Malnutrition in later life - the Challenge Dr Mike Stroud Consultant Gastroenterologist, Southampton Co Chair Malnutrition Task Force Chair NICE Guidance Group ON Nutrition Support President Elect BAPEN

British Association for Parenteral and Enteral Nutrition A multi-disciplinary charity committed to raising awareness of malnutrition and the options for nutritional treatment, along with the impact on health outcomes, resource utilization, and health & social care budgets. B A P E N Malnutrition Matters

Vulnerability Malnutrition in the UK PHYSICAL Disease related Feeding Swallowing Low activity Decreased organ reserve Specific disease Multiple drugs (taste) SOCIAL Isolation Poverty PSYCHOLOGICAL Depression/bereavement Dementia Alcohol Mobility Vulnerability

Potential causes of malnutrition in older people Access: being able to get to food or can food get to you (i.e. home delivery of shopping/cooked food). Physical mobility and transport to get shops etc? Availability: do shops offer healthy affordable food? Are they close by? Ability: is older person Physically able to cook & have facilities to do so, do they have cooking skills? Can they open the packaging’, ‘can you eat yourself (or have the help to eat)’? Affordability: income and poverty - 1 in 5 older people are in poverty in the UK, most of it preventable Awareness: do they have interest in food and what may or may not be appropriate, awareness of reasons which have reduced appetite or understanding of the risks of not eating,? The messages and myths around healthy eating for older persons. Aspiration: the desire, motivation and will to do something about it Assessment: of malnutrition risk when suffering from disease or illness. Are the symptoms or risk recognised? Assumption: that its normal to get thinner as you get older or with illness and disease. Appetite: The desire to eat and drink Lead: Janine

Inadequate food intake is common in hospital European Nutrition Day survey* found that of patients aged >75 years only1: 46% ate all of breakfast 34% ate all of lunch 35% ate all of dinner Older inpatients in a hospital elderly care unit in the UK were judged to be eating inadequately at only 67% of assessments2 *748 units in 25 countries, total n=16455, aged >75 years n=4799. Schindler KE, Schuetz E, Schlaffer R, Schuh C, Mouhieddine M, Hiesmayr M. NutritionDay in European hospitals: risk factors for malnutrition in patients older than 75 years. Clin Nutr 2007; 2:10. Patel MD, Martin FC. Why don’t elderly hospital inpatients eat adequately? J Nutr Health Aging 2008; 12(4):227-231.

Inadequate food intake in nursing homes NutritionDay survey of Austrian and German nursing homes* showed 1 in 3 residents ate ≤ 50% of their lunch on the assessment day1 Eating difficulties found to be common (56%) in special accommodation residents i.e. nursing home-type care in Sweden2 *n=1922. Valentini L, Schindler K, Schlaffer R, Bucher H, Mouhieddine M, Steininger K et al. The first nutritionDay in nursing homes: participation may improve malnutrition awareness. Clin Nutr 2009; 28(2):109-116. Westergren A, Lindholm C, Axelsson C, Ulander K. Prevalence of eating difficulties and malnutrition among persons within hospital care and special accommodations. J Nutr Health Aging 2008; 12(1):39-43.

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Prevalence of malnutrition Hospitals Care Homes Mental Health Units Centres (n=) Patients (n=) Residents (n=) 2007 Autumn 175 9336 173 1610 22 332 2008 Summer 130 5089 75 614 17 185 2010 Winter 9668 148 857 20 146 2011 Spring 171 7541 78 523 67 543 Prevalence 25-34% 30-42% 18-20%

Malnutrition in the Community Incidence of low body weight (BMI < 20) >5% of the ‘healthy’ UK adult population over 65 yrs >10% of the chronically sick (higher for those suffering from cancer, lung disease, GI problems, neurological and psychiatric illness.

Individuals at risk of malnutrition Communities - little or no contact with services Communities in contact with services Care Homes Hospital 93% 5% 2% 3 million malnourished Lead: Janine

You are what you eat! Genes Age Activity Disease & Injury Nutritional Intake (past & present) Good nutrition = health and resistance to disease FORM AND FUNCTION Poor nutrition = ill health and susceptibility

Consequences of Malnutrition (within days) Psychology – depression & apathy Poor breathing and cough from loss of muscle strength Poor Immunity and infections Liver fatty change, functional decline necrosis, fibrosis Decreased Cardiac output Hypothermia – decline in all functions Impaired wound healing and susceptibility to pressure ulcers Renal function – limited ability to excrete salt and water General quick intro to malnutrition being both a cause and consequence of disease (and your usual whiz round this slide would be great) Impaired gut integrity and immunity Loss of muscle and bone strength - falls and fractures

The Malnutrition Carousel PRIMARY CARE  dependency  GP visits  prescription costs  hospital admissions NURSING HOME CARE HOME Malnutrition SECONDARY CARE  complications  length of stay  readmissions  mortality HOSPITAL HOME

Nutritional Treatment should: Improve general status Immunity and resistance to infections Wound healing Breathing and coughing Mobility and falls Psychology

Nutrition support in adults 2006 February 2006

The effectiveness of Nutrition Support 10 RCT, n = 494; RR 0.29 (CI 0.18 to 0.47) 30 RCT, n = 3258 RR 0.59 (CI 0.48 to 0.72) Controls Controls Treatment Treatment Mortality % Complications %

NICE ONS and length of stay

Nutritional Care & Quality Safety Effectiveness Equality Patient experience

The Cost of Malnutrition 2014 - ?? >£15 billion p.a. Public expenditure associated with <3 million individuals in UK who are malnourished or at risk of malnutrition 2003 - >£7.3 billion p.a 2007 - >£13 billion p.a. Self explanatory – may be worth pointing out that if we were to redo the health economics analysis on 2011 figures we would expect much higher costs NICE Cost Saving Guidance places effective treatment of malnutrition as 3rd in ranking of potential biggest cost savers to the NHS

Nutrition in a Cold Climate Easy Targets: Social Services Meals on Wheels Catering Budgets Dietetic Departments ONS prescriptions Nutrition Nurse specialists Mike – I had to supply a title while you were in India; hope this is ok BAPEN Chair 20

We know what excellent nutritional care looks like We know how to do it but ......

MTF Guides

Reliable systems of nutritional care Good nutritional care for every individual, in every setting, on every day IDENTIFY Design systems to screen all patients using a validated screening tool Use local CQUINs TREAT Develop personal nutritional care plans EDUCATION & TRAINING STRUCTURES AND PATHWAYS Continuity across boundaries Senior Leadership PREVENT Work with Public Health, Local Government and Social Services 23

Making it happen ‘’This guide is easy to use since we have defined the top three priority actions for each level of the care system. Simply go to the part that relates to your organisation and take action’’ Lead: Janine

Thank you Questions?