Management of Malnutrition 8/12/10

Derby PCT recently produced and released:  Nutritional Management Algorithm for Effective Prescribing of Oral Nutritional Supplements (ONS) for Adults

MUST Score MUST= Malnutrition Universal Screening Tool Five-step screening tool to identify adults, who are malnourished, at risk of malnutrition or obese Includes management guidelines which can be used to develop a care plan

MUST Score Step 1: ◦ Measure height and weight to get a BMI and BMI score BMI kg/m2 Score: ◦ >20 (>30 Obese) = 0 ◦ = 1 ◦ <18.5 = 2 Step 2: ◦ Note percentage unplanned weight loss in past 3-6 months and score using tables provided Unplanned weight loss score: ◦ <5 %= 0 ◦ 5-10 %= 1 ◦ %>10 = 2

MUST Score Step 3: ◦ Establish acute disease effect and score If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days= Score 2 Step 4: ◦ Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition Score 0 Low Risk Score 1 Medium Risk Score 2 or more High Risk Step 5: ◦ Use management guidelines and/or local policy to develop care plan

Management based on MUST score Low risk/Score 0: ◦ Repeat screening  Care Homes : monthly  Community : annually for special groups e.g. those >75 yrs Medium risk/Score 1: ◦ Observe ◦ Dietary intake record ◦ Dietary advice including food fortification and OTC oral nutritional support

Dietary Advice Eat Little and often and choose high calorie options where possible 3 small meals plus 2-3 snacks or milky drinks (Horlicks, Ovaltine, Complan, Build up or milkshakes) Bread, rice, pasta, cereal, chapatti or potatoes at each meal Meat, fish, eggs, cheese, yoghurt, nuts, lentils or beans at each meal Fruit, vegetables or fruit juice at each meal Use a pint of full cream milk each day, fortified with 4 tablespoons of milk powder and use in place of ordinary milk for cereals, custards, sauces, drinks 8 cups of fluid, include a variety of drinks

Dietary advice Breakfast cereals – Add one or more of the following: fortified or evaporated milk, cream, yoghurt, fresh or dried fruit, nuts, syrup, honey or sugar. Soups and sauces – Add one or more of the following: grated or cream cheese, cream, milk powder, fortified or evaporated milk, fried onions, margarine, butter, croutons or pasta Potatoes and vegetables – Add one or more of the following: grated cheese, cream, margarine, butter, mayonnaise, salad cream or fried onions Puddings and cakes – Add one or more of the following: cream, evaporated milk, custard, ice cream, jam, syrup, treacle, chocolate or fruit sauces, dried fruit.

Management based on MUST score High risk/ Score 2: ◦ Refer to dietician

Prescribing of Oral Nutritional Supplements Nutritional suplements e.g. Fortisip, are borderline substances which can be prescribed as drug treatment if ACBS (Advisory Committee on Borderline Substances) standards are meet Standard indications included: ◦ Disease related malnutrition ◦ Intractable malnutrition ◦ Preoperative preparation of malnourished patients ◦ Dsyphagia ◦ Proven IBD ◦ Following total gastrectomy ◦ Short bowel syndrome ◦ Bowel fistula

Thank you any questions?