Scottish Government

Promoting Nutrition for Older Adult In-Patients in NHS Hospitals in Scotland

1. INTRODUCTION

Introduction

1. The National Nursing, Midwifery and Health Visiting Advisory Committee, (NNMHVAC), established a Working Group to consider how the nutritional needs of older people could be promoted in NHS hospitals using the Nursing Home Core Standards as a template for introduction or implementation. Although the Core Standards were primarily aimed at nursing homes, the final paragraph of NHS MEL (1999)54 ¹ requested that NHS Boards and Trusts note that the standards should be applied to all NHS care facilities.

2. The Group chose to focus on older people as they represent a major group of patients within the NHS that has over time experienced problems with their nutritional intake and status while in hospital. The Group would, however, like to emphasise that the principles underlying the guidance in the report could be applied to many patient groups and that, while nutrition is a multidisciplinary issue, nurses have an essential role to play in promoting nutrition amongst vulnerable patient groups. The UKCC recently subscribed to this view when it corresponded with every hospital in the UK to remind managers that: ' Nurses have a clear responsibility for ensuring that the nutritional needs of patients are met'².

Background

3. The importance of nutrition and its contribution to both survival and health is generally recognised. Despite this, however, the assessment of the nutritional status of older people is often neglected and as a consequence malnutrition may not be recognised or managed.

4. The terms malnutrition, under-nutrition and over-nutrition are often used interchangeably.

5. Malnutrition is an overarching term that includes:

• under-nutrition - inadequate food intake and/or the presence of metabolically active disease.
• over-nutrition - excessive food consumption
• specific nutrient deficiencies
• dietary imbalance due to inappropriate intake. ³

6. Under-nutrition is a term used to refer to depleted body mass (body weight) resultant from energy deficiency (calories), protein and trace-metal deficiencies. The presence of metabolically active disease can exacerbate any energy intake deficit. In older people, this type of nutritional deficiency can readily be mistaken for signs of ageing or symptoms of an underlying disease. Under-nutrition in hospital patients is of significant concern and can result in substantial morbidity and mortality ². For example, it is known to complicate illness, delay recovery and prolong hospital stay as well as reduce wound healing and increase risk of infection.

7. Over-nutrition is a term used to refer to excessive energy consumption of food and, like under-nutrition, can detrimentally impact on morbidity and mortality. Over-nutrition can also impact on other conditions such as diabetes and coronary heart disease. Whilst under-nutrition is the main focus of concern in older adults, the impact of over-nutrition should not be neglected.

8. Comprehensive reviews of the literature on nutrition and older people in hospital ^2,4 and the links between nutrition, ageing and health ⁵ make it clear that malnutrition, in particular, under-nutrition, is a significant problem facing a considerable proportion of patients in both acute and long stay NHS facilities. Disturbing evidence ⁶ points to deteriorating nutritional status following hospital admission beyond that which exceeds the pathophysiological impact. This is recognised in the recent Service Standards Report for the NHS Care of Older People ⁷.

9. Recognition of malnutrition in clinical care is not new yet there are claims that "malnutrition remains largely unrecognised" and "all too common in hospitals" ⁸ and suggests that the nutritional plight of older people is being ignored ⁹. The publication of Hungry in Hospital ⁶ has highlighted the "failure of NHS hospitals to attend the basic nutritional needs of mainly older patients" ¹⁰. Despite heightened interest in the issue, the Director of the Relatives Association has asserted that "just because the problem of malnourishment in hospitals is being talked about doesn't mean it is solved" ¹¹.

10. It is suggested that the clinical and economic consequences of undernutrition in hospital patients are considerable ^12,13. Increased susceptibility to pressure sores and prolonged healing times following hip fracture are among the clinical problems identified ^5,13 as potentially leading to prolonged hospital stay. It is suggested that the "economic consequences of undernutrition have been underestimated", and that treating malnutrition saves the average US hospital $1 million ¹². The King's Fund Centre estimate that savings of 226 million annually could be made in the UK by adopting a proactive feeding approach for undernourished patients thus improving recovery rates, decreasing complications, reducing length of stay and reducing costs per day of stay ¹⁴.

Factors Affecting the Nutrition of Older People

11. Factors relating to under-nutrition in older people in hospital, and in other vulnerable groups, are many and varied. Age-related factors and impaired nutritional status following hospital admission are comprehensively covered in 'Eating Matters' ² and it is not the intention of the Group to duplicate that work.

Evidence of Malnutrition in Older People

12. A recent Scottish national audit project by Walker ¹⁵ included a survey of the nutritional status of long-term care elderly in the NHS and non-NHS sectors. Mean values of Body Mass Index (BMI) of the population audited were compared with comparable values for a 'healthy' age-matched group. The prevalence of malnutrition identified from this survey was approximately 29% in the first year with some improvement and reduction to 21% in year three of the audit.

13. As well as depletion of endogenous fat and muscle reserves there is also poor functional ability but these take time, anything up to several months, before they are noticed and too often in the past they have been dismissed as signs of ageing or symptoms of an underlying disease.

The Problem of Nutrition

14. Nutrition in the Health Service has continually been highlighted as an area of concern. A number of organisational factors linked to undernutrition are highlighted in the British Association for Parenteral and Enteral Nutrition (BAPEN) Report 'Summary of Hospital Food as Treatment' ¹². A lack of clarity as to who is responsible for the nutritional care of clients has been identified as one factor ¹⁶ as have some of the rules and rituals which can occur in clinical practice ¹¹. For example, a recent report suggests that nutritional provision by some Trusts may itself be inadequate to sustain nutrient balance ¹³ . It has also been shown that provision of an adequate diet by the organisation may not necessarily equate to adequate intake ¹⁷.

Nutrition in Hospital

15. The BAPEN report ¹² advocates the concept of nutrition as an integral part of treatment and this approach is gaining support. In order to be effective, however, it is recommended that all staff become involved in the nutrition pathway from cooks, porters, catering assistants, nursing staff, hostesses, PAMs and doctors. It is also essential that there is an element of joint training which recognises the role of each individual in the nutrition pathway and the effect a break in the link would have on the patient. The role of management in supporting this approach is paramount for the promotion and development of the nutritional pathway.

Method of Working

16. The Group met on 6 occasions between October 1999 and October 2000.

17. In order to fulfil its remit, the Group was asked to:

• refer to existing literature, eg Health Advisory Service 2000;
• address each of the standards as outlined in the Nursing Homes Scotland Core Standards for Nutritional Care, NHS MEL(1999) 54 ¹, ie nutritional screening, dietary assessment, dietary intake, training and monitoring in view of content, delivery, choice and flexibility within an acute setting;
• identify in response to a request for information from Directors of Nursing Services innovative/transferable practice; and
• offer examples of how the standards have been implemented.

18. The composition and membership of the Group is shown at Appendix I.

Structure of Report

19. The report sets out to provide practical advice and examples of how the promotion of nutritional standards for older people in hospital has been addressed. To facilitate this approach and produce 'user' friendly guidance, the Group has:-

• outlined the problem of nutrition in older people, including a selective literature review;
• summarised the Nursing Home Core Standards for Nutrition;
• identified for each standard a practical working example of how the standard has been applied drawing on the range of professions involved, eg catering, nursing and dietetics; and
• made realistic recommendations which are believed to be sustainable and, where possible, lend themselves to the audit process.