The focus of this assessment is quality of life and specifically this paper considers how malnutrition affects quality of life of community settings' patients. According to the Scottish Governments publication "Older people living in community - Nutrition needs, barrier and interventions: a literature review", malnutrition is an umbrella term for undernutrition, overnutrition and imbalance diet intake (The Scottish Government, 2009). Malnutrition has previously been described in the various ways (The Scottish Government, 2009). However, for purpose of this assessment the following term will be used as defined by World Health Organisation (WHO) "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions" (see European Nutrition for Health Alliance, 2005).
According to Saunders, Smith and Stroud (2010) 2 per cent of the UK population is underweight: Body Mass Index (BMI) is lower than 18.5 kg/m. However, they agreed that patients could be still at risk of malnutrition whatever their BMI is (Saunders, Smith and Stroud, 2010).
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Malnutrition, as well as other factors, has negative effect on the person's quality of life (The Scottish Government, 2009). In the UK, hospitals admission rate and mortality were greatest in patients with BMI below 20 (kg/m2) (Teo and Wynne, 2001). During nutrition screening survey in the UK various settings it was found that malnutrition doubles risk of mortality in the hospital patients and triples morality in elderly patients in hospitals following discharged (RCN and NPSA, 2009). Care Homes' nutrition survey shown that 30 per cent of service users recently admitted to care homes were at risk of malnutrition (RCN and NPSA, 2009).
According to Hickson (2006), malnutrition may be secondary to certain health conditions which is increasing risks for patients to become malnourished and those risk factors will be discuss later in this assessment (Hickson, 2006 and Teo and Wynne, 2001). However, European Nutrition for Health Alliance (2005) argued that malnutrition should be classified as independent disease (European Nutrition for Health Alliance, 2005), its due to undernutrition has a negative effect on all organs systems such as muscle-skeleton, cardiovascular, respiratory, gastrointestinal, endocrine systems and in addition, malnutrition has a psychosocial effect (Saunders, Smith and Stroud, 2010).
It was found that undernutrition could cause following health conditions: in the healthy individuals and has advance exacerbation effects upon existent illnesses or injuries, reduced psychological wellbeing (increase anxiety, depression apathy, and loss of concentration and self-neglect) (Webb and Copeman, 1996 and Saunders, Smith and Stroud, 2010). According to Morley and Kraenzle (1995), balanced diet in general, is improving cognitive and memory performance in elderly (see Vetta et al, 1999).
Chandra (1993) found that undernutrition is depressing organism immune function (see Webb and Copeman, 1996). It could be due to impaired cell-mediated immunity and cytokine, complement and phagocyte function this most commonly could lead to developing bacterial and parasitic infections and poor wounds healing (Saunders, Smith and Stroud, 2010).
Malnourished patients have reduced muscle function, loss of cardiac muscle and reduce cardiac output, which results in impact on the renal function (Saunders, Smith and Stroud, 2010). The same individuals have reduced respiratory response to oxygen deficit by poor diaphragmatic and respiratory muscle function (Saunders, Smith and Stroud, 2010), increased risk of hypothermia, increase risk of falls and injuries (Webb and Copeman, 1996). In addition, redaction of fat and muscles mass are more obvious signs of malnutrition (Saunders, Smith and Stroud, 2010). According to Clayton (1991), malnourished elderly clients have a poor prognosis for recovery from following fractured femur, hypothermia, pressure ulceration and other conditions (Clayton, 1991). Fracture risk is high then calcium, magnesium and vitamin D intake is insufficient, during the weight loss bone mass is reducing as well (Saunders, Smith and Stroud, 2010).
Early stage of malnutrition leads to loss of digestive enzymes that result in intolerance of lactose. The colon loses its ability to absorb liquid, electrolytes, and secretions of small and large bowels, which results in diarrhoea (Saunders, Smith and Stroud, 2010).
According to Saunders, Smith and Stroud (2010), endocrine system is affected in malnourished patience. For example, chronic malnutrition will change the pancreatic exocrine function by reducing the insulin secretion (Saunders, Smith and Stroud, 2010).
An author is currently working a nursing and residential care home for elderly patients as well as nursing and social recruitment agency, which is covering biggest part of the North West of England. Being allocated in hospitals and nursing homes the author noticed that patience's nutrition needs are being met well but where are still some areas for improvement. During the study carried out in the large the UK hospitals, it was found that 40 per cent patients admitted to hospitals were malnourished and two-thirds subsequently lost weight during their hospital stay (Teo and Wynne, 2001).
