Nutrition

Introduction

Poor appetite affects 15-20% of community dwelling older adults. Studies link poor appetite with frailty and sarcopenia; however, lack of longitudinal evidence exists to inform potential causality. We aimed to determine if poor appetite predicts frailty or sarcopenia-related factors in community dwelling older adults.

Methods

Secondary data analysis on adults aged >60 years recruited from, syncope, fragility fracture and comprehensive geriatric assessment clinics with 2.5 year follow up. Appetite was assessed by Simplified Nutritional Appetite Questionnaire (SNAQ); a score of <14/20 defining poor appetite. Hand grip strength (HGS) was measured using a dynamometer, low HGS was defined by European criteria (<27kg for males and <16kg for females). Frailty was measured using self-report of Fried phenotype.

Results

86 participants, mean age of 78 years, 62% female. Sixty-two (72%) were followed up, of those 9 had died.

Baseline mean SNAQ score was 15.2 (SD 8.1); 14 (16.3%) scored <14. Mean SNAQ score for the 53 participants at 2.5 year follow up was 14.9, 12 (22%) scored <14. Baseline and follow up SNAQ scores correlated moderately (Pearson’s r=0.5; P=<.001).

Fifteen (28%) individuals had low HGS at follow up, 12 had frailty (22%). Baseline SNAQ score <14 was associated with increased odds of frailty (OR 18.00; 95% CI 2.92-111.00) and low HGS (OR 7.76; 95% CI 1.62-37.30) after 2.5 years. The association of baseline SNAQ <14 with presence of frailty was robust to adjustment for age and comorbidities (OR 13.50; 95% CI 1.14-160.03), while association with low HGS was attenuated (OR 2.29; 95% CI 0.27-19.39).

Conclusion

Poor appetite is predictive of presence of frailty and low HGS after 2 years in community dwelling older adults. This suggests poor appetite as causative in the development of poor health outcomes in older people and so a key intervention target to optimise healthy ageing.

Introduction

The importance of nutritional support has been extensively investigated in studies of people with hip and fragility fractures. Hospital nutritional assessments vary in quality, and this limits the extent to which risk assessment can be viewed as a meaningful indicator of nutritional support. Provision of supplements is an alternative measure, but only if known to have been consumed. For this reason, we developed a protocol to capture actual consumption of prescribed supplements. Methods Following nutritional risk assessment, the prescription and distribution of supplements was recorded on patients’ drug charts in the usual way. Our protocol required that when supplement cups were cleared, nurses should annotate the drug chart with the volume of supplement each patient had actually consumed. Following this protocol’s introduction, we conducted a point prevalence survey of patients’ supplement consumption in orthogeriatric rehabilitation wards in May 2024.  Results Of 25 inpatients with hip fracture, 21 (84%) had been identified as being at nutritional risk and prescribed Fortisip compact protein. Patients were recorded to have consumed between 50 and 100% of the supplement. This quantification of actual consumption allowed us to calculate that, on average, these patients with hip fracture had consumed an average of 188ml/day — which would provide an additional daily 27.4g of protein and 460 kcal of energy. Figures for 15 patients with other forms of orthopaedic injury indicated that 8 (53%) were at risk. These patients recorded similar levels of supplement consumption. Conclusion The prevalence of nutritional risk and malnutrition among patients with hip fracture would suggest that all should be considered ‘at risk’. A performance indicator might be constructed which starts with this assumption and measures whether such patients have actually consumed nutritional supplements. Our simple approach captures actual consumption, whilst reminding us of the importance of nutrition.

Introduction

Malnutrition is common in patients with hip fractures. Early post-operative ONS (oral nutritional supplements) have been shown to reduce the length of stay in hospital and improve post-operative outcomes. The aim of this audit is to determine the number of people within the Royal Victoria Hospital Fracture Unit with NOF (neck of femur) fractures who are receiving ONS; it also determined the reasons for doses missed. Additionally, it covers if baseline refeeding bloods were done as per Trust Guidelines.

Method

A two cycle audit was completed on the use of ONS in patients with NOF fractures in the Royal Victoria Hospital Fracture Unit. Data from 29 patients in the first audit and 30 patients in the re-audit was analysed. The amount of people who had ONS prescribed, the amount of doses they received, and the reasons doses were missed were recorded. The data was collected, analysed, and the following interventions were put in place. Reviewing ONS compliance with each patient in the standard day 1 and day 4 post-operative reviews commenced. The medical team were informed that baseline refeeding bloods (bone profile and magnesium) should be done on admission.

Results

From the first cycle to the second cycle, the number of patients getting refeeding bloods within 3 days of admission increased from 20.1% to 56.7%. The proportion of patients who missed ≤ 25% of doses of ONS increased from 38% to 76%. The number of doses missed per patient due to refusal dropped from 1.1 to 0.6.

