Hospital Nutritional Care and

Protected Mealtimes

Dr Mary Hickson

Therapy Research Lead, Imperial College

Healthcare NHS Trust

&

Honorary Senior Lecturer, Imperial College

London

Hospital population • 63% of 65-74 year olds and 72% of people

aged over 75 years report a long-standing

illness

• Almost two thirds of general and acute

hospital beds are used by people aged over

65 years

• People over 75 years have on average

significantly longer hospital stays

2002 data

Who are Elderly?

UK National Statistics, 2009

Prevalence of malnutrition

• 3 million at risk of malnutrition in the UK

• 93% live in the community

Malaysia:

• Children

• Elderly – rural and care home populations

• Increasing problems with obesity in adults

Prevalence of malnutrition

Increased risk in hospital

Malnourished people have:

Costs: £13 billion / year (UK)

Also:

Mortality

OR:

1.6-1.9

Functional

Decline

OR:2.2-2.8

Pressure

Ulcers

OR: 1.9-2.6

Infections

OR: 1.5

Change in malnutrition risk

0

5

10

15

20

25

30

35

40

45

50

Not at risk Moderate Risk High Risk

%week 1

week 2-3

Nematy et al. JHND

2006; 19(3): p209-18.

BMI on admission

• Mean age 85.3yrs (sd=1.5)

• Significantly lower mean BMI than UK elderly

population

• 22kg/m2 v 27kg/m2

• 36% had BMI <20kg/m2

• 72% had a BMI <24kg/m2

Energy deficit

9 month follow up

• Mortality

• 9 deaths

• 7 from high risk of malnutrition group

• 1 moderate risk

• 1 not at risk

Poor food intake

3083 3230

5040

6115

0

1000

2000

3000

4000

5000

6000

7000

B D E Normal

Diet Category

En

erg

y i

nta

ke (

KJ)

Wright et al, (2005) J Hum Nutr Diet 18(3) 213–219

General Hospital Patients

• Daily meals provided 2007+/-479 kcal and 78+/-21 g of protein and exceeded patients' minimum needs by 41% and 15%, respectively.

• 975/1416 (69%) patients did not eat enough.

• The food intake of 572/975 (59%) underfed patients was not predominantly affected by disease but other factors.

Dupertuis et al 2003

Factors associated with

inadequate energy intake (multivariate analysis)

• poor appetite

• higher BMI

• diagnosis of infection or cancer,

• delirium

• need for assistance with feeding. Mudge AM et al. Helping understand nutritional gaps in the elderly (HUNGER):

A prospective study of patient factors associated with inadequate nutritional

intake in older medical inpatients. Clin Nutr. 2011 Jan 22; 30(3):320-5.

Hospital Malnutrition cycle

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What is the best way to screen?

71 tools in the literature (Green & Watson

2005)

• Only some are validated

• Only any good if used routinely

• Only any good if the results are followed

through

Recommended tools

• ESPEN

–NRS 2002 (hospital use)

–MUST (community)

–MNA (elderly – NH / RC etc)

• BAPEN

–MUST (all areas)

Nutritional Risk Screening (NRS 2002) Table 1: Initial screening Ye

s

No

1 Is BMI <20?

2 Has the patient lost weight within the last 3 months?

3 Has the patient had a reduced dietary intake in the last week?

4 Is the patient severely ill ? (e.g. in intensive therapy)

Yes: If the answer is 'Yes' to any question, the screening in Table 2 is

performed.

No: If the answer is 'No' to all questions, the patient is re-screening at

weekly intervals. If the patient e.g. is scheduled for a major operation, a

preventive nutritional care plan is considered to avoid the associated

risk status.

Table 2: Final screening Impaired nutritional status Severity of disease ( increase in requirements)

Absent

Score 0

Normal nutritional status Absent

Score 0

Normal nutritional requirements

Mild

Score 1

Wt loss >5% in 3 mths

or

Food intake below 50-75% of normal

requirement in preceding week.

Mild

Score 1

Hip fracture*

Chronic patients, in particular with acute

complications: cirrhosis*, COPD*.

Chronic hemodialysis, diabetes, oncology.

Moderate

Score 2

Wt loss >5% in 2 mths

or

BMI 18.5 - 20.5 + impaired general

condition

or

Food intake 25-50% of normal

requirement in preceding week

Moderate

Score 2

Major abdominal surgery*

Stroke*

Severe pneumonia, hematologic

malignancy.

Severe

Score 3

Wt loss >5% in 1 mth (>15% in 3

mths)

or

BMI <18.5 + impaired general

condition

or

Food intake 0-25% of normal

requirement in preceding week in

preceding week.

Severe

Score 3

Head injury*

Bone marrow transplantation*

Intensive care patients (APACHE>10).

Score: + Score: = Total score:

Age: if 70 years: add 1 to total score above = age-adjusted total score:

Score 3: the patient is nutritionally at-risk and a nutritional care plan is initiated

Score < 3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a

preventive nutritional care plan is considered to avoid the associated risk status.

