BAPEN has just published its Nutrition Screening Week (NSW) Care Home Reports which cover the UK as a whole and England. The Reports contain the amalgamated data obtained from the care homes that participated in its four Nutrition Screening Weeks which took place over a five year period between 2007 and 2011, each in a different season of the year. The results suggest that ‘malnutrition’ (medium + high risk according to ‘MUST’) is common within care homes, and, with a prevalence of about 35% among residents admitted in the previous 6 months, it poses a substantial social care burden.
The four NSW surveys involved a total of 474 care homes in the UK (75-148 per survey) and 3971 adult residents (577-1610 per survey). The majority of data were provided from care homes in England and to a progressively smaller extent from those in Scotland, Wales and Northern Ireland.
Apart from providing a comprehensive analysis of the amalgamated data obtained from care homes the two new reports provide a variety of new information. This includes establishment of trends over time, comparisons between England and the rest of the UK, and an analysis of the extraordinarily large and variable weight changes that occur in care homes during the six months after admission. Residents who were malnourished on admission to care were more likely to lose further weight during their residency, while ‘non-malnourished’ subjects gained weight. Most residents who were underweight on admission remained underweight at the time of the survey.
The reports also compare weight status and its distribution between care home residents and the general public. Underweight (BMI < 20 kg/m2) was significantly more common among care home residents than the general population and obesity less common. Underweight among care home residents increased with age, while obesity decreased with age.
Importantly the reports highlight that during the five year period there was some evidence of improvements throughout the UK in terms of awareness of ‘malnutrition’, in nutritional screening practice and the vast majority of care homes reported linking the results of screening to a care plan. In addition trend analysis of consecutive surveys indicated that the majority of care homes routinely weighed residents on admission and during their stay and that there were significant improvements in the recording of height on admission, and access to dietetic services.
However, there was room for improvement in some aspects of nutritional care, such as awareness of the existence of weighing scale standards and undertaking audits on nutritional screening. Encouragingly the ‘Malnutrition Universal Screening Tool’ (‘MUST’) was the most commonly used screening tool being used by 90% of care homes that reported using a nutrition screening tool – in 2010 86% had reported using it. . The use of the consistent ‘MUST’ criteria within and between care homes and in multiple other care settings can facilitate continuity of nutritional care.
The prevalence of ‘malnutrition’ did not differ significantly between countries (England, Scotland, Wales and Northern Ireland), but it was lower (27%) in residents who had been admitted into exclusively residential care homes than all other types of care homes (38%), and it was also lower in those admitted from their own homes (30%) than from hospitals (39%) and other care homes (37%). In contrast it was found to be higher in women (38%) compared to men (30%), who were about four years younger than women, and in older than younger residents (27% in those <75 years, 39% in those 70-84 years, and 39% in those ≥85 years). It varied with disease category, and was higher in residents with cancer than those without and in those suffering from multiple rather than a single condition.
There were no significant differences in the prevalence of ‘malnutrition’ between countries, and no significant difference between England and other parts of the UK.
Malnutrition According to type of Care Home
‘Malnutrition’ was found to be significantly less common in exclusively residential homes (27%) than other types of care homes in combination (38%). This may be because residents in the other types of care homes, especially nursing homes, are expected to have more severe disease. The source of admission was another major factor that influenced the prevalence of ‘malnutrition’. It was higher among those admitted from hospital (39%) and other care homes (37%) than in those admitted from the subjects’ own homes (30%). Again this may reflect the type and severity of disease likely to predispose to or be the result of ‘malnutrition’ and vice versa.
The reports indicate that ‘malnutrition’ in care homes is a major health and social care burden. While care homes are generally funded to provide social care, the boundaries between social and healthcare are ill defined and sometimes problematic, suggesting that more integrated health and social care strategies to combat the problems would be beneficial. The care home surveys suggest that there have been some improvements in the operational infrastructure for the management of ‘malnutrition’, but there is still room for further improvement, in line with the conclusions of the Dignity and Nutrition Inspections of care homes undertaken by the Care Quality Commission.
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*. ‘Malnutrition’ – refers to those at medium + high risk according to 'MUST'
Notes for Editors
The four surveys and audits on nutritional screening were undertaken by BAPEN during 2007 - 2011 in collaboration with the British Dietetic Association and the Royal College of Nursing and with support from the Welsh Government, the Scottish Government, the Chief Nursing Officers for England and Northern Ireland and the Patient Safety, Domain 5, NHS England (who have taken on responsibilities of the former National Patient Safety Agency).
