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RELEVANT DOCUMENTS TO SUPPORT THE CONTENT OF THE PRESENTATIONS OF THE WEBINAR
NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
WATCH WEBINAR
The European Federation of the Associations of Dietitians
T H E V O I C E O F E U R O P E A N D I E T E T I C S
NEW
SFLASH
Special thanks to EFAD for their cooperation and support of the webinar
Chair biography: Prof. Jos MGA Schols
References
Speaker biography: Prof. Tommy Cederholm
Appendix I
Speaker biography: Maria Mckenna
Appendix II
Appendix III
Introduction by Nutricia
Practical resources
About Nutricia
About EFAD
CONTENTS
2NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
INTRODUCTION BY NUTRICIA
Dear Webinar Attendees,
I am delighted to welcome you to this webinar hosted by Nutricia with special thanks to the European Federation of the Associations of Dietitians (EFAD) for their collaboration and support. The aim of this event is to empower healthcare professionals (HCPs) to optimize nutritional management in care homes, which is even more relevant in the current COVID-19 setting. In this webinar three excellent speakers will share their knowledge and experience relating to the nutritional challenges facing care home residents during the COVID-19 pandemic, current evidence on the importance of nutrition in this setting and the application of nutritional care pathways adapted to the COVID-19 context.
The COVID-19 pandemic has deeply affected care home residents, not only due to the direct impact of infection, but also due to the challenges of social isolation and reduced face-to-face care.
Much attention until now has been directed towards patients who have been hospitalized due to COVID-19 in the acute and post-acute phases. Through this webinar we want to add focus on care homes and the nutritional management of this very vulnerable population.
Whilst there is little evidence yet published on nutritional management of care home residents in the COVID-19 context, there is a wealth of information on nutrition in care homes in general. We believe that sharing and disseminating insights and learnings from experts in this field who have been intimately involved in research, patient management and development of guidance and care pathways is the best way to support optimization of nutritional care in this sector. This knowledge sharing will be of tremendous value to HCPs around the world.
3NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
This booklet will introduce our speakers: Professor Jos Schols (The Netherlands), Professor Tommy Cederholm (Sweden) and Maria Mckenna (Ireland). At the end of this webinar you can expect to have gained the following insights:
• Awareness of the issue of malnutrition and of the impact of COVID-19 on nutritional status of care homes residents.
• Scientific evidence underpinning the role of optimal nutritional management in care homes
• Practical management of COVID-19 in the care home setting from a dietetic perspective based on a care pathway approach
If you are not able to attend the live event, the recordings of the webinar presentations, expert discussion, and questions and answers will be accessible by clicking on links in this booklet.
I hope you will enjoy this webinar and be able to apply some of the learnings to your daily practice.
With kind regards,
Ceri Green, PhD Medical Affairs Director Disease-Related Malnutrition and Frailty Nutricia Specialized Nutrition
4NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
PRACTICAL RESOURCES
COVID-19 nutritional care pathways in care homes (Ireland)Nutrition Support Pack for Residential Care Facilities for Older People during Covid 19 (May 2020) See decision treeCOVID-19 Nutrition Care Pathway (Nutricia)
ESPEN guidelinesESPEN Guideline on clinical nutrition and hydration in geriatricsESPEN Guideline on clinical nutrition and hydration in geriatrics : A summary for clinical practice developed by NutriciaBarazzoni R, Bischoff SC, Breda J, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clin Nutr. 2020;39(6):1631-8.
Nutritional resources for older patientsNutrition and Dementia – a practical guide when caring for a person with dementiaMaking The Most of Every Bite – High Protein High Calorie Cookbook for Patients and their Carers
Resources on the role of medical nutrition for older patientsBetter care through better nutrition: Value and effects of Medical Nutrition” (2018)
Useful linksOptimal Nutritional Care for All (ONCA)Health Service Executive (HSE, Ireland)International Dysphagia Diet Standardisation Initiative (IDDSI)Irish Nutrition and Dietetic Institute (INDI)Irish Society for Clinical Nutrition & Metabolism (IrSPEN)
5NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
PROFESSOR JOS MGA SCHOLSProf. of Old Age Medicine Maastricht University The Netherlands
Prof. Dr. Jos M.G.A. Schols is professor of Old Age Medicine. He works at the Department of Family Medicine and the Department of Health Services Research; CAPHRI, Maastricht University, The Netherlands. His main research topics are: 1) frailty and sarcopenia, 2) geriatric rehabilitation, 3) the epidemiology of and interventions for relevant health and care problems in chronic care and 4) transformation issues of chronic care. Schols is author of over 500 national and international publications and reviewer for a number of scientific journals and research funding agencies. He participates in several national and international boards, amongst which the Health Council of the Netherlands, an independent scientific advisory body for the Dutch government.
