Transcript `high risk patients` directly to the Community Dietitian

Dublin Mid-Leinster
First Line Management of
Malnutrition in the
Community
Education Session
Facilitated by
Community Dietitian –
Sharon Kennelly
Topics
1.
2.
3.
4.
5.
6.
Malnutrition-Introduction
Use of the MUST screening tool for adults and
Referral to community dietetics services
Giving dietary advice to patients with poor
appetite
The appropriate use of Oral Nutritional
Supplements (ONS)
Monitoring patients
Strategies for dealing with underlying causes ?
Background
Definition of Disease Related Malnutrition
 Incidence of Malnutrition in the Community
 High cost of treatment
– Malnourished consume more resources
ONS project - baseline data
 Need for a more evidence based approach

Cost Considerations ?
Between Aug 2003 and August 2004 € 314,000
was spent on Oral Nutritional Supplements in
this county.
 2 cartons/day for 1 year = € 1600 approx .

MEDICAL
Chronic Disease
States
Malignancy
G.I Disease
Medications
3+ per day
Affect appetite
Other
G.I Disturbances
Poor Detention
SOCIAL
PovertyInability to shop and /or cook
Inability to feed self
Living alone
CONTRIBUTING
FACTORS
TO
MALNUTRITION
IN THE
COMMUNITY
PSYCHOLOGICAL
Alcoholism
Bereavement
Depression
Dementia
Food aversions
Signs and Symptoms related to possible risk
of malnutrition-what to look out for ?

VISUAL
– Clothes or jewellery lose not fitting properly ,belt notch change
– Obvious thin/Wasted appearance

MOBILITY
– History of decreased activity, decreased ADL score

CHANGE IN EATING BEHAVIOUR
– History of decreased intake/poor appetite, portion sizes changed
– Altered taste/smell
– Change in food preferences avoiding food e.g. meat
– Poor appetite/disinterest in food reported
– GI DISTURBANCES-SMALL APPETITE :
– Nausea, early satiety, diarrhoea, constipation , dry mouth, lack of appetite
difficulty swallowing
Levels of risk of malnutrition?

High risk: More pre-disposed to longer term
chronic ill-health

Low risk:
ill-health
Less pre-disposed to chronic
Introduction to Malnutrition
Universal Screening Tool (MUST)

Tested and verified as a quick and easy to
use tool

Developed by a multidisciplinary group in
the UK including doctors, dietitians, nutritionists
and nurses for adults

Validated as an effective method of
identifying and managing malnutrition

Takes approx 3-5 minutes to complete for
initial assessments and as little as 1 minute for
reviews
How to use the MUST Nutritional
screening tool
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
The MUST tool can be used an for initial
assessment or as a monitoring tool
It is designed for use with adults only
5 steps to follow:
Aim is to add 3 scores to get a total risk score
and then follow management guidelines
It is important to record scores for future
reference and to have a planned review
Who is MUST not suitable for ?


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
Children and young adults (<18 years)
Athletes –people with high muscle mass
Patients with fluid retention/Oedema
Post-amputation
Pregnancy/Lactation
STEP 1-BMI score

Body Mass Index (BMI) is a weight for height measurement that
gives a rapid interpretation of chronic protein energy status.

Measure the person’s height in metres (m)
Measure the persons weight in kilograms (kg)
If calculating it’s the weight /(height)2
Use the BMI chart to determine
their BMI Score (kg/m²)

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
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Alternative measurements
 Ulna length can be used to determine height , see instructions
 You can also used patient reported height
 Mid Upper Arm Circumference can be used to determine BMI-see
instructions
Example :BMI SCORE
A man’s weight is 58 kg and his height is
1.78m
 What is his current BMI ?
 Using the BMI Score Guide his BMI .....
18.5 kg/m²
 What is his BMI Score ?.................
His score is 1

Step 2- Weight Loss Score

Weight loss refers to unintentional weight loss in
the last 3-6 months

Weight loss is an important clinical sign

Ask the patient or examine the medical records
for previous weight history

Previous weight –Current Weight = weight loss.

