, 1995) A prevalence of up to 30% (undernutrition) at admission to hospitals has been reported from all over Europe ( Council of Europe 2002)

5 common barriers in Europe: Nutrition in Institutional Care (Council of Europe 2002) Lack of clearly defined responsibilities in planning & managing nutritional care Lack of sufficient education (Nutrition) to all staff groups Lack of influence & knowledge of the patients/residents Lack of co-operation between different staff groups Lack of involvement from management

‘..all patients have the right: ... to expect that their nutritional needs will be fulfilled during a hospitalisation’ … to choose what they want to eat, when & with whom’ Council of Europe 2002

Recommendations (Council of Europe 2002) Organisational framework to food & nutrition in hospitals Food & Nutrition as a Management issue Nutrition Screening & Assessment Nutritional support Nutrition Teams Education & Training Policies & standards of care

What did we do? Established ‘Nutrition teams’ 9 Long stay residential care sites for Older people 4 counties of HSE Midland Area Commenced 2001 Phased basis over 3 year period

Structure of Nutrition Teams CQI approach Quality Facilitator liaison MDT approach ‘Steps of Activity’

Membership of teams: Chairperson: Community Dietitian Director of Nursing Nursing staff Catering staff Catering project manager Care assistants/attendants Speech & Language Therapy Occupational Therapy Day Care staff

Aims To increase awareness & understanding of the role of nutrition for the older person To focus on Food To empower staff to improve & standardise nutrition & feeding practices for the older person To develop & implement Nutrition policies for Care of the older person

First impressions! Nutrition low on the agenda Attitude of staff to nutrition ‘Not my job’ Staff not knowing their power to influence

What did we record? Ward level: 1. Satisfaction surveys: Staff satisfaction surveys Patient satisfaction surveys 2. Laxative use: baseline figure of total orders over 6 months 3. Oral Nutritional Supplement use: baseline figure for total orders over 6 months

4. Staff allocation at meal times ‘hands on’ for assistance 5. Feeding practice use of appropriate utensils; feeding positions

Catering level: 1. Menu analysis 2. Meal times: nutritional content; available choice; therapeutic diets; modified texture diets 2. Meal times: main meals; snacks; suppers; drink rounds 3. Meal ordering systems structure of communication between wards & catering

4. Presentation of meals: modified textures; portion sizes 5. Communication structures

What did we find? Barriers to good nutrition: poor awareness & understanding amongst staff identifying residents at risk of malnutrition inadequate menus poor provision for modified textures diets poor communication poor standard of feeding practices little attention to Environment

‘The Fox & the stork’ (Jean de la Fontaine (1621-95)) “ Brother Fox got dressed up one day & invited Sister Stork to dinner. He served them soup on a shallow plate. With her long beak, the stork didn’t catch a drop, but the fox’s plate was licked in a jiffy! To get even with that trick, the Stork invited him sometime later! Dinner was cooked to perfection. Bon appetit! Foxes are always hungry; the meat especially smelled heavenly, cut into tiny pieces, delicious looking. They were served, to his embarrassment, in a Vase with a long & narrow neck. The Stork’s beak could pass through, but the Fox’s snout couldn’t! He had to return home hungry…….”

Impact on the residents: inadequate nutrient intake (ave. 881 kcals/day) increased use of Oral Nutritional Supplements increased use of laxatives delayed wound healing dissatisfied with evening meal; choice; meal times ‘resident fitting into the system’

Implementation Encourage staff to identify individual site priorities Agree & tailor ‘Steps of Activity’ to each site Pilot interventions

Implementation Ward level: On site training/education for all staff Dysphagia, Malnutrition, Screening & Assessment, Therapeutic diets Nutrition Screening & Assessment tool (Mini Nutritional Assessment (MNA) ) Structured system of referring to Community Dietitian

Meal Ordering sheet Use of Food Diaries In between meal snack & supper provision Nutrition Resource pack

Catering level: Nutritionally adequate recipes 3 week menu cycle Food fortification techniques Standardised therapeutic diets; modified texture diets Provision of appropriate snacks & evening supper Nutrition Resource pack

Outcomes Improved Nutrition awareness amongst staff Patients at risk of malnutrition identified Improved nutrient intake: (ave. 1881 kacls/day) ‘Focus on Food’ Clear staff roles & responsibilities defined

Local level projects being developed by staff Fluid awareness Fibre Finger Food trials Regional Policies in development Nutritional Screening & Assessment Nutrition & Dementia Management of constipation Use of Oral Nutritional Supplements Management of Enteral Tube Feeding Meal Environment

“ There is clear evidence that patient outcomes are improved where nutrition teams exist in hospitals” (BAPEN 2002)

Next steps Evaluations 2005, 2006 Annual audits of policies Ongoing training & development ‘Essence of Care’ model: nutrition benchmarking

Conclusion Effective forum for addressing nutrition related issues Staff empowered to make appropriate decisions on residents nutritional status Communication links improved between ward staff & catering; nursing staff & MDT; management & staff

Thank You!