Professional Comment

Malnutrition Matters

By Lesley Carter, Programme Lead, The Malnutrition Task Force, and Dr Trevor Smith, President of BAPEN

BAPEN1 and the Malnutrition Task Force2, came together again earlier this month to run the third UK Malnutrition Awareness Week3 – #UKMAW2020. This is an important week in the nutritional calendar as it highlights national efforts to raise awareness of the causes and consequences of malnutrition for more vulnerable, older people, and for those with disease-related risks of malnutrition in the UK.

The care home sector is under exceptional and extraordinary amounts of pressure and managers are having to finding new and innovative ways of working to keep everyone safe. It is now even more important that nutrition remains a priority. There are many challenges; we already know that 30-42% of people who were admitted into a care home setting pre COVID-19 were already malnourished or at a higher risk. New admissions will likely be even more vulnerable. Residents

may be admitted recovering from COVID-19, others may have experienced a deterioration of their physical condition during the lockdown in their own homes, making them unable to cope independently. People living with dementia may experience more rapidly advancing symptoms, family carers may be finding it more diffi- cult to cope with less available domiciliary care, and therefore may be seeking admission to residential care.

There are grave concerns about the nutritional status of older people who are already resident in care homes, whose lives have been changed dramatically because of COVID-19 related issues, isolation in their own rooms, reduction in the amount of usual contact with staff and other residents, their lack of understand- ing and fear about staff dressed in PPE and most importantly, their lack of usual contact with their friends and relatives. These difficult changes in circumstances are often translated into loneliness, with a lack of well- being, less interest in food, and a smaller appetite. Residents may be reluctant to eat because of oral health difficulties which have been hard to treat, resulting in dehydration and weight loss, which we know can lead to health complications associated with poorer outcomes.

Care homes must have a food and drink strategy that addresses the nutritional needs of people using the service4. The strategy needs to be underpinned with a robust policy for nutritional screening and development of appropriate nutritional care plans, with guidelines and staff training. Each resident must have a personalised nutritional care plan (which is shared with the kitchen and menu planning staff) which manages their nutritional risk, with regular monitoring and evaluation which will ensure that residents do not experience unplanned weight loss, or if they do it is picked up immediately.

Alongside this it is positive practice to have a section in the ‘getting to know you’ conversations with the resident and their friends and relatives, prior to or during admission, to get a clear understanding of what, how and when the new resident likes to eat and drink. This knowledge helps to ensure that mealtimes are an enjoyable experience.

We know that undernutrition is not always obvious, it’s often hidden and not easy to identify by just looking at a person. Measuring of malnutrition risk (undernutrition) and assessment through screening is essential to accurately identify risk. This can be done easily using BAPEN’s Malnutrition Universal Screening Tool (‘MUST’). It is then important to put in place an individualised nutritional care plan based on the results of screening for malnutrition risk. Some guidance on this can be found here.

Undertaking a nutritional assessment using the ‘MUST’ tool on admission will identify any risk, and help to compile a personalised nutritional care plan which clearly sets out the plan for all staff to see and follow. It will include food and drink preferences, identify the help that is needed to eat and drink independently, be specific about the help that is required to cut food, and physically support someone to get food from the plate to the mouth. Special requirements must be set out e.g. IDDSI5 (International Dysphagia Diet Standardisation Initiative) and any adaptations required e.g. to cutlery or sitting positions. The ‘MUST’ score and care plan should be updated regularly, but at least monthly, and any changes or concerns should be mentioned at the regular GP round.

There are other, small changes that can make a significant difference to the overall mealtime experience, making sure that there is a calm and comfortable feel about mealtimes. It is important to ensure that people have the tools and support they need to allow them to eat and drink as independently as possible.

In these new ways of working in the COVID world, the importance of not rushing a resident who needs help to eat and drink or is slow to chew and swallow cannot be over emphasized as often they will just give up – and if this happens at each meal the malnutrition risk is great. When people are forced to eat alone because of isolation or social distancing, listening to a favourite piece of music or the radio, or watching an enjoyed tel- evision programme can help. Think about how a focus on food can be integrated into the residents’ activities schedule.

There are many tools, information sources and resources that can help organisations to make significant and beneficial changes that are easily achievable and can help to positively improve the experience of eating and drinking in care homes.