The current 2 reports are based on the amalgamated data from the four surveys. A copy of these Reports can be downloaded here
‘Malnutrition’, in terms of undernourishment, is both a cause and consequence of disease in adults and children. It is common and affects over 3 million people in the UK1 with associated health and social care costs around £20 billion annually for England alone.2 It is often unrecognised and therefore untreated, yet it has a substantial impact on health and disease in all community care settings and hospitals.1,3
The benefits of improving nutritional care and providing adequate and appropriate hydration are immense, especially for those with long term conditions and problems such as stroke, pressure ulcers or falls. The evidence shows clearly that if nutritional needs are ignored health outcomes are worse and meta-analyses of trials suggest that provision oforal nutritional supplements (sip feeds) to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40%.3
Better nutrition and hydration care for individuals at risk can result in substantial cost savings Recent guidance from the NICE (NICE CG32 and NICE Quality Standard QS24) identifies better nutritional care as a large potential source of cost savings to the NHS,4 and CCGs should use the NICE data to calculate potential cost savings for their local Trusts.
1. Elia M, Russell CA (eds). Combating malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN. Redditch: BAPEN, 2009.
2. Elia M. The cost of malnutrition in England and the potential cost savings from nutritional interventions A report from the Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre; 2015
3. Stratton RJ, Green C and Elia M. Disease related malnutrition; an evidence-based approach to treatment. Oxford:CABI, 2003.
4. NICE. Cost saving guidance. 2012. (Accessed November 18, 2012, at http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp.)
BAPEN is a charitable association that raises awareness of malnutrition and works to advance the nutritional care of patients and those at risk from malnutrition in the wider community. www.bapen.org.uk
The association is made up of influential professional and patient organisations, which work in collaboration to improve and deliver safe and effective nutritional care throughout the UK:
BAPEN Medical is primarily aimed at doctors but is open to all those with an interest in clinical nutrition. Its aims are: Education and training of clinicians at all levels; to encourage research and development and to foster collaborations between members’ research groups; to foster inter-disciplinary links and collaboration between medical specialties; to foster multi-professional links and collaboration between health professionals. www.bapen.org.uk
BAPEN regional reps are a multidisciplinary team of professionals working in the field of nutrition. Providing a local resource for education, training and support in England, Scotland, Wales and Northern Ireland, they can be contacted via the BAPEN website.
The British Pharmaceutical Nutrition Group ((BPNG) is a specialist group for primarily pharmacists and scientists, but open to all with an interest in clinical nutrition. The group was founded in 1988 following growing concerns about the stability of parenteral nutrition feeds. BPNG has published position statements on ‘multichamber bags’, in-line filtration of PN and calcium phosphate stability. Education is now a focus for the group which runs multidisciplinary ‘fundamental parenteral nutrition’ and ‘advanced’ nutrition courses. Publications include the ‘Handbook for drug administration via enteral feeding tubes’ and a competency framework for pharmacists working within clinical nutrition. www.bpng.co.uk
The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) provides professional leadership and promotes standards of care for children with nutritional, gastrointestinal and hepatological disorders. Its membership includes consultants and specialist rainees in paediatric gastroenterology, hepatology and nutrition as well as specialist dietitians, nurses and nutrition pharmacists. The society supports research, training and education for members and the development of standards of care for children with nutritional disorders; it also gives advice and support to implement child-centred strategies to deliver nutrition assessment and nutrition support through the Nutrition & Intestinal Failure Working Group. www.bspghan.org.uk
The National Nurses Nutrition Group (NNNG) The NNNG was established in 1986. It is a registered charity which aims to promote education and the nursing role in nutrition and related subjects for the nursing profession for the benefit of patients in hospital and community environments. Over recent years the focus of the group has widened to reflect the increasing profile of nutrition: from screening strategies and mealtimes to the complex nature of artificial feeding. www.nnng.org.uk
The Parenteral and Enteral Nutrition Group (PENG) is a specialist group of the British Dietetic Association. The PENG strives to train, educate, support and represent dietitians working in oral, enteral and parenteral nutrition support in all care settings. The group acts as the professional voice on matters pertaining to nutritional support and is a founder group of BAPEN. Members are registered dietitians who aim to ensure that nutritional support for patients is safe and clinically effective both in hospital and at home. www.peng.org.uk
PINNT is the UK support group for patients on home enteral or parenteral nutrition. Established 25 years ago, PINNT has grown into a community that provides genuine understanding to help individuals and carers, deal with the many challenges faced on artificial feeding at home. They also work closely with healthcare professionals, suppliers and manufacturers in order to enhance the patient journey. The PINNT network provides a unique and united voice to campaign for a better, flexible and safer service. www.pinnt.com