Promoting Good Nutritional Care in Care Homes

The importance of good nutritional care

BAPEN estimates that 93% of malnourished individuals with or at risk of malnutrition live in community settings (1). Unfortunately, malnutrition is often unrecognised and untreated, particularly in vulnerable populations (2).

Malnutrition can affect every system in the body, leading to adverse changes in body form and function.

Physical effects include (3):

• Impaired immunity
• Pressure sores
• Delayed wound healing
• Muscle wasting
• Adverse changes to the gastrointestinal structure and function
• Generalised weakness
• Increased risk of falls
• Increased risk of bone conditions (i.e. osteoporosis)

Other studies have shown that malnutrition is associated with more hospital readmissions (4), longer length of stay, increased complications and greater risk of mortality (5).

The good news is that dietary counselling given with or without oral nutritional supplements (ONS) is effective at increasing nutritional intake and weight (6). Therefore, interventions which combine ONS and a food first approach are commonly used in care homes.

Identifying nutritional risk in care homes

Nutrition risk screening is a rapid and simple way to detect those with or at risk of malnutrition, so that suitable care plans can be implemented. Nutritional screening for malnutrition is recommended in NICE clinical guideline 32 for all admissions to care homes and when there is clinical concern (7).

The Malnutrition Universal Screening Tool (MUST) (www.bapen.org.uk/pdfs/must/must_full.pdf) is the most frequently used screening tool in the UK. It is a five-step tool suitable for screening adults across all care settings. It is used to detect those who are malnourished or at risk of malnutrition.

The five steps are as follows:

• Measure height and weight to determine Body Mass Index (BMI)
• Calculate percentage of unplanned weight loss in the past 3-6 months
• Establish acute disease effect and score
• Add scores together to obtain an overall score for risk of malnutrition
• Use management guidelines and/or local policy to establish treatment plan

All staff involved in nutrition-risk screening should be suitably trained to meet required standards for their organisation.
Person-centred approach to nutritional care

Person-centred care (www.hee.nhs.uk/our-work/person-centred-care) means “focusing care on the needs of the individual.” It’s about ensuring that people’s preferences, needs and values guide clinical decisions, whilst delivering care that is respectful of and responsive to their needs (8).

One-size does not fit all when it comes to good nutritional care. People’s dietary preferences are highly individual due to religious, cultural and ethical factors. Additionally, nutritional requirements may differ according to medical need.

Food provisions in care homes must be able to meet an individual’s needs. Having a discussion with care home residents and/or their family, friends or carers to obtain further information about food preferences can be useful when delivering person-centred nutritional care. Menus should provide variety and choice, with systems in place to gather the views about food and drink from their residents, families and friends.

Every mealtime matters, and individuals should receive appropriate support and assistance to ensure optimal nutritional intake. Organisational approaches such as communal dining and protected mealtimes are useful strategies.

Oral nutrition support should be considered in patients who have inadequate oral intake of food and fluids to meet their nutritional requirements. This may include a food first approach (i.e. food fortification, extra snacks, nourishing drinks, energy-dense meals), oral nutritional supplements (ONS) and dietary counselling.

ONS products are used for medical purposes in patients who meet the Advisory Committee on Borderline Substances (ACBS) prescribing criteria, have been screened using a validated malnutrition screening tool and have been deemed to be at nutritional risk. ONS should always be given under medical supervision and must be used appropriately and in accordance with local prescribing guidelines.

Local prescribing guidelines for the treatment of disease-related malnutrition often recommend powdered ONS products such as AYMES Shake (aymes.com/products/aymes-shake) as first-line interventions in care home settings. AYMES Shake is a nutritionally balanced, milkshake-style supplement, providing 383kcal and 19g protein per serving when mixed with 200ml whole milk. AYMES Shake is one of the best value powdered ONS products available (9), and is therefore a sensible choice for cost savings.

About AYMES International:

AYMES International manufactures delicious, cost-effective oral nutrition supplements for the dietary management of patients with, or at risk of disease-related malnutrition. For more information, visit https://aymes.com/ or call +44 (0) 845 680 5496.

References:

1.Malnutrition Task Force. Malnutrition in the UK Factsheet. Available at: http://www.malnutritiontaskforce.org.uk/resources/malnutrition-factsheet/

2.BAPEN Nutritional Screening Surveys in Hospitals in the UK, 2007 – 2011 (2014). Available at: https://www.bapen.org.uk/pdfs/nsw/bapen-nsw-uk.pdf

3.Gandy, J. Manual of Dietetic Practice, chp. 6.2 Malnutrition (2014).

4.Sharma, Y. et al. (2017). ‘Malnutrition and Its Association with Readmission and Death within 7 Days and 8-180 Days Postdischarge in Older Patients: A Prospective Observational Study’. BMJ Open.

5.Correia, M. et.al. (2003). ‘The Impact of Malnutrition on Morbidity, Mortality, Length of Hospital Stay and Costs Evaluated through a Multivariate Model Analysis’. Clinical Nutrition.

6.Baldwin, C. & Weekes, C. E. (2012) 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. [Online].

7.NICE, ‘Nutrition support in adults: NICE guideline CG32’, 2006. Available at: https://www.nice.org.uk/guidance/cg32/chapter/1- Guidance

8.NHS Health Education England. Person-Centred Care. Available at: https://www.hee.nhs.uk/our-work/person-centred-care

9.MIMS April 2020