PROFESSOR TOMMY CEDERHOLMProf. Emeritus, Clinical Nutrition Senior Consultant Geriatrics Sweden
Prof. Cederholm is a Professor Emeritus of Clinical Nutrition, Uppsala University. He also serves as Senior Consultant, Head of R&D, Theme Ageing, Karolinska University Hospital, Stockholm, board certified in geriatric medicine and internal medicine. Research focus on catabolism in old and chronically ill subjects. Served as Executive Committee member of ESPEN 2012-2016. Member of the European Working Group on Sarcopenia in older people. Facilitator of the GLIM Criteria for malnutrition.
MARIA MCKENNAChair OPDIG-INDI Senior Community Dietitian Ireland
Maria Mckenna is chair of the Older Persons and Dementia Interest Group (OPDIG) of the Irish Nutrition and Dietetic Institute (INDI) and is a senior community dietitian in Dublin, Ireland. She has worked in both acute, rehabilitation and community dietetics over the past 10 years and has nine years experience working in nursing homes, residential units and day centres in both the National Health Service (NHS) in the UK and the Health Service Executive (HSE) in Ireland. Maria has a passion for improving nutritional care for people that live in residential settings with an Multidisciplinary Team (MDT) approach.
SPEAKERS
6NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
The OPEN studyGrönstedt H, Vikström S, Cederholm T, et al. Effect of Sit-to-Stand Exercises Combined With Protein-Rich Oral Supplementation in Older Persons: The Older Person’s Exercise and Nutrition Study. J Am Med Dir Assoc. 2020; in pressFaxen-Irving G, Cederholm T, Grönstedt H, et al. Relationships between nutritional status, sarcopenia and frailty in nursing-home residents. Clin Nutr. 2018;37(Suppl 1):S59-S60 (Abstract)
Other references Faxen-Irving G, Cederholm T. Energy dense oleic acid rich formula to newly admitted geriatric patients - Feasibility and effects on energy intake. Clin Nutr. 2011;30(2):202-08.Tylner S, Cederholm T, Faxén-Irving G. “Effects on Weight, Blood Lipids, Serum Fatty Acid Profile and Coagulation by an Energy-Dense Formula to Older Care Residents: A Randomized Controlled Crossover Trial.” J Am Med Dir Assoc. 2016;17(3):275.e5-11. Liberman K, Njemini R, Luiking Y, et al. Thirteen weeks of supplementation of vitamin D and leucine-enriched whey protein nutritional supplement attenuates chronic low-grade inflammation in sarcopenic older adults: the PROVIDE study. Aging Clin Exp Res. 2019;31(6):845-54.
Appendix ICovid-19 Nutrition Support Pathway for Residential Care Facilities for Older Persons (HSE, V1, May 2020), page 3. Full version available here.
Appendix IINutricia COVID-19 Nutrition Care Pathway. Supported by
Appendix IIIESPEN Guideline on clinical nutrition and hydration in geriatrics: A summary for clinical practice developed by Nutricia
REFERENCES
7NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
The full version of the pathway is available here
COVID-19 Nutrition Care Pathway for Nursing Homes Guidelines recommend that the prevention, diagnosis and treatment of malnutrition should be routinely included in the management of COVID-19 patients1. The aim of this pathway is to provide guidance, focused to those in the presence of older age and polymorbidity whom are at risk for poor outcomes following infection with SARS-COV-2.
Can the patient swallow safely?
Efficacy and expected benefit of ONS should be assessed
once a month.Have nutritional goals
been met?
Commence an ONS appropriate to the recommended IDDSI Level 125ml/200ml/125g BD
Nutilis Fruit Level 4
FortisipCompact Fibre
Nutilis Complete Level 3
Fortisip Extra
Commence Fortisip Compact Protein 125mls BD
Give dietary advice and encourage oral intake. Consider reducing ONS prescription for 2 weeks before stopping.
Seek advice of the dietitian. Check ONS compliance, amend prescription as necessary. WHEN TO STOP ONS PRESCRIPTION: Goals of intervention have been met and individual is no longer at risk,
if advised by dietitian or SLT, or if no further clinical input would be appropriate.
YesNo
*Please remember, your Nutricia Care Dietitians continue to be available at this time and referrals can be processed via a telephone dietetic assessment. Referrals to be sent to [email protected] or call
Freephone 1800 923 404 with any queries.
Patient with COVID-19 identified at risk of malnutrition using a validated screening tool e.g. ‘MUST’ screening toolNote: • Weighing residents may be more difficult at this time. Where possible continue to take weights on a monthly basis and use the opportunity to
weigh the resident when transferring from bed for dressing/washing to minimise physical contact and distress for the resident.• There is likely to be increased frequency of an “Acute Disease Effect’’ score within MUST screening with a diagnosis of COVID-19
(Acute Disease Effect score = If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days).