Then use tables to establish weight loss score.
Example: Weight Loss Score

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The same man has a previous weight of 62kg in
his chart from 4 months ago.
What is his Weight Loss Score -Using the %
unplanned weight loss table ?
62-58 kg = 4kg
5-10% weight loss
SCORE 1 for Weight Loss
Step 3: Acute Disease Score
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Generally not applicable to community dwelling
patients
Apply this score if the patient is affected by an acute
patho-physiological or psychological condition
Example :Acute pancreatitis
There should be very little or no food intake for
the last five days or there is likely to be no intake for
the next five days
The Score is always 2
Step 4 : Calculate The Overall Risk of
Malnutrition
Add the Scores From Step 1 ,2 and 3
= MUST TOTAL SCORE
0 =Low risk
1 = Moderate/Medium risk
2+ = High Risk
STEP 5 : Follow the Management
Plans
LOW RISK
MEDIUM RISK
HIGH RISK
Treat
Underlying Causes
Give basic dietary advice
Routine Clinical
Management
REVIEW
If no progress
commence ONS
Refer to Community
Dietitian
Management of ‘Low Risk’

Continue routine clinical treatment

As a guide these patients do not require
Oral Nutritional Supplement Prescriptions
unless they are part of ‘exception group’

NOTE:If you are concerned about a patient’s
nutritional status even with a MUST score of 0 contact Community Dietitian
Management of ‘Moderate Risk’
Identify underlying medical causes and
treat if possible
 Liase with appropriate community
voluntary services/public health nurse
 Give basic diet advice for small
appetite/weight loss using patient leaflet
 Make plans to review
 If no improvement consider prescription of
ONS -liase with Community dietitian

Management of ‘HIGH RISK’
These patients can be referred directly to the
Community Dietitian and will be generally be
assessed within 2-4 weeks
 A referral form which can also be used to
record the MUST results can be faxed or posted
to the Community dietitian
 Liase with the public health nurse if there are
social concerns regarding the patient

How will this system work in practice ?
Practice Nurses
G.P
Public Health
Nurses
Nurses in
Nursing
Homes
•Identify and screen patients using MUST tool
•Take steps to manage ‘moderate risk’ patients
•Refer ‘high risk patients’ directly to the Community Dietitian
Role of Community Dietitian:
Manage and arrange review of high risk patients
Gate keeper for ONS prescriptions
Support , advice & nutrition resources to the primary care practice
Patients who can be referred
directly to the Community dietitian
‘Exception Groups’
 Renal disease –chronic renal failure
 Active inflammatory bowel disease –Crohns,
Ulcerative Colitis
 Patients with chronic wounds or sores
 Pancreatic Disease
 Liver disease
 Head and Neck Cancers, GI Cancers
 Chronic Respiratory Diseases
Dietary Advice
for Patients with Poor Appetite
‘FOOD FIRST’
 Use the Patient Leaflet : ‘Eating when you
have a small appetite’ as a guide

– 3 small meals plus 3 snacks –Little and often
approach’
– Choose protein and energy dense foods at each
meal- meat, chicken, fish, dairy products, fats
,sugars
– Drink at least 1 pint of full fat milk/milky
drinks per day
Food Enrichment

Adding protein and energy dense
foods/products to their normal
meals
– Dairy Products: milk cream, yoghurt,
cheese, skimmed milk powder
– Fats: butter ,oil (frying), margarine
– Sugars: sugar, jam, honey

Example :Adding skimmed milk
powder to fresh milk, adding honey to
porridge, cream to soup etc.
Food enrichment example –
NORMAL DIET
Breakfast
Porridge with water
Slice brown bread and butter
Cup of tea with milk
Lunch
Two slices brown bread with butter
1 Slice of ham and 1 tomato
Cup of tea with milk
Dinner
2 small boiled potatoes
Breast Chicken
1 tablespoon boiled vegetables
Glass of milk
Food enrichment example –
ENRICHED DIET
Breakfast
Porridge with milk and 2 teaspoon sugar
Slice brown bread and butter and jam
Cup of tea with milk
Lunch
Two slices brown bread with butter
1 Slice of ham and 1 tomato & 30g cheese
Cup of tea with milk
Dinner
2 scoops mashed potatoes plus 2 pats butter
Breast Chicken
1 tablespoon boiled veg
Glass of fortified milk
1 custard style yoghurt
600
KCALS
EXTRA
!
Oral Nutritional Supplements
Sip Feeds: Milk
,juice, yoghurt or
savoury based drinks
 Disease Specific
formulation sip feeds
 Desert /Mouse
type products
 Modular ProductsLiquid and powder
varieties

