MUST and Malnutrition - · PDF file(NICE guideline – Nutritional support in adults, ... such as Crohn's disease ... • Effective management of malnutrition reduces the

Northern Devon Healthcare NHS Trust

MUST and Malnutrition

Presenter


Housekeeping


Confidentiality

• To respect confidentiality

within the group unless it is

necessary to address a current

concern about the safety of an adult at risk.


Quiz


Learning Objectives

• What is malnutrition

• What causes malnutrition

• What are the symptoms of malnutrition

• What is nutritional screening

• Why screen patients

• The MUST tool - what is it?

• The MUST tool – how can it be used?


What is Malnutrition ?

No universally accepted definition but it

can be defined as:

‘ A state in which a deficiency of nutrients

such as energy, protein, vitamins and minerals

causes measurable adverse effects on body

composition, function or clinical outcome’

(NICE guideline – Nutritional support in adults, February 2006)


Malnutrition Facts and Figures • More than 3 Million people in the UK are at risk of

malnutrition with the vast majority (93%) living in a

community setting.

• It is estimated that 1 in 10 people over the age of 65

living in the community are malnourished or at risk.

• Of the 3 million people at risk of malnutrition 150,000

(5% ) are living in residential accommodation.

• The health and social care costs in the UK directly

associated with malnutrition comes to more than £19.6

billion per annum.


Malnutrition Facts and Figures • For most adults a healthy BMI is between 18.5

and 24.9.

• Body Mass Index (BMI) and weight loss are not

the only indicators of malnutrition.

• A person can be overweight or obese and still

be malnourished. This can be due to having a

diet consisting of food and drink that is high in fat

and sugar and low in essential vitamins and

minerals


Consequences of Malnutrition Evidence that malnourished patients: •65% increase in the number and frequency of visits to their GP. •Need more prescriptions •82% more hospital admissions and 30% longer stays •Have an increased morbidity and mortality •Have a reduced quality of life


The Malnutrition Carousel

25 -34% of hospital admissions are at risk of

malnutrition

70% of patients weigh less on Hospital

Discharge

More GP visits

More Prescriptions More hospital admissions

Longer stay, more complications.

More support needed after discharge from hospital

More likely to need care.


Causes of Malnutrition Medical conditions • A condition that causes a lack of appetite, such as cancer,

liver disease, persistent pain or nausea • A mental health condition, such as depression or

schizophrenia, which may affect your ability to look after yourself

• A health condition that requires frequent hospital admissions

• A health condition that disrupts your body’s ability to digest food or absorb nutrients, such as Crohn's disease or ulcerative colitis


Causes of Malnutrition Medical Conditions • Dementia – people with dementia may be unable to communicate

their needs when it comes to eating • Dysphagia – a condition that makes swallowing difficult or painful • Persistent vomiting or diarrhoea • An eating disorder, such as anorexia nervosa • Some types of medication may increase your risk of developing

malnutrition. More than 250 types of medicine are known to disrupt the body’s ability to absorb and then break down nutrients.

• You may also be at risk of becoming malnourished if your body has an increased demand for energy – for example, if it's trying to heal itself after major surgery, or a serious injury such as a burn.


Causes of Malnutrition Physical factors

• If your teeth are in a poor condition, or if

dentures don't fit properly, eating can be difficult

or painful

• You may lose your appetite as a result of losing

your sense of smell and taste

• You may have a physical disability or other

impairment that makes it difficult for you to cook

or shop for food yourself


Causes of Malnutrition

Social factors

• Living alone and being socially isolated

• Having limited knowledge about nutrition or

cooking

• Reduced mobility

• Alcohol or drug dependency

• Low income or poverty


Symptoms of Malnutrition

• Unplanned and unexplained weight loss

• Feeling tired all the time and lacking energy

• Taking a long time to recover from infections

• Delayed wound healing

• Poor concentration

• Depression

• Difficulty keeping warm


Why Screen for Malnutrition ?

• Malnutrition is frequently unrecognised and untreated • Effective management of malnutrition reduces the

burden on healthcare and care resources • Regular screening is the only way that malnourished

individuals can be identified and appropriate action taken


When Do We Screen ? • All hospital inpatients on admission • All outpatients at their first appointment • All people in care homes on admission • All people on registration at GP surgeries • And upon clinical concern Clinical concern includes, unintentional weight loss,

fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes, or prolonged intercurrent illness


When Do We Screen .. • Consider screening at other opportunities ie. health

checks, flu injections • Repeat screening weekly when there is clinical concern • Screening should be carried out by health and social

care professionals with appropriate skills and training • Screening should assess BMI (Body Mass Index) and

percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this


What is MUST ? • 5 step tool used to identify adults who are malnourished or a

risk of malnutrition • A validated tool across various settings including Care

Homes, Hospital wards, Outpatient Clinics and General Practice

• Quick and easy to use and give reproducible results • Useful for patients in whom height and weight are difficult to

obtain as it includes alternative measures and subjective criteria which are given to obtain BMI ( Body Mass Index )

• Provides management guidelines which can be used to develop a care plan


Components of MUST

• A flow chart showing 5 steps to use for screening and management

• BMI chart • Weight loss tables • Alternative measurements


The Five Steps

Steps 1 and 2

• Gather nutritional measurements (height, weight, BMI, recent

unplanned weight loss)

Step3

• Consider the affects of acute disease

Step 4

• Determine the overall risk score or category of malnutrition

Step 5

• Using the management guidelines and / or local policy, form an

appropriate care plan


Step 1 - BMI • Obtain weight and height • Calculate BMI or use BMI chart provided • Use recalled height and weight or recommended

alternative methods of measurement if actual values cannot be obtained

• Consider use of the MUST calculator tool located at www.bapen.org.uk/screening-and-must/must-calculator


Step 2: Weight Loss Score (Unplanned weight loss over 3-6 months)

• Unplanned weight loss over 3-6 months is a more acute

risk factor for malnutrition than BMI

• Ask is there has been any weight loss in the last 3 – 6

months and if so how much ?