Conclusion

To conclude, ONS have been proven to help reduce post-operative complications and improve rehabilitation. Integration of ONS as a part of the post-op review process should be highly encouraged. This gives a standardised way for the department to ensure compliance with the guidelines.

Background: ‘IN REACH’ was established, having identified a significant need to improve nutrition for cognitively and physically frail hospital inpatients, admitted to the Complex Medical Units (CMU) at the John Radcliffe Hospital. The IN REACH team includes the CMU multi-disciplinary team (MDT), representatives from patient and volunteer groups, caterers and medical illustrators.

Introduction: IN REACH identified that food and drink is often unreachable by inpatients. The project’s aim is to ensure food and drink is always within patient reach, improving nutritional intake, avoiding dehydration, reducing weight loss, reducing family anxiety, promoting independence and improving health outcomes.

Method: MDT members, patients and their families were engaged in the design. Baseline observational data included whether both food and drink were in reach and whether the patient had cognitive impairment. Interventions to be evaluated by Plan-Do-Study-Act (PDSA) methodology include: raising awareness at daily MDT meetings; focussed education by presenting observational data to catering team; involvement of volunteers; the introduction of IN REACH champions; and prompting by signage, both physical and digital. Improved inpatient nutrition will be correlated with data on length of stay and health outcomes. Improved rates of return to baseline function and independence are anticipated, by keeping food and drink, in reach.

Results: Baseline data showed out of 319 inpatients, only 33% had both food and drink within reach. 67% had cognitive impairment and only 27% were able to reach food and drink. Following 4 initial PDSA cycles 58% of patients had food and drink within reach.

Conclusions: Most CMU patients have food and drink left out of reach. Patients with cognitive impairment are particularly at risk. Changing ward culture is challenging. Further and repeated interventions are necessary.

Introduction

Prevalence of malnutrition in care homes is high and oral nutritional supplements (ONS) often prescribed. Prescription and monitoring of ONS use varies considerably within residential settings. Locally dietetics are not funded to visit care homes and input is limited. This project explored dietetic ONS prescribing within care homes in one primary care network within Devon, recording the potential impact on costs.

Methods

All patients prescribed ONS (n=50) across 16 care homes were reviewed, alongside referrals to dietetics (n=39) from November 2022-March 2023. Supplements were switched to first-line formulary supplements where possible, stopped where unnecessary according to dietetic assessment, and a “food first” approach encouraged within homes. Cost of supplements prescribed pre-dietetic assessment, cost of new prescriptions, dietetic staff time and mileage costs were recorded. Supplement cost was calculated from the local formulary and staff cost from NHS oncosts.

Results

Patients seen represented 20% of all residents (89/436) within the 16 care homes, suggesting high suspected clinical need. Mean age was 90 years, ranging from 73-103 years. Female patients accounted for the majority (n=68). Addressing inappropriate prescribing saved £57.62 per day in prescriptions through stopping or changing ONS. Cost of dietetic staff time and milage totalled £3105.80 over the five-month period meaning that after 54 days the dietetic review service was saving money. Patients often preferred first line powder-based supplements, and these were either similar or more appropriate in nutrient content than initially prescribed ONS. For example, one patient affected by pressure ulcers was prescribed a fat emulsion supplement. It contained no protein or micronutrients to promote skin healing (cost £3.15) whilst first-line supplements provided macronutrient and micronutrient needs (cost 52p each and £1.04 total prescription).

Discussion

Dedicated dietetic input for care home residents appears to save costs on ONS prescribing whilst providing specialist nutritional expertise.

Background:

Nutrition is one of the cornerstones of healthy aging. As we age there are many changes in our bodies, including decreased appetite and poor dentition, that contribute to increasing malnutrition. The MUST (Malnutrition Universal Screening Tool) score is a quick and effective tool to assess this.

Aim:

In this project, we aimed to review MUST score and food chart completion on the frailty wards at EDGH to attempt to improve the nutrition of elderly patients.

Methods:

The charts of 75 patients were reviewed over a period of one month. Following this, a training program for all the nursing staff was put in place. The initial results were discussed and the importance of nutrition in the elderly was highlighted. The staff were shown how to fill in the MUST score and follow management guidelines. Also, a reminder was set up on Nervecentre (electronic patient record) for all staff.

Results:

Of the initial 75 patients;

1 – a MUST score was completed for only 64% on admission.

2 – 41.3% of patients were eating 50% or less of their meals.

3 – In only 27% the reasons why they were not eating were documented.

In the second cycle, 80 patients were included and the results were markedly improved.

1 – The percentage of MUST score completion on admission increased to 91.3%.

2 – Management guidelines were followed in 92.5% of the cases.

3 – 18.8% with a MUST score of two or more, were referred to dietitians at an early stage.

Conclusion:

- Our quality improvement project significantly increased MUST score completion and prompted action at an early stage. 

- The next step is to improve the documentation of patient’s food charts and encourage staff to look for and document the reasons why patients are not eating.

