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Managing malnutrition in older people



Key learning points:

  • Primary care nurses have a key role in the identification and management of those at risk of malnutrition
  • New initiatives, approaches and resources such as the Wessex Academic Health Science Network (AHSN) Nutrition in Older People programme can help to reduce malnutrition
  • Partnership and collaboration can facilitate the sharing of good practice locally and nationally to reduce malnutrition in older people

The growing problem of malnutrition in older people is still poorly recognised in the community. As discussed in part 1 of this series (Nursing in Practice, issue 92), managing it requires a combination of approaches and practice nurses have a responsibility to undertake screening which is essential to identifying those at risk of malnutrition.  This article presents initiatives to train nursing professionals to tackle the issue, through the work of the Wessex Academic Health Science Network (AHSN).
Across England there are 15 academic health science networks, established by NHS England in 2013 to pioneer innovative ways to address unmet needs in the health system by collaborating with patients, the NHS, academia and industry. Wessex AHSN covers a population of three million across nine local authorities, bringing together 10 CCGs, 11 NHS trusts and five universities. Its Nutrition in Older People programme aims to be a catalyst for the screening, prevention and treatment of malnutrition in older people.

Progress to date
During the first two years of the programme, two major projects were run by health and social care professionals.  

1. Purbeck pilot, Dorset
The programme created a collaboration with Dorset health and social care organisations following the launch of a joint nutritional care strategy for adults in Dorset in May 2013. Through this partnership, it has been possible to train health and social care staff in the community to provide nutritional screening and advice following care pathways.
During 2015/16 in the Purbeck pilot, 561 people were screened by health and social care teams. In total, 140 were found to be at risk of malnutrition (25% of those screened). Of these people at risk, 60 (43%) had a decreased malnutrition universal screening tool (MUST) score, resulting in an estimated potential total cost avoidance of £86,830. These individuals would probably not have been identified without the pilot as the majority of screenings before then had been done by teams who had not been trained.
There were 120 health and social care staff trained (92% of the total). In February 2016 the initiative was delivered in a second locality, Christchurch. Some 173 people living in Christchurch have now been screened and 80 health and social care staff have been trained.

2. Eastleigh, Hampshire – Older People’s Essential Nutrition (OPEN) project
The OPEN project aimed to reduce the number of older people who were malnourished and evaluate their health and social care needs. Through the implementation of new locally agreed care pathways and raised awareness of malnutrition issues, 375 older people were screened by community nurses, care home staff, social care and practice nurses. A total of 190 staff were trained from health (48), social care (48), care home (50) and voluntary sector workers (44), representing over 80% of the health and social care workforce in the project area.
Increased awareness of malnutrition was evident across all staff groups from analysis of pre- and post-session knowledge. Of the 61 patients screened more than once, 51% (31) had improved nutritional status reflected by a decreased MUST score or increased weight.
The project also revealed some key challenges, including problems sharing information between teams and competition from other clinical priorities and pressures.
Interestingly, only a small number of people were screened by practice nurses. In an effort to explore their current knowledge and practice, we delivered an online survey to 204 practice nurses in West Hampshire Clinical Commissioning Group (CCG). A total of 32 responses was received – a 16% response rate. Although this number was small, the findings of the survey indicated that 81% of practice nurses (26) were concerned about the issues of malnutrition and nearly 75% (22) felt that practice nurses should be screening for malnutrition.
In total, 87% of practice nurses (28) had not received any training on malnutrition or nutrition screening in the last five years and only three indicated they were currently using MUST for nutrition screening. The barriers to screening were identified as lack of time, training and knowledge of the action to take if a patient had a raised MUST score.
These issues were raised at three follow-up practice nurse forums with 41 nurses to provide an in-depth insight into the barriers to screening and how they could be overcome. Feedback received was consistent with the findings of the survey. The issue of ‘time’ was related to the time needed to provide nutrition advice and support during assessment and follow-up, not the time required to perform the screening.  

Wider application
While the projects are a measure of the use and attitudes towards nutrition screening in one region, there is opportunity to extend the work to other geographies. This positive contribution by practice nurses will enable further work to implement and develop training.  
Overall, the projects have demonstrated a positive impact on changing practice. They have also provided insight into the disruptive nature of innovations when professionals have to
adopt new tasks and reach new sections of the population. These projects have highlighted the difficulties in reaching many of the older people in the community at risk of undernutrition, and the importance of the social care and voluntary sectors in combating this.
Other initiatives to date include the development of a malnutrition toolkit that draws on the learning of evidence-based practice. The tools were tested using a multidisciplinary approach and include training and awareness materials (leaflets, posters, training packs and a hydration toolkit) and generic nutritional care pathways for community care settings. This toolkit is suitable for any professional (health, social care, voluntary sector) planning to implement this kind of service and has been endorsed by the British Dietetic Association (BDA). All materials have been published on the Wessex AHSN website (http://wessexahsn.org.uk/programmes/9/nutrition).  
The programme has developed an evaluation framework to help support providers and staff with the evaluation of nutritional initiatives.
The spread of the work is a key aspect of the programme, and is being achieved through learning workshops across Wessex, an annual conference, newsletters and local and national research conferences.

Moving forward
More projects are now starting up across Dorset and Hampshire. The programme will continue with a couple of key longer-term projects in the health, social care and voluntary arenas and will share the evaluation of the projects completed in 2016/17. It will encourage the wider spread of these practices by working with national groups and stakeholders (eg Age UK, Malnutrition Taskforce, other AHSNs). A research project funded by the Burdett Trust for Nursing will provide new evidence to demonstrate the benefits of implementing approaches for good nutritional care in the community setting for nurses achieved through collaborative working between Wessex AHSN, universities and the NHS.
The programme has identified and evaluated solutions that will help to promote improved care of older people at risk of malnutrition, while being mindful of other care needs and priorities. It is clear that the implementation of such cultural change can take a significant time to influence local teams and individuals but ultimately has the potential to offer far-reaching benefit in terms of health and wellbeing and reduced costs.