Please commence a high protein high calorie diet. Dietitian referral recommended*. Agree goals of nutritional intervention.
Consider commencing oral nutritional supplements (ONS) when dietary counselling and food fortification are not sufficient to increase dietary intake and reach nutritional goals.
1. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection (2020) available at https://www.espen.org/files/Espen_expert_statements_and_practical_guidance_for_nutritional_management_of_individuals_with_sars-cov-2_infection.pdf
This information is intended for Healthcare Professionals only. April 2020.Important Notice: All products shown are Foods for Special Medical Purposes for the dietary management of disease related malnutrition or dysphagia and must be used under medical supervision.
CL2220
No Yes
Level 1 Level 2 Level 3 Level 4
Supported by
Pa
rt I
Basic
que
stio
ns a
nd g
ener
al p
rincip
les (
all o
lder
peo
ple)
Pr
ovisi
on o
f ene
rgy
and
nutr
ient
s 1.
Gi
ve a
bout
30
kcal
/kg/
body
wei
ght/
day
2.
Give
at l
east
1 g
pro
tein
/kg/
body
wei
ght/
day*
3.
Us
e fib
re-c
onta
inin
g pr
oduc
ts fo
r ent
eral
nut
ritio
n (2
5 g
per d
ay co
nsid
ered
ade
quat
e)
4.
Give
micr
onut
rient
s acc
ordi
ng to
EFS
A or
nat
iona
l rec
omm
enda
tions
for h
ealth
y ol
der p
eopl
e un
less
th
ere
is a
spec
ific d
efici
ency
(cor
rect
with
supp
lem
enta
tion)
Or
gani
satio
n of
nut
ritio
nal c
are
5.
Scre
en a
ll* o
lder
peo
ple
with
a v
alid
ated
tool
to id
entif
y (ri
sk o
f) m
alnu
triti
on
6.
If ris
k of
mal
nutr
ition
is fo
und
unde
rtak
e sy
stem
atic
asse
ssm
ent,
indi
vidu
alise
d in
terv
entio
n,
mon
itorin
g an
d co
rres
pond
ing
adju
stm
ent o
f int
erve
ntio
ns
Esta
blish
stan
dard
ope
ratin
g pr
oced
ures
for n
utrit
iona
l and
hyd
ratio
n ca
re in
inst
itutio
nal s
ettin
gs.
Regu
late
resp
onsib
ilitie
s
*In
depe
nden
t of s
pecif
ic di
agno
sis a
nd in
cludi
ng o
verw
eigh
t and
obe
se p
eopl
e.
B
B
B
GPP
GPP
GPP
GPP
Perf
orm
ing
nutr
ition
al ca
re
8. P
erfo
rm in
divi
dual
ised
and
com
preh
ensiv
e nu
triti
onal
and
hyd
ratio
n ca
re to
: ✓
en
sure
ade
quat
e nu
triti
onal
inta
ke
✓
mai
ntai
n or
impr
ove
nutr
ition
al st
atus
✓
im
prov
e cli
nica
l cou
rse
✓
impr
ove
qual
ity o
f life
9.
Car
ry o
ut n
utrit
iona
l int
erve
ntio
ns a
s par
t of a
mul
timod
al a
nd m
ultid
iscip
linar
y te
am in
terv
entio
n to
: ✓
Su
ppor
t ade
quat
e di
etar
y in
take
✓
M
aint
ain
or in
crea
se b
ody w
eigh
t ✓
Im
prov
e fu
nctio
nal o
utco
me
✓
Impr
ove
clini
cal o
utco
me
10. I
dent
ify a
nd e
limin
ate
pote
ntia
l cau
ses o
f mal
nutr
ition
and
deh
ydra
tion
11. A
void
die
tary
rest
rictio
ns th
at m
ay li