Background:

Good nutrition and hydration are essential to patient’s health and wellbeing. Reduced nutrition leads to increased hospital admissions, re-admissions, longer length of recovery, poor wound healing and sarcopenia. Introduction: In hospital inpatients, especially when frail or vulnerable, the ward’s duty is to ensure that appropriate pathways exist to support their nutritional status and identify those who need additional support, additionally making sure patients have access to food and drink. Our ward wasn’t compliant with hospital standards. Additionally, patients experienced social isolation at mealtimes which negatively impacted on patient mood and calories consumed.

Methods:

Over 4 weeks, utilizing existing ward staff, we implemented a lunch club. This involved facilitating a communal lunch on the ward. Our main outcome measures were calorie and protein consumption. 40 data sets were obtained from what was recorded on the patient’s food chart and cross referencing it with the dietary information provided by the health board catering department. We also gathered data on WAASP score compliance comparing wards who had regular lunch clubs to those who did not.

Results

Attending lunch club resulted in a 68% increase in calorie consumption. In addition to this protein intake was increased by 73%. Wards where there was a DSW 97% of patients were screened for malnutrition, compared to only 61% on the wards without a DSW. Furthermore, on the wards without a DSW only 30% of patients were weighed once a week compared to 100% of those on a ward with a DSW. Not only did we see an objective increase in the calories consumed, patient enjoyment of mealtimes was increased as well as their time socializing during their in-patient stay

Conclusion

Lunch club increased calorie consumption, but it’s not sustainable without appropriate staffing. Comparing wards with and without DSW, there are clear discrepancies managing malnutrition.

Introduction: Oral nutritional supplement (ONS) prescription is commonly recommend for malnourished patients in hospital. However, compliance to ONS is often low. Ice cream may be a promising nutritional intervention. We undertook a study designed to compare the acceptability of high protein, fortified, ice cream called Nottingham-Ice Cream (N-ICE CREAM) with routinely prescribed milkshake ONS.

Methods: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited from Queens Medical Centre, Nottingham. Patients were randomised into two groups, receiving two days of N-ICE CREAM and milkshake ONS. Group A received N-ICE CREAM first and Group B, milkshake ONS first. We measured compliance, acceptability (hedonic characteristics; rating 0 dislike a lot to 7 like a lot), attitudes towards length of prescription (rating 0 very unconfident to 4 very confident) and preference.

Results: Mean (standard deviation, SD) age of patients was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both Groups (Group A (n = 22) 69.9 (30.0) % and Group B (n = 26) 56.3 (39.3)%) compared to the milkshake ONS (Group A (n = 22) 43.4 (4.7) % and Group B (n = 26) 53.6 ± (40.2) %). This was statistically significant in Group A (p < 0.05). Mean hedonic ratings were higher for N-ICE CREAM with an overall impression score of 5.8 compared with 4.6 for milkshake ONS. Confidence score for both products decreased with increasing time length. Both had an overall confidence score of 2.9.

Conclusions: High protein N-ICE CREAM is more accepted and preferred by older patients with a hip or spine fracture compared to standard milkshake ONS. Further research should explore optimal timing for N-ICE CREAM administration and long-term compliance, as well as clinical outcomes.

Introduction: Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.

Methods: Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.

Results: Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).

Conclusions: Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.

Background: Weight loss in the older adult is often multifactorial and can be associated with increased morbidity and mortality. Our quality improvement project focused on nutritional care of patients 75 years or older. This hospital has a standardised Nutrition and Hydration Policy based on NICE guidelines to prevent malnutrition in hospital inpatients including weighing patients every 72 hours, daily screening and food/hydration charts. Our project aimed to increase adherence, with a focus on increasing the percentage of patients being regularly weighed over a 6-month period to 90%.

Methods: Our stakeholder analysis highlighted the multidisciplinary nature of our project, particularly involving the healthcare assistants. The percentage of patients weighed within 72 hours was recorded weekly. The first PDSA cycle introduced the project and gained buy-in from the MDT, highlighting required weights in MDT meetings/board rounds. The second cycle included an education session for doctors. The third cycle involved a poster in each bay aiming to act as a prompt and promote patient and family involvement.

Results: Our run chart shows that following our first two PDSA cycles eight consecutive results were higher than the baseline (40% of patients weighed). Results ranged from 70-90%. Following the third intervention compliance returned to baseline but coincided with significant disruption to the ward structure and team. Our successful intervention of nutritional teaching was then repeated as a fourth PDSA cycle and the mean returned to 80%.

Conclusions: Nutritional care requires multidisciplinary involvement. The educational session had the most impact and in future could be delivered to additional MDT members. Disappointingly the poster did not stimulate patient or family participation. We would like to create an ethos on elderly wards where nutrition routinely features in ward-based comprehensive geriatric assessments. Future plans hope to further engage patients and families as visiting restrictions eased.