1. Malnutrition in later life - the Challenge
Dr Mike Stroud
Consultant Gastroenterologist, Southampton
Co Chair Malnutrition Task Force
Chair NICE Guidance Group ON Nutrition Support
President Elect BAPEN

2. British Association for Parenteral and Enteral Nutrition
A multi-disciplinary charity committed to raising awareness of malnutrition and the options for nutritional treatment, along with the impact on health outcomes, resource utilization, and health & social care budgets.
B A P E N
Malnutrition Matters

3. Vulnerability Malnutrition in the UK PHYSICAL Disease related
Feeding
Swallowing
Low activity
Decreased
organ reserve
Specific
disease
Multiple drugs
(taste)
SOCIAL
Isolation
Poverty
PSYCHOLOGICAL
Depression/bereavement
Dementia
Alcohol
Mobility
Vulnerability

4. Potential causes of malnutrition in older people
Access: being able to get to food or can food get to you (i.e. home delivery of shopping/cooked food). Physical mobility and transport to get shops etc?
Availability: do shops offer healthy affordable food? Are they close by?
Ability: is older person Physically able to cook & have facilities to do so, do they have cooking skills? Can they open the packaging’, ‘can you eat yourself (or have the help to eat)’?
Affordability: income and poverty - 1 in 5 older people are in poverty in the UK, most of it preventable
Awareness: do they have interest in food and what may or may not be appropriate, awareness of reasons which have reduced appetite or understanding of the risks of not eating,? The messages and myths around healthy eating for older persons.
Aspiration: the desire, motivation and will to do something about it
Assessment: of malnutrition risk when suffering from disease or illness. Are the symptoms or risk recognised?
Assumption: that its normal to get thinner as you get older or with illness and disease.
Appetite: The desire to eat and drink
Lead: Janine

5. Inadequate food intake is common in hospital
European Nutrition Day survey* found that of patients aged >75 years only1:
46% ate all of breakfast
34% ate all of lunch
35% ate all of dinner
Older inpatients in a hospital elderly care unit in the UK were judged to be eating inadequately at only 67% of assessments2
*748 units in 25 countries, total n=16455, aged >75 years n=4799.
Schindler KE, Schuetz E, Schlaffer R, Schuh C, Mouhieddine M, Hiesmayr M. NutritionDay in European hospitals: risk factors for malnutrition in patients older than 75 years. Clin Nutr 2007; 2:10.
Patel MD, Martin FC. Why don’t elderly hospital inpatients eat adequately? J Nutr Health Aging 2008; 12(4):

6. Inadequate food intake in nursing homes
NutritionDay survey of Austrian and German nursing homes* showed 1 in 3 residents ate ≤ 50% of their lunch on the assessment day1
Eating difficulties found to be common (56%) in special accommodation residents i.e. nursing home-type care in Sweden2
*n=1922.
Valentini L, Schindler K, Schlaffer R, Bucher H, Mouhieddine M, Steininger K et al. The first nutritionDay in nursing homes: participation may improve malnutrition awareness. Clin Nutr 2009; 28(2):
Westergren A, Lindholm C, Axelsson C, Ulander K. Prevalence of eating difficulties and malnutrition among persons within hospital care and special accommodations. J Nutr Health Aging 2008; 12(1):39-43.

7. 7

8. Prevalence of malnutrition
Hospitals
Care Homes
Mental Health Units
Centres (n=)
Patients (n=)
Residents (n=)
2007
Autumn
175
9336
173
1610 22
332
2008
Summer
130
5089 75
614 17
185
2010
Winter
9668
148
857 20
146
2011
Spring
171
7541 78
523 67
543
Prevalence
25-34%
30-42%
18-20%

9. Malnutrition in the Community
Incidence of low body weight (BMI < 20)
>5% of the ‘healthy’ UK adult population over 65 yrs
>10% of the chronically sick (higher for those suffering from cancer, lung disease, GI problems, neurological and psychiatric illness.

10. Individuals at risk of malnutrition
Communities - little or no contact with services
Communities in contact with services
Care Homes
Hospital
93% 5% 2%
3 million malnourished
Lead: Janine

11. You are what you eat!
Genes
Age
Activity
Disease &
Injury
Nutritional
Intake
(past &
present)
Good nutrition = health and resistance to disease
FORM AND FUNCTION
Poor nutrition = ill health and susceptibility

12. Consequences of Malnutrition (within days)
Psychology –
depression & apathy
Poor breathing and cough from loss of muscle strength
Poor Immunity and infections
Liver fatty change,
functional decline necrosis, fibrosis
Decreased Cardiac output
Hypothermia – decline in all functions
Impaired wound
healing and susceptibility to pressure ulcers
Renal function – limited ability to excrete salt
and water
General quick intro to malnutrition being both a cause and consequence of disease (and your usual whiz round this slide would be great)
Impaired gut
integrity and
immunity
Loss of muscle and bone strength - falls and fractures

13. The Malnutrition Carousel
PRIMARY CARE
 dependency
 GP visits
 prescription costs
 hospital admissions
NURSING
HOME
CARE
HOME
Malnutrition
SECONDARY CARE
 complications
 length of stay
 readmissions
 mortality
HOSPITAL
HOME

14. Nutritional Treatment should:
Improve general status
Immunity and resistance to infections
Wound healing
Breathing and coughing
Mobility and falls
Psychology

15. Nutrition support in adults 2006
February 2006

16. The effectiveness of Nutrition Support
10 RCT, n = 494;
RR 0.29 (CI to 0.47)
30 RCT, n = 3258
RR 0.59 (CI 0.48 to 0.72)
Controls
Controls
Treatment
Treatment
Mortality %
Complications %

17. NICE ONS and length of stay

18. Nutritional Care & Quality
Safety
Effectiveness
Equality
Patient experience

19. The Cost of Malnutrition
?? >£15 billion p.a.
Public expenditure associated with <3 million individuals in UK who are malnourished or at risk of malnutrition
>£7.3 billion p.a
>£13 billion p.a.
Self explanatory – may be worth pointing out that if we were to redo the health economics analysis on 2011 figures we would expect much higher costs
NICE Cost Saving Guidance places effective treatment of malnutrition as 3rd in ranking of potential biggest cost savers to the NHS

20. Nutrition in a Cold Climate
Easy Targets:
Social Services
Meals on Wheels
Catering Budgets
Dietetic Departments
ONS prescriptions
Nutrition Nurse specialists
Mike – I had to supply a title while you were in India; hope this is ok
BAPEN Chair 20

21. We know what excellent nutritional care looks like
We know how to do it but

22. MTF Guides

23. Reliable systems of nutritional care
Good nutritional care for every individual, in every setting,
on every day
IDENTIFY
Design systems to screen all patients using a validated screening tool
Use local CQUINs
TREAT
Develop personal nutritional care plans
EDUCATION
& TRAINING
STRUCTURES AND PATHWAYS
Continuity across boundaries
Senior Leadership
PREVENT
Work with Public Health, Local Government and Social Services 23

24. Making it happen
‘’This guide is easy to use since we have defined the top three priority actions for each level of the care
system. Simply go to the part that relates to your organisation and take action’’
Lead: Janine

25. Thank you Questions?