2)Different Ways to use ONS
FOOD ENRICHMENT PRODUCTS
Powders and liquids
Protein, Fat and
Sugar
Come in Neutral Flavours
Neutral Flavoured
SIP Feeds
SUPPLEMENTARY DRINKS
(SIP FEED STYLE)
Milk ,yoghurt and juice flavours
Sweet and savoury flavours
Tetra packs ,Bottles,
Powders to add to milk
(See Recommended SIP Feeds
Chart in resource pack)
Oral Nutritional Supplements evidence of benefits ?

ONS can produce improved clinical and functional
outcomes as well as overall decreased mortality

E.g. Liver disease : Their use is associated with lower
incidence of severe infections, and lower frequency of
hospitalisation

Among patients in the community,
showed that their benefits are greatest in
patients with a BMI< 20kg/m² (High Risk
of malnutrition)
GUIDELINES FOR USING
ORAL NUTRITIONAL SUPPLEMENTS

SECTION 4 RESOURCE PACK
1) Identify a clear need for ONS
USE THE MUST NUTRITIONAL TOOL
2)Pick the right type of product
- Food enrichment Vs Sip feeds
3)Use Patient Leaflet advice how to use ONS
4)The type of ONS used can make a difference to
cost.
– Food fortification type ONS offer better value for money
– 1.5kcal/ml products offer better value for money
How long should ONS
be prescribed for ?

Compliance decreases the longer ONS are used

Long term use > 2 months may be associated
with decreased overall energy intake

ONS may begin replace some normal foods

If a patient has been using ONS for > 2 months
with no improvement in appetite/weight/MUST
score –refer to the community dietitian
How much to prescribe ?

As a general guideline a patient needs approx....
500-600kcals extra to promote weight gain.

2 cartons of an energy type sip feed (1.5kcals/ml)
per day as an initial prescription .

If using food enrichment ONS a similar amount of
energy (kcals ) would be prescribed

See info in the resource pack.
2 cartons per day
Avoid ‘Once off’ Prescriptions

May have a big impact on total spending at your
practice

NOT EVIDENCE BASED USE

Special cases :post op patients with poor
appetite and those with short term decreased
mobility

Resist the temptation to prescribe ONS as a
tonic
Dealing with potential problems
with ONS prescribing

Inappropriate patient use of ONS

Patient and family demands
Dealing with potential problems
with ONS prescribing
•Collection and Storage of ONS
•Powdered products and food enrichment ONS can be
less bulky easier to carry but require more preparation
•Packaging
•Sip style products come in tetra packs and some come in
plastic bottles –ease of use
• Taste fatigue
•Patients who require longer term use of ONS > 2 months
will may require changes to their prescription type,
flavours to improve compliance
Dealing with potential problems
with ONS prescribing

Inappropriate patient use of ONS

Patient and family demands
Monitoring

Why :Monitoring is key to evaluating the success
the success any nutritional intervention

Who is responsible for monitoring ? Depends on
the patient location and local roles

What should be monitored: MUST score,
compliance with dietary advice and ONS use, any
problems

When : how frequently should they be monitored ?
depends on the level of risk and location
Monitoring
Patient Location

Nursing home patients -staff nurses in liaison with the GP and dietitian
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Home bound patients- Public Health Nurses in liaison with the GP and
community dietitian

Patients who visit the surgery frequently can be reviewed by
appointment at GP surgery (ideal) or opportunistically when they attend the
surgery by the GP or Practice Nurses
Level of risk

High risk patients will be seen in primary care clinics for review, or
visited at home by the Community Dietitian

High risk patients will need to be reviewed at least every 2 months ,
moderate risk can be reviewed at two –four months.
Questions