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

2. 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)

3. 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)

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

5. 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)

6. 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)

7. 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

8. ‘..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

9. 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

10. 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

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

12. 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

13. 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

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

15. 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

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

17. 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

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

19. 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

20. ‘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…….”

21. 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’

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

23. 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

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

25. 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

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

27. 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

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

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

30. 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

31. Thank You!