mit
diet
ary
inta
ke a
s the
se a
re p
oten
tial h
arm
ful
A
B GPP
GPP
Part
III R
ecom
men
datio
ns fo
r old
er p
eopl
e w
ith sp
ecifi
c con
ditio
ns
Part
II R
ecom
men
datio
ns fo
r old
er p
eopl
e w
ith m
alnu
triti
on o
r risk
of m
alnu
triti
on
Supp
ortiv
e in
terv
entio
ns to
supp
ort d
ieta
ry in
take
12
. Offe
r mea
ltim
e as
sista
nce
to th
ose
with
eat
ing
depe
nden
cy
13. I
n in
stitu
tions
pro
vide
hom
e-lik
e pl
easa
nt d
inin
g en
viron
men
t (al
so su
ppor
ts Q
oL)
14. E
ncou
rage
shar
ed m
ealti
mes
(also
supp
orts
QoL
) 15
. Mea
ls on
whe
els s
houl
d be
ene
rgy
dens
e an
d/or
inclu
de
addi
tiona
l mea
ls
16. O
ffer n
utrit
iona
l inf
orm
atio
n an
d ed
ucat
ion
to p
atie
nt
17. P
rovi
de n
utrit
iona
l edu
catio
n to
HCP
s and
info
rmal
ca
regi
vers
Nu
triti
onal
coun
selli
ng to
supp
ort d
ieta
ry in
take
and
im
prov
e/m
aint
ain
nutr
ition
al st
atus
18
. Offe
r ind
ivid
ualis
ed n
utrit
ion
coun
selli
ng to
pa
tient
/car
egiv
er
19. I
t sho
uld
be d
eliv
ered
by
a qu
alifi
ed d
ietit
ian,
cons
ist o
f at
leas
t 2 in
divi
dual
sess
ions
whi
ch m
ay b
e co
mbi
ned
with
gro
up
sess
ions
, tel
epho
ne co
ntac
t and
writ
ten
advi
ce. M
aint
ain
over
a lo
nger
per
iod
of ti
me
(at l
east
8 w
eeks
) Fo
od M
odifi
catio
n to
supp
ort/
facil
itate
die
tary
inta
ke
20. O
ffer f
ortif
ied
food
**
21. O
ffer a
dditi
onal
snac
ks a
nd/o
r fin
ger f
oods
22
. Offe
r tex
ture
-mod
ified
, enr
iched
food
s to
thos
e w
ith si
gns o
f or
opha
ryng
eal d
ysph
agia
*G
rade
A fo
r ins
titut
ions
and
GPP
for h
ome
sett
ing.
**I
ncre
ases
ene
rgy
and
prot
ein
inta
ke, e
vide
nce
insu
ffici
ent t
o m
ake
reco
mm
enda
tions
on
food
fort
ifica
tion
with
m
icron
utrie
nts.
A/GP
P*
A GPP
B
B B B GPP
B GPP
GPP
Oral
Nut
ritio
nal S
uppl
emen
ts (O
NS)
23. O
ffer O
NS w
hen
diet
ary
coun
selli
ng a
nd fo
od fo
rtifi
catio
n no
t su
fficie
nt to
incr
ease
die
tary
inta
ke a
nd re
ach
nutr
ition
al g
oals
in
patie
nts w
ith ch
roni
c con
ditio
ns
24. O
ffer O
NS to
hos
pita
lised
pat
ient
s to:
✓
Im
prov
e di
etar
y in
take
✓
Im
prov
e bo
dy w
eigh
t ✓
Lo
wer
risk
of i
nfec
tion
✓
Lo
wer
risk
of r
eadm
issio
n 25
. Offe
r ONS
afte
r hos
pita
l disc
harg
e to
: ✓
Im
prov
e di
etar
y in
take
✓
Im
prov
e bo
dy w
eigh
t ✓
Lo
wer
risk
of f
unct
iona
l dec
line
26. O
NS o
ffere
d sh
all p
rovi
de a
t lea
st 4
00 k
cal a
nd ≥
30 g
pro
tein
/day
27
. ONS
shal
l be
cont
inue
d fo
r at l
east
1 m
onth
. Ass
ess e
ffica
cy a
nd
bene
fit o
f ONS
at l
east
onc
e a
mon
th
28. A
sses
s com
plia
nce
with
ONS
regu
larly
. Ada
pt ty
pe, f
lavo
ur, t
extu
re
and
time
of co
nsum
ptio
n to
pat
ient
’s ta
ste
and
eatin
g ca
pacit
ies.
