14 Mar, 16 | by BMJ
Doctors have faced up to the challenge of treating obesity. Is it now time to address that other major weight disorder—malnutrition? Less common in the general population than obesity, malnutrition is an ever-present health risk for older people—with one in ten over 65s either already suffering or at risk of becoming under-nourished, according to a new report by BAPEN (the British Association of Parenteral and Enteral Nutrition).
Malnutrition affects around one million older people in the UK—typically the result of a loss of appetite alongside an increase in mobility problems, mental or physical disability, and isolation. Essentially a process of slow starvation, malnutrition leads to low energy and mood, increased susceptibility to infections, loss of muscle mass increasing the risk of falls, and reduced mobility as well as loss of subcutaneous fat leading to pressure sores and delayed wound healing, thereby significantly extending hospital stays. It’s also linked to mild cognitive impairment. As such malnutrition, “accounts for 30 per cent of hospital admissions, 35 per cent of care home admissions, 15 per cent of outpatient clinic attendances, and 10 per cent of those presenting at their GP”, BAPEN reports. The costs are huge: £19 billion in health and social care every year.
Yet it remains “under-detected and under-treated,” according to the report’s author, Professor Marinos Elia of the Malnutrition Action Group of BAPEN and Professor of Clinical Nutrition & Metabolism at the National Institute for Health Research Southampton Biomedical Research Centre. “We spend extremely large amounts on this problem, which could be readily helped by doing simple things well,” he said at the launch of the report in London in December 2015.
A key step forward is greater awareness and increased diagnosis of the problem--with professionals, and more recently the general public, able to access a screening tool called MUST (Malnutrition Universal Screening Tool). The Malnutrition Task Force’s pilot scheme at Salford Royal NHS Foundation has also developed a Paperweight Armband, claimed to be “a non-intrusive, non-medical intervention solution that health care providers and the voluntary sector would be able to implement quickly and easily into their practice.” But what then? Research by the Malnutrition Task Force in February 2016  showed that only 51 per cent of health professionals thought malnutrition was a priority in their organisations and 47 per cent “felt confident that their knowledge and skills were sufficient to help people most at risk.”
Yet clinicians shouldn’t assume that tackling malnutrition in older people is beyond their scope. For a start, screening for under-nutrition on admission to hospital should be universal, according to Andy Jones, immediate past chair of the Hospital Caterers Association and a co-organiser of Nutrition and Hydration Week. And once identified, the disorder should be documented in discharge summaries and referral letters. It’s not good enough, Elia points out that when spotted in hospital, for instance, ‘patients are not then given a care plan that will carry over from hospital to GP surgery.’
Once identified, “food and drink must become an integral part of the recovery plan,” argues Andy Jones. He says hospitals should have a “mealtimes matters” policy, with no wards rounds to be done when patients are eating—and “doctors encouraged to be on the wards and get involved if they can in assisting people to eat.” This focus on mealtimes is an essential part of the evidence-based “Namaste” programme  for people with dementia, developed by St Christopher’s Hospice and the South London and Maudsley Foundation Hospital and already implemented in care homes in South London.
As to the best source of nutrients for frail older people, prescription fortified shakes and other foods have a part to play particularly in providing protein. But, says Andy Jones, doctors could also encourage consumption of real food. “Currently it’s too easy for a doctor to prescribe a fortified shake when a scone with cream would be eaten and probably better received,” he says. What is also working in a number of trusts, he says, are “24/48 discharge packs” handed to patients who are deemed at risk and “which contain essentials like ½ pt milk, small loaf. Coffee/tea, soup, dinners, cheese, jam all of which gives the person food to eat when they get home and allows social care processes to ‘kick in’ again.” And once GPs are able and willing to identify frail older people at risk of, or already suffering from malnutrition, they can then be helped by voluntary schemes led by dietitians—such as Age UK’s Staffordshire Make Every Mouthful Matter Care Pathway, developed and introduced by the Stoke on Trent and Staffordshire Partnership.
Such schemes don’t rely on doctors feeding malnourished patients. But it makes a huge difference when doctors identify frail older people at risk of malnutrition and make systems work to support those who can help them. “The key for doctors is to recognise that malnutrition co-exists with obesity—and it’s just as important to treat it,” says Dr Simon Gabe, chair of BAPEN. “That will make a huge difference.”
Jane Feinmann is a freelance medical journalist with a particular interest in patient safety based in London. She belongs to Imperial College Health Partners’ Patient Safety Champion Network.
Competing interests: The author has no competing interests to declare.
 Online survey of health and care professionals conducted by Dods Research, sample size 1518, fieldwork conducted between 9th and 18th December 2015
 Stacpoole M, Hockley J, Thompsell A, Simard J, Volicer L. (2014) The Namaste Care programme can reduce behavioural symptoms in care home residents with advanced dementia. Int J Geriatr Psychiatry.
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