• Deduct current weight from previous weight to calculate

amount of eight loss

• If the subject has not lost weight score 0


Step 3 – Acute Disease Effect

• Patients who have had or are likely to have no

nutritional intake for more than 5 days

• Most likely to apply to patients who are critically

ill, those who have swallowing difficulties, or

head injuries or are undergoing gastrointestinal

surgery


Step 4 – Overall Risk of Malnutrition

• Add up scores from Steps 1, 2 and 3

• Document score

0 = Low risk

1 = Medium risk

2 or more = High risk


Step 5 – Management Guidelines

• Record residents overall risk score, agree and

document a care plan and any advice given.

• Residents who fall into the high or medium risk

categories typically require some form of

intervention

• Management guidelines are contained within the

MUST flowchart.


Alternative measurements Estimating Height from ulna length

• Ask resident to bend arm (left if possible), palm across chest, fingers pointing to opposite shoulder.

• Using a tape measure, measure the length in centimeters to the nearest 0.5cm between the point of the elbow and the mid point of the prominent bone of the wrist.

• Use the table to convert the ulna length to height.


Estimating BMI from mid upper arm

circumference (MUAC)

If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2 If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2


Estimating BMI

• The resident should be standing or sitting

• Use the left arm if possible, ask resident to remove

clothing so arm is bare

• Locate the top of the shoulder and the point of the elbow

• Measure the distance between the two points and mark

the arm

• Ask the resident to let the arm hang loose and with tape

measure, measure the circumference of arm at mid

point.


MUST Screening

Tool…How do we

use it ?


Activity

Group work • Undertaking MUST Measurements • Case Studies • Discussion



Case Study A • Mr A is 69 year old man living in a residential home, has

rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea.

• Height: 1.73m • Previous weight: 71kg (2 months ago when weighed at GP

Surgery) • Current weight: 69kg • Is patient at low, medium or high risk of malnutrition? • What would be your action plan?


Case Study A - Answer • 69 year old man living in a residential home, has rheumatoid arthritis,

takes multiple painkillers and suffers with constipation and nausea • Height: 1.73m • Previous weight: 71kg (2 months ago when weighed at GP Surgery) • Current weight: 69kg Is patient at low, medium or high risk of malnutrition? Answer = Low Risk What would be your action plan? • Repeat MUST monthly due to constipation, nausea and some

weight loss • Ensure balanced diet is advised, for a regular meal pattern and

adequate fibre intake • Give and discuss fluid advice sheet


Case Study B • Miss B is a 38 year old lady living at home with regular visits during

the day from Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less

• Height: ulna length 24.0cm • Previous weight: 62kg (6 months ago at OP clinic) • Current weight: 57kg • Is patient at low, medium or high risk of malnutrition? • What would be your Action Plan?


Case Study B - Answer • 38 year old lady living at home with regular visits during the day from

Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less

• Height: ulna length 24.0cm • Previous weight: 62kg (6 months ago at OP clinic) • Current weight: 57kg Is patient at low, medium or high risk of malnutrition? Answer = Medium risk What would be your Action Plan? • Repeat MUST monthly due to weight loss • Refer to Speech and Language therapist • Food and fluid chart


Case Study C •Mr C is a 89 year old man admitted to hospital after a fall at home and whilst

an inpatient he contracted c.diff infection. Two months later he has been

discharged to your care home, he still has diarrhoea but it is improving with

treatment.

•Height: 6’ 0” (estimated)

•Weight: 56kg (estimated)

•Previous weight: 65kg (before admission)

•Is patient at low, medium or high risk of malnutrition?

•What would be your Action Plan?


Case Study C - Answer • 89 year old man admitted to hospital after a fall at home and whilst

an inpatient he contracted c.diff infection. Two months later he has been discharged to your care home, he still has diarrhoea but it is improving with treatment.

• Height: 6’ 0” (estimated) • Weight: 56kg (estimated) • Previous weight: 65kg (before admission to hospital) Is patient at low, medium or high risk of malnutrition? Answer = High Risk What would be your Action Plan? Start food and fluid chart Discuss weight loss with GP Consider referral to Dietician


What will you do

differently after

today?


Questions?


QUIZ


References

• NICE guideline – Nutritional support in adults, February

2006

• Malnutrition Universal Screening Tool, Bapen, November

2011

• Dietician Key Facts – Malnutrition – British Dietetic

Association 2014

• http://malnutritionpathway.co.uk/


Contacting the Care Homes Team

• Becky Young: RN, Barnstaple care homes

• Martine Butler: RN, BLIS care homes

• Bridget Tait: RN, Torridge care homes

• Sarah Bishop: Paramedic Educator, Torridge care homes

• Meg Hill: Occupational therapist, North Devon care homes

• Sarah Winfield-Davies: RN, Safeguarding Nurse, North Devon care

homes

e-mail: [email protected]

Documents

MUST and Malnutrition - · PDF file(NICE guideline – Nutritional support in adults, ... such as Crohn's disease ... • Effective management of malnutrition reduces the