GPP
A A A GPP
GPP
Ente
ral N
utrit
ion
(EN)
and
Par
ente
ral N
utrit
ion
(PN)
29
. Offe
r EN
if re
ason
able
pro
gnos
is an
d or
al in
take
ex
pect
ed to
be
impo
ssib
le fo
r >3
days
or <
50%
of
ener
gy re
quire
men
ts fo
r >1
wee
k de
spite
in
terv
entio
ns to
ens
ure
adeq
uate
ora
l int
ake
to:
✓
Mee
t nut
ritio
nal r
equi
rem
ents
✓
M
aint
ain
or im
prov
e nu
triti
onal
stat
us
30. E
valu
ate
expe
cted
ben
efits
and
pot
entia
l risk
s on
an
indi
vidu
al b
asis
and
re-a
sses
s reg
ular
ly a
nd w
hen
clini
cal
cond
ition
chan
ges
31. O
ffer c
omfo
rt fe
edin
g in
stea
d of
EN
whe
n in
take
low
in
the
term
inal
pha
se o
f illn
ess
32. I
f EN
indi
cate
d, st
art E
N w
ithou
t del
ay
33. U
se N
G tu
be w
hen
EN re
quire
d fo
r <4
wee
ks
34. U
se P
EG w
hen
EN re
quire
d fo
r >4
wee
ks o
r whe
n NG
no
t wan
ted
or to
lera
ted
by p
atie
nt
35. E
ncou
rage
mai
nten
ance
of o
ral i
ntak
e as
far a
s saf
ely
poss
ible
in tu
be fe
d pa
tient
s 37
. EN,
PN
and
hydr
atio
n ar
e m
edica
l tre
atm
ents
(not
ba
sic ca
re),
use
only
of t
here
is re
alist
ic ch
ance
of
impr
ovem
ent/
mai
nten
ance
of p
atie
nt’s
cond
ition
and
QoL
38
. Do
not u
se p
harm
acol
ogica
l sed
atio
n or
phy
sical
re
stra
int t
o m
ake
EN, P
N or
hyd
ratio
n po
ssib
le
39. S
tart
EN
and
PN e
arly
, gra
dual
ly in
crea
se o
ver f
irst 3
da
ys to
avo
id re
feed
ing
synd
rom
e 40
. Mon
itor b
lood
leve
ls of
P0 4
, Mg,
K a
nd th
iam
ine
over
fir
st 3
day
s of E
N an
d PN
in m
alno
urish
ed o
lder
pat
ient
s. Su
pple
men
t eve
n in
case
of m
ild d
efici
ency
GPP
GPP
GPP
GPP
GPP
GPP
GPP
GPP
GPP
GPP
Exer
cise
inte
rven
tions
in a
dditi
on to
nut
ritio
nal i
nter
vent
ions
41. E
ncou
rage
phy
sical
act
ivity
and
exe
rcise
to m
aint
ain
or
impr
ove
mus
cle fu
nctio
n an
d m
ass
GPP
42
. Pro
vide
ade
quat
e am
ount
s of e
nerg
y an
d pr
otei
n du
ring
perio
ds o
f exe
rcise
inte
rven
tions
to m
aint
ain
body
wei
ght a
nd
mai
ntai
n or
impr
ove
mus
cle m
ass
B
Adju
st a
ccor
ding
to in
divi
dual
nut
ritio
nal s
tatu
s, ph
ysica
l ac
tivity
leve
l, di
seas
e st
atus
and
tole
ranc
e.
Hip
fract
ure/
orth
opae
dic
surg
ery
Delir
ium
and
risk
of d
eliri
um
Depr
essio
n Pr
essu
re u
lcer/
risk
of
pres
sure
ulce
r Ov
erw
eigh
t or o
besit
y Di
abet
es M
ellit
us
ESPE
N Gu
idel
ine
on cl
inica
l nut
ritio
n an
d hy
drat
ion
in g
eria
trics
1 : A
sum
mar
y fo
r clin
ical p
ract
ice d
evel
oped
by
Nutr
icia*
1.
Volk
ert D
, Bec
k AM
, Ced
erho
lm T
, et a
l. ES
PEN
gui
delin
e on
clin
ical n
utrit
ion
and
hydr
atio
n in
ger
iatri
cs. C
lin N
utr.
2019
;38:
10-4
7.
*D
ocum
ent n
ot o
ffic
ially
end
orse
d by
ESP
EN
Reco
mm
enda
tions
sum
mar
ised.
See
gui
delin
e fo
r ful
l wor
ding
and
def
initi
ons o
f gra
des o
f evi
denc
e. N
ote
wor
ding
in g
uide
lines
as f
ollo
ws:
Gra
de A
= ‘s
hall’
, Gra
de B
= ‘s
houl
d’, G
rade
0 =
‘can
’ or ‘
may
’, GP
P =
base
d on
exp
ert o
pini
on, w
ordi
ng ch
osen
del
iber
atel
y.
Pa
rt IV
Rec
omm
enda
tions
to id
entif
y, tr
eat a
nd p
reve
nt d
ehyd
ratio
n in
old
er p
eopl
e Lo
w in
take
deh
ydra
tion
Fl
uid
inta
ke
61. O
ffer a
t lea
st 1
.6 L
of d
rink/
day
to o
lder
wom
en a
nd a
t lea
st 2
.0 L/
day
to o
lder
men
unl
ess t
here
is a
clin
ical
cond
ition
that
requ
ires a
diff
eren
t app
roac
h 62
. Offe
r a ra
nge
of a
ppro
pria
te (i
.e. h
ydra
ting)
drin
ks a
ccor
ding
to o
lder
peo
ples
pre
fere
nces
Id
entif
icatio
n of
low
-inta
ke d
ehyd
ratio
n
63. C
onsid
er ri
sk o
f low
-inta
ke d
ehyd
ratio
n in
all
olde
r peo
ple.
