Identifying and managing malnutrition in the older person

Key learning points:

• Malnutrition in the older person can be prevented
• Primary care nurses have a responsibility to undertake screening, which is essential to identify those at risk of malnutrition
• Managing malnutrition requires a combination of approaches for longer-term impact

Malnutrition is a huge public health problem, which currently affects more than three million people in the UK.¹ With an aging population, the number of people aged 65 and over is projected to rise by almost 40% in the next 20 years.² Malnutrition is a problem that cannot be ignored. Studies show that 1.2 million people over 65 living in the community,2 33% of people admitted to hospital and 37% of those who have recently moved to a care home are malnourished or at risk of malnutrition.³
Not only is malnutrition a growing burden, it costs more than £19.6 billion annually and accounts for 15% of the total spend on health and social care.³ Proactive efforts are needed to raise the profile of malnutrition and to improve its management. Improving the identification and treatment of malnutrition is estimated to have the highest potential to deliver cost savings to the NHS⁴ due to its effects on health, disease and wellbeing. This article is the Part 1 (Part 2 will be published in the next Nursing in Practice Journal, issue 93) that will consider the definition and causes of malnutrition, current national guidance to assess risk, management and the role of the primary care nurse. Part 2, will discuss new innovative approaches and strategies to implement nutritional care in the community and the screening, prevention and treatment of malnutrition in older people.
Malnutrition is defined as having too many or too few nutrients in the diet (generally energy from fats, carbohydrates or protein). For the purpose of this article, malnutrition will refer to a state of under-nutrition which is commonly used in practice and is defined by the National Institute for Health and Clinical Excellence (NICE)⁵ as “a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function (including social and psychological) and clinical outcome”.

Causes of malnutrition
Unintentional weight loss is a common problem in older people due to reduced food intake, increased need for nutrients, inability to absorb and use enough nutrients from the diet.  The onset of malnutrition can be slow, occurring over weeks or months if food intake does not match need.
Common indicators of malnutrition include:

• Weight loss revealed by loose clothes, rings or dentures.
• Loss of appetite.
• Heart failure.
• Increased tendency to develop pressure sores.
• Impaired immune response and increased risk of respiratory tract infections.
• Poor wound healing.

The onset of nutritional depletion and malnutrition may be accelerated if nutritional requirements are higher than usual due to infection, pressure sores or increased losses such as vomiting or diarrhoea. There may be other contributing factors, associated with ageing, lifestyle, psychological and social issues:

• Arthritis, stroke or reduced cognitive ability can cause physical problems with eating or preparing food.
• Medication side-effects can lead to appetite changes, dry mouth, taste changes and constipation. 
• Indigestion and discomfort can make the person reluctant to eat and drink.
• Oral problems such as poorly fitting dentures or sore gums can make mealtimes a painful experience. Swallowing and chewing difficulties leading to dysphagia may mean food looks unpalatable. Cases of dysphagia should be referred to healthcare professionals with skills in the diagnosis, assessment and management of swallowing disorders. 
• Incontinence or difficulties with physically getting to the toilet can mean individuals are reluctant to drink, which will compound constipation and other health problems.
• Mental health and wellbeing – depression can lead to loss of interest in food. Dementia and cognitive impairment can be a major cause of not eating and drinking due to difficulties such as communication, the activity of eating, lack of concentration and extra energy needs due to wandering.
• Tiredness caused by sleep disorders or medication can lead to difficulties concentrating at meal times and co-ordinating oneself to prepare meals.
• Fear or pride can prevent people asking for assistance.
• Social isolation, always eating alone and depression can affect the enjoyment of food, especially after a long-term partner dies.
• Reduced physical activity and lack of involvement in food and drink can lead to a lack of appetite.
• Poverty can affect food choices and acces sibility to purchasing food.

Screening
Best practice nutrition care involves five key principles, which incorporate NICE’s nutrition support in adults quality standard⁵ and clinical guidance.⁶ These are:

• Raising awareness to prevent and treat malnutrition.
• Working together within and across organisations.
• Identifying malnutrition risk early using screening tools.
• Developing individualised care plans.
• Monitoring and evaluating the impact of care on an individual.

The most important way to identify those at risk of malnutrition is by regular weighing and reporting of changes in weight. The five-step validated malnutrition universal screening tool (MUST) is now widely used in hospitals, primary care and care homes.⁷  It is supported by a range of organisations including the Royal College of Nursing (RCN) and the Registered Nursing Home Association (RNHA) and consists of:⁸
1. Calculating the individual’s BMI using weight and height measures. If BMI cannot be established through weighing and measuring, an approximate measure can be obtained using mid-upper-arm circumference. In the absence of any measurements the observational warning indicators mentioned earlier can help form a judgment.
2. Determining how much weight has been lost intentionally over the last six months.
3. Establishing if the individual is acutely ill and if they have failed to eat for more than five days.
4. Calculating the overall risk of malnutrition.  
5. Using management guidelines or local policy to develop a care plan with goals to boost food and energy intake for risk scores of medium (1) or high risk (2).
The malnutrition pathway₉ recommends initial screening when an individual has their first contact in a care setting, for example upon registration with a GP practice, at a first home visit, or on admission to a care home or hospital. Other occasions might include where there is clinical concern such as unintentional weight loss, poor wound healing or pressure ulcers. Regular screening should be undertaken when an individual has been highlighted as at risk of malnutrition and will help to determine further action.
Further details of MUST and how to use it can be found at:  
http://www.bapen.org.uk/screening-and-must/must/introducing-must