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Taste and

Smell

Teeth and

oral health

Medical

conditions

Social

Factors

Psychological

factors

Appetite and

thirst

What prevents good intake?

Taste and smell First taste of puree:

Young 80%

Old 33%

Young 63%

Old 7%

Schiffman SS (1997) JAMA 278,

(16) 1357-1362.

Roberts et al (1994) jama 272(20) 1601-1606

Underfeeding Ad libitum

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

underfeedinghunger score

underfeedingsatiety score

ad lib HS Ad lib SS

young

old

Moriguti et al. (2000) J Gastroent Biol Sci, 55A, 12, B580-587

Re-nutrition Research suggests it is more difficult to treat

malnutrition in the elderly than in the young.

Hebuterne X, et al (1997) Clinical Nutrition 16, 283-289.

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Nutritional supplements

• Reduced mortality: RR = 0.79 (95% CI: 0.64-

0.97) (undernourished only)

• Weight gain: 2.2% (95% CI: 1.8%-2.5%)

• Risk of complications reduced: RR=0.86

(95% CI 0.75-0.99)

• But no difference in LoS: -0.8days

(95% CI: -2.8d - 1.3d)

• No functional benefits Milne AC, 2009, Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003288.

• Groups most likely to benefit from supplements are:

– Over 75yrs

– Unwell

– Hospitalised

– Given an addition 400kcal+ / day

• Compliance seems to be good in many studies but

this may be ‘trial effect’

• Worse in older adults in hospital

Milne AC, 2009, Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003288.

Supplement use

• UK NICE Guidance

• Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition. [A]

Timing of supplements

• Give between meals

• >1 hour before the next

meal.

• Supplements with

meals adversely affects

intake

Wilson M-M.G. et al. (2002) Effect of liquid dietary supplements

on energy intake in the elderly. Am J Clin Nutr. 75 p944-7.

High energy and protein meals

• Improve energy and protein intake

• Some evidence for weight gain

• No evidence for functional gains

• BUT

• Weak study designs

• Many fewer studies

Hospital related factors

• Systems fail

• Inflexible food service

• Lack of food choices

• Quality and presentation of food

• Eating environment

• Lack of clear responsibility for food

• Low priority placed on food and eating in

hospital

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0

10

20

30

40

50

60

70

80

South Eastern Southern Western Nordic CCEE total

proportion of units screening Schindler et al. How

nutritional risk is

assessed and

managed in

European

hospitals: A

survey of 21,007

patients findings

from the 2007–

2008 cross-

sectional

nutritionDay

survey

Volume 29, Issue 5,

October 2010,

Pages 552–559

What are screening rates in

your hospital or wards?

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How are patients at risk of

malnutrition cared for in your

hospital or wards?

Nutritional care

• Nutritional care processes not well

implemented

• Limited studies with objective data

• Inappropriate nutritional intervention

• Inadequate mealtime assistance

• Hospital mealtime environment

• Inadequate monitoring

Nutrition care processes

O’Flynn 2005 Clin Nutr

Nutrition Assistants • Duncan et al, (2006) Age Ageing, 35, 148-153

• Dietetic assistants in orthopaedic ward increased energy intake and decreased mortality.

• Hickson et al (2004) Clin Nutr, 23, 69-77.

• Healthcare assistants showed no benefit – but this was not targeted care.

• Lassen et al (2008) BMC Hlth Serv Res. 8, 168

• Trained healthcare assistants – showed reduced food wastage

Volunteers

• Wright et al (2008) J Hum Nutr Diet, 12, 555-562

• Volunteers to help dysphagic patients increased energy intake.

• Robinson et al (2002) Geriatr Nurs. 23, 332-5.

• Trained volunteers, Higher meal intake as % of food served

• Walton et al (2008) Appetite 51, 244-8

• Increased energy and protein at lunch but only daily protein increased

• Wong et al (2008) J Nutr, Hlth Aging 12, 309-12

• Volunteers to help semi-dependent patients, intake improved at lunch and weight increased

Assistance

• Mixed results

• Positive effects

• Well accepted

• But could reduce care provided by routine

staff

• Needs to be in context of improved

nutrition care environment and assignment

of responsibility

Mealtime environment

• Improve the environment

• Reduce interruptions

• Focus on eating

• Protected mealtimes

• Family style dining

• Ward dining room

Does protected mealtimes work? • Limited data

• Lack of evidence of implementation

• 1 study showed increased energy intake and

reduced interruptions

• Latest study: Modest increases in the

proportion of elderly patients meeting their

daily energy and protein requirements.

Similar in both PM and assistants groups.

Young AM et al. Clin Nutr. 2012. [Epub ahead of print]

Dining room to increase intake

L. Wright, M. Hickson & G. Frost (2006) Eating together is important: using a dining

room in an acute elderly medical ward increases energy intake. J Hum Nutr Dietet,

19, pp. 23–26

Take home messages

• Hospital is a challenging environment to

support nutritional intake

• Screening is important but useless without

implementation of care plans

• Supplements work

• Assistance, improved environment, &

dinning rooms have a small effect