Enc
oura
ge co
nsum
ptio
n of
ade
quat
e am
ount
s of
drin
ks
64. S
cree
n fo
r low
-inta
ke h
ydra
tion
whe
n ol
der p
eopl
e ar
e:
• in
cont
act w
ith th
e he
alth
care
syst
em
• if
clini
cal c
ondi
tion
chan
ges u
nexp
ecte
dly
• m
alno
urish
ed o
r at r
isk o
f mal
nutr
ition
(scr
een
perio
dica
lly fo
r low
-inta
ke d
ehyd
ratio
n)
65. M
easu
re se
rum
or p
lasm
a os
mol
ality
to id
entif
y lo
w-in
take
deh
ydra
tion
66. U
se th
e cu
t off
of >
300
mOs
m/k
g (d
irect
ly m
easu
red
seru
m o
smol
ality
) to
iden
tify
low
-inta
ke d
ehyd
ratio
n 67
. Alte
rnat
ivel
y w
hen
dire
ctly
mea
sure
d se
rum
osm
olal
ity n
ot a
vaila
ble,
use
the
osm
olar
ity e
quat
ion
to id
entif
y lo
w-
inta
ke d
ehyd
ratio
n (o
smol
arity
= 1
.86
x (Na
+ +
K+) +
1.1
5 x g
luco
se +
ure
a +
14 (a
ll m
easu
red
in m
mol
/L) w
ith a
n ac
tion
thre
shol
d of
>29
5 m
mol
/L)
68. D
o no
t use
the
follo
win
g co
mm
on te
sts t
o as
sess
low
-inta
ke d
ehyd
ratio
n: sk
in tu
rgor
, mou
th d
ryne
ss, w
eigh
t ch
ange
, urin
e co
lour
or s
pecif
ic gr
avity
69
. Do
not u
se b
ioel
ectr
ical i
mpe
danc
e to
ass
ess h
ydra
tion
stat
us a
s it i
s not
dia
gnos
tical
ly u
sefu
l 70
. App
ropr
iate
tool
s may
be
used
by
olde
r peo
ple
and
thei
r inf
orm
al ca
rers
to a
sses
s flu
id in
take
. The
y sh
ould
ask
he
alth
care
pro
vide
rs to
ass
ess s
erum
osm
olal
ity p
erio
dica
lly
Trea
tmen
t of l
ow-in
take
deh
ydra
tion
71. E
ncou
rage
incr
ease
d flu
id in
take
from
pre
ferr
ed d
rinks
in o
lder
peo
ple
who
app
ear w
ell a
nd w
ho h
ave
mea
sure
d se
rum
or p
lasm
a os
mol
ality
>30
0 m
Osm
/kg
(or c
alcu
late
d os
mol
arity
>29
5 m
mol
/L)
72. O
ffer s
ubcu
tane
ous o
r int
rave
nous
flui
ds in
par
alle
l with
enc
oura
ging
ora
l flu
id in
take
in o
lder
adu
lts w
ho a
ppea
r un
wel
l and
who
hav
e m
easu
red
seru
m o
r pla
sma
osm
olal
ity >
300
mOs
m/k
g (o
r cal
cula
ted
osm
olar
ity >
295
mm
ol/L
)
B B GPP
GPP
GPP
B B A A GPP
GPP
A
73. C
onsid
er in
trav
enou
s flu
ids f
or o
lder
adu
lts u
nabl
e to
drin
k w
ith w
ho h
ave
mea
sure
d se
rum
or p
lasm
a os
mol
ality
>30
0 m
Osm
/kg
(or c
alcu
late
d os
mol
arity
>29
5 m
mol
/L)
Inte
rven
tions
to su
ppor
t old
er a
dults
to d
rink
wel
l and
pre
vent
low
-inta
ke d
ehyd
ratio
n 74
. Im
plem
ent m
ultic
ompo
nent
stra
tegi
es a
cros
s ins
titut
ions
for a
ll re
siden
ts
75. S
trat
egie
s sho
uld
inclu
de h
igh
avai
labi
lity,
var
ied
choi
ce a
nd fr
eque
nt o
fferin
g of
drin
ks
and
staf
f aw
aren
ess o
f the
nee
d fo
r ade
quat
e flu
id in
take
, sta
ff su
ppor
t for
drin
king
an
d in
taki
ng o
lder
peo
ple
to th
e to
ilet q
uick
ly w
hen
they
nee
d it
76. A
t reg
ulat
ory
leve
l, co
nsid
er m
anda
tory
mon
itorin
g an
d re
port
ing
by in
stitu
tions
of
hydr
atio
n ris
ks in
indi
vidu
al re
siden
ts a
nd p
atie
nts
77.