Managing malnutrition in the older person
Once an individual has been identified as at risk of malnutrition, person-centred goals should be established immediately. These should involve all those who contribute to their care, such as nurses and family. When the individual experiences a blend of settings such as the community, hospital or care home, or has a range of health conditions, communication across these settings will enable these goals to be met.
Management should address food availability, social issues, the eating environment and activity, based on local policy. National guidance says that goals should include a food-based approach as well as the use of oral nutrition supplements.9 Food and energy intake can be enhanced through:

• Food fortification – adding butter, double cream and cheese to recipes can increase energy intake considerably. This works particularly well with mashed potato, custard, milk puddings, smoothies, milk shakes, porridge and mousses.
• For smaller appetites, suggest smaller, more frequent meals including finger food, high protein and energy snacks and mini-meals. If insomnia is a problem, consider encouraging some food and drink consumption 24 hours a day. 

Oral nutrition supplements are useful, especially when food intake is inadequate, and should be included as part of an integrated care pathway. These are available on prescription and evidence strongly supports this combined approach, which can lead to weight gain in older people and reduced mortality.¹⁰  However, prescription rates vary across the country, largely because of lack of expertise and protocols for malnutrition.11  Longer term, it is important that nutrition supplements are used to augment meals and not as meal replacers. More research is needed to understand the impact of other nutritional interventions.¹²
There is also a need to address other influencing factors.

• Relationships and social interaction can affect how we enjoy food and drink. This includes family, visitors, health professionals and staff in a residential environment. Our culture is based on socialisation when consuming food and drink – eg special occasions or coffee with friends.  It is important to enable the older person to maintain a sense of community if they would like it. 
• A comfortable supportive environment will encourage independence, including  specific eating, drinking and food preparation tools (seek specialist help when necessary).
• Training of support staff to ensure understanding of MUST screening, person-centred and dignified nutritional care and understanding of nutritional care pathways.
• Food preferences should be respected. 
• Food-related activities can increase anticipation of meal times, assist the gastric enzymes to work and increase appetite. Other activities can promote a sense of purpose and belonging as well as independence and wellbeing, which can positively impact on food and drink consumption.

As part of a multi disciplinary team, primary care nurses are at the forefront of identifying the risk factors associated with malnutrition and hence in the best position to undertake screening. National guidelines stress the importance of identifying individuals at risk of malnutrition with subsequent person-centred goal setting to manage weight gain which can have a positive impact on the health and wellbeing of the older person.

References
1. NHS England. Guidance – Commissioning Excellent Nutrition and Hydration 2015 – 2018. NHS, 2015.
2. Age UK. Later Life in the United Kingdom. Age UK. 2016.
3. Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions. BAPEN, 2015.
4. NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, 2006. nice.org.uk/guidance/cg32/chapter/Introduction (accessed 25 August 2016).
5. National Institute for Clinical Excellence. Nutrition Support in Adults [QS24], 2012. nice.org.uk/guidance/qs24/chapter/Quality-statement-1-Screening-for-the-risk-of-malnutrition (accessed 15 August 2016).
6. National Institute for Health and Care Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition [CG32], 2006. nice.org.uk/guidance/cg32 (accessed 15 August 2016).
7. Russel EA, Elia M. Nutrition Screening Survey in the UK and Republic of Ireland in 2011. BAPEN, 2012.
8. Elia M, Russell C, Stratton R, Todorovic V, Evans. L, Farrer K. The ‘MUST’ Explanatory Booklet: A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults. BAPEN; 2003.
9. Brotherton A, Holdoway A, Mason P, McGregor I, Parsons B, Pryke R. Managing Adult Malnutrition in the Community. malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf (accessed 15 August 2016).
10. Baldwin C, Weekes CE. Dietary counselling with or without oral nutritional supplements in the management of malnourished patients: a systematic review and meta-analysis of randomised controlled trials. Journal of Human Nutrition and Dietetics 2012;25:411–426.
11. Brotherton A, Holdeway A Stroud M. Malnutrition in the UK, Appropriate Prescribing of Oral Nutritional Supplements, 2012.  abbottnutrition.co.uk/media/28825/malnutrition_in_the_uk.pdf (accessed 15 August 2016).
12. Kimber K, Gibbs M, Weekes, CE, Baldwin C. Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults: a systematic review of nonrandomised studies. Journal of Human Nutrition and Dietetics 2015;28:(6):517-545.