Reco
rd in
divi
dual
pre
fere
nces
for d
rinks
, how
and
whe
n se
rved
and
cont
inen
ce
supp
ort i
n ca
re p
lans
in in
stitu
tions
. Ass
ess i
ndiv
idua
l bar
riers
and
pro
mot
ers o
f dr
inki
ng.
78. E
xper
ienc
ed sp
eech
and
lang
uage
ther
apist
shou
ld a
sses
s, tr
eat a
nd fo
llow
up
olde
r ad
ults
with
sign
s of d
ysph
agia
. Mon
itor n
utrit
ion
and
hydr
atio
n st
atus
in co
nsul
tatio
n w
ith
spee
ch a
nd la
ngua
ge th
erap
ist a
nd d
ietit
ian
79
. Inc
lude
old
er p
eopl
e, st
aff,
man
agem
ent a
nd p
olicy
mak
ers w
hen
to d
evel
op st
rate
gies
to
supp
ort a
dequ
ate
fluid
inta
ke
Volu
me
depl
etio
n 80
. Ass
ess v
olum
e de
plet
ion
follo
win
g ex
cess
ive
bloo
d lo
ss u
sing
post
ural
pul
se ch
ange
fro
m ly
ing
to st
andi
ng (≥
30 b
eats
per
min
ute)
or s
ever
e po
stur
al d
izzin
ess r
esul
ting
in
inab
ility
to st
and.
81
. Ass
ess v
olum
e de
plet
ion
follo
win
g flu
id a
nd sa
lt lo
ss w
ith v
omiti
ng o
r dia
rrhe
a by
ch
ecki
ng a
set o
f sig
ns. A
per
son
with
at l
east
four
of t
he fo
llow
ing
seve
n sig
ns is
like
ly to
ha
ve m
oder
ate
to se
vere
vol
ume
depl
etio
n: co
nfus
ion,
non
-flue
nt sp
eech
, ext
rem
ity
wea
knes
s, dr
y m
ucou
s mem
bran
es, d
ry to
ngue
, fur
row
ed to
ngue
, sun
ken
eyes
. 82
. Old
er a
dults
with
mild
/mod
erat
e/se
vere
vol
ume
depl
etio
n sh
ould
rece
ive
isoto
nic
fluid
s ora
lly, n
asog
astr
ically
, sub
-cut
aneo
usly
or i
ntra
veno
usly
.
A B B GPP
GPP
GPP
B B B B
Part
III R
ecom
men
datio
ns fo
r old
er p
eopl
e w
ith sp
ecifi
c con
ditio
ns
Hip
fract
ure
and
orth
opae
dic
surg
ery
43. O
ffer O
NS p
osto
p to
: ✓
im
prov
e di
etar
y in
take
✓
re
duce
risk
of
com
plica
tions
44
. Do
not o
ffer s
uppl
emen
tary
ov
erni
ght E
N un
less
EN
indi
cate
d fo
r oth
er re
ason
s 45
. Pos
t op
ONS
may
be
com
bine
d w
ith p
erio
p PN
to:
✓
impr
ove
nutri
tiona
l in
take
✓
re
duce
risk
of
com
plica
tions
46
. Giv
e nu
tritio
nal
inte
rven
tions
as p
art o
f in
divi
dual
ly ta
ilore
d,
mul
tidim
ensio
nal,
mul
tidisc
iplin
ary
team
in
terv
entio
n to
: ✓
en
sure
ade
quat
e di
etar
y in
take
✓
im
prov
e cli
nica
l ou
tcom
es
✓
mai
ntai
n Qo
L
A
GP
P O A
Delir
ium
and
risk
of
delir
ium
47
. To
prev
ent d
eliri
um,
give
a m
ulti-
com
pone
nt
non-
phar
mal
ogica
l in
terv
entio
n th
at in
clude
s hy
drat
ion
and
nutr
ition
al
man
agem
ent t
o ol
der
patie
nts h
ospi
talis
ed to
ha
ve u
rgen
t sur
gery
48
. To
prev
ent d
eliri
um,
give
a m
ulti-
com
pone
nt
non-
phar
mal
ogica
l in
terv
entio
n th
at in
clude
s hy
drat
ion
and
nutr
ition
al
man
agem
ent t
o al
l old
er
patie
nts a
dmitt
ed to
a
med
ical w
ard
and
at
mod
erat
e to
hig
h ris
k of
de
liriu
m
49. I
n ho
spita
lised
old
er
patie
nts s
cree
n fo
r de
hydr
atio
n an
d m
alnu
triti
on a
s pot
entia
l ca
uses
or c
onse
quen
ces o
f de
liriu
m
A A GP
P
Depr
essio
n 50
. Scr
een
for
mal
nutr
ition
51
. Do
not r
outin
ely
give
nut
ritio
nal
inte
rven
tions
unl
ess
risk
of m
alnu
triti
on
or m
alno
urish
ed
GP
P O
Pres
sure
ulce
rs/r
isk
of p
ress
ure
ulce
rs
52. O
ffer n
utrit
iona
l in
terv
entio
ns to
old
er
peop
le a
t risk
of
pres
sure
ulce
rs (P
U)
to:
✓
prev
ent
deve
lopm
ent o
f PU
53
. Offe
r nut
ritio
nal
inte
rven
tions
to o
lder
pa
tient
s with
PU
to:
✓
impr
ove
heal
ing
B B
Over
wei
ght o
r obe
sity
54. A
void
wei
ght r
educ
ing
diet
s in
over
wei
ght o
lder
peo
ple
to:
✓
prev
ent l
oss o
f mus
cle m
ass
✓
prev
ent a
ccom
pany
ing
func
tiona
l dec
line
55. I
n ob
ese
olde
r peo
ple
with
w
eigh
t-rel
ated
pro
blem
s con
sider
w
eigh
t red
ucin
g di
ets o
nly
afte
r ca
refu
l and
indi
vidu
al w
eigh
ing
of
bene
fits a
nd ri
sks
56. I
f wei
ght r
educ
tion
is co
nsid
ered
in o
bese
old
er p
eopl
e,
rest
rict e
nerg
y on
ly m
oder
atel
y to
: ✓
ac
hiev
e slo
w w
eigh
t re
duct
ion
✓
pres
erve
mus
cle m
ass
57. I
f wei
ght r
educ
tion
is co
nsid
ered
in o
bese
old
er p
eopl
e,
com
bine
die
tary
inte
rven
tions
with
ph
ysica
l exe
rcise
to:
✓
pres
erve
mus
cle m
ass
GP
P GP
P GP
P A
Diab
etes
Mel
litus
58
. Scr
een
for m
alnu
triti
on
with
a v
alid
ated
tool
59
. Avo
id re
stric
tive
diet
s to
: ✓
pr
even
t mal
nutr
ition
an
d ac
com
pany
ing
func
tiona
l dec
line
60. M
anag
e m
alnu
triti
on
and
risk
of m
alnu
triti
on
acco
rdin
g to
the
reco
mm
enda
tions
for
mal
nour
ished
old
er p
eopl
e w
ithou
t dia
bete
s (se
e se
ctio
n II
abov
e/ov
erle
af)
GP
P GP
P
NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19 12
Since 1896, Nutricia has pioneered nutritional solutions that help people live longer, more joyful and healthier lives. Building on more than a century of research and innovation, Nutricia has harnessed the power of life-changing and life-saving nutrition to create a leading specialized nutrition portfolio that can change a health trajectory for life.
With its nutritional solutions, Nutricia supports healthy growth and development during the first 1000 days and helps to address some of the world’s biggest health challenges; pre-term birth, faltering growth, food allergy, rare metabolic diseases, age-related conditions and chronic disease, such as frailty, cancer, stroke and early Alzheimer’s disease.
As part of Danone, Nutricia embraces the company’s “One Planet. One Health” vision reflecting that the health of people and the health of the planet are interconnected and therefore seeks to protect and nourish both.
For more information visit: www.nutricia.com
ABOUT NUTRICIA
The European Federation of the Associations of Dietitians (EFAD) is the voice of 35,000 European dietitians in 29 European countries representing more than half the profession in Europe. Through its membership of 33 National Dietetic Associations and 38 Higher Education Institutes, EFAD aims to improve European nutritional health and reduce health inequalities among the populations its members represent.
Our Mission
To support member Associations in developing the role that dietitians have in the improvement of nutritional health in Europe.
Our Vision
EFAD, National Dietetic Association members (NDAs), Education Associate Members and dietitians are the recognised leaders in the field of dietetics and nutrition.
To achieve our vision, EFAD:
• supports the highest quality of dietetic education, professional practice, research activity and partnership
• pro-actively initiates and grows collaborations in order to improve nutritional health, reduce socio-economic health inequalities and contribute to economic prosperity.
Registered Address:
The European Federation of the Associations of Dietitians (EFAD) De Molen 93 3995AW Houten The Netherlands
Kamer van Koophandel (Chamber of Commerce in NL) registration number: 40215656
European Commission Transparency Register Identification number: 99138006725-91
Email: [email protected]
Website: www.EFAD.org
NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19
ABOUT EFAD
13