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During the service users' meeting in the care home author working in, carried out in January this year, all 14 service users have stated that they are satisfied with food they are getting. However, two patients are still at risk of malnutrition. They have been referred to the GP for dietician support. The author strongly believes that nursing home is providing adequate food to the service users. Catering manager in the UK hospitals compare to chefs in nursing home have a small budge of £11 to £15 per patients a week (Teo and Wynne, 2001). The author's care home spends around £30 per service user a week. However, in March 2007, Royal College of Nursing (RCN) carried out survey questioning nearly 2200 of their member relating nutrition issues. Survey has revealed that 42 per cent said the food provided for patients were below overage expectancy (RCN, 2011).
In various reasons government and health profession organisations are now advising for routing screening of all patients admitted to any healthcare facilities (RCN and NPSA, 2009). In author's opinion, the main priority for addressing this issue is promoting patience's health and wellbeing and cutting financial cost. For example, annual financial cost of treatment malnutrition patience and any associated illnesses in the UK was estimated around 7.3 billion pounds. This figure includes treatment malnourished patience in the hospital setting, round 3.8 billion pounds and long-term care facility such as care home, round 2.6 billion (Elia M., et al., 2005).
Causes of Malnutrition
The author is currently looking after two service users who are scoring on the MUST. All two patients are elderly from 65 to 80 years old, with different background and health conditions. Patient No 1 is 87 years old female, was diagnosed with Alzheimer's Disease, history of Transient Ischemic Attack (TIA), high blood pressure, right wrist fracture and Dysphasia. Current BMI is 19, which was stable after referral to dietician and commencing on oral supplements, than BMI was 17 back in the October 2010. Patient No 2 is 72 years old man, diagnosed with alcohol excess, CA oesophagus, Gout, Heart Failure. Current BMI is 23, which was stably increasing over past months following admission to nursing home, than his BMI was 17. Both patients have a poor appetite at present. Nursing home's staff cannot establish reasons for anorexia and BMI reduction in one patient.
There are number of risk factors, which could cause malnutrition among elderly population. However, the most important factor leading to undernutrition is reducing of oral intake (Saunders, Smith and Stroud, 2010). Inadequate dietary intake is depending on various factors (Saunders, Smith and Stroud, 2010), which could be divided into three main categories: medical, social and psychological (Hickson, 2006). Firstly, age related changes such as changing in appetite or sensory (Teo and Wynne, 2001). Working in the care homes author noticed, an appetite is reducing with advanced age. Some people refused or preferred to omit meals, for example, one patient does not take breakfast, then the author asked her why she is not taken breakfast that patient replied that she is not a "breakfast person". In addition, during the study carried out in USA it was discovered that elderly population are consumed less energy intake and follow more traditional eating pattern then younger population (Teo and Wynne, 2001). Poor appetite or anorexia is a most common factor leading to malnutrition in both young and old generation (Hickson, 2006). However, during the study commenced by Roberts et al (1994), it was found that ageing seemed to affect the ability to control food intake and weight lost will take longer to re-gains in elderly men compare to young (see Hickson, 2006). In addition, according to work of De Castro (1993), older people are less responsive to stomach contents than younger people, in term of hunger (see Hickson, 2006). Anorexia may occur as process of aging as well as during underlying illnesses (Teo and Wynne, 2001 and Hickson, 2006).
Hetherington (1998) argued that changing in taste and smell could lead to loss of appetite through a perceived decline in the pleasantness of food. Loss of taste and smell could be associated with advance age and medications therapy mechanism of these changes are remains unknown (see Hickson, 2006). In author's care environment patients prefer to eat strong flavour and taste meals such as a roast meat with gravy, bacon, fish which are being served with traditional sauces or salt and vinegar to encourage patients to their food. According to Hickson (2006), a few works have been done to find out that improving the flavour of the food can improve diet intake and follow weight increase in hospitals and community healthcare patients (Hickson, 2006). A few patients do not like vegetables, intake of which have being recommended by NHS "5 a day" complain based on the WHO (NHS, 2009).
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Patient No 1 and Patient No 2 do not have own teeth which is reducing ability to chew tender food. For both patients oral problems have not been reported. However, according to Finch et al (1998), National Diet and Nutrition survey, energy consumption was lower in edentate individuals compare to individuals with own teeth (see Hickson, 2006).
Dysphasia or swallowing problem is leading concern in reducing dietary intake (Hickson 2006). The author has experienced that often care and catering staff do not understand the different between soft and liquidised diet and which diet should be given to each patients with dysphasia. Moreover, care staff that is responsible for feeding patients, needed assistant, every often do not understand the sings for swallowing problem. This concern has been addressed in the care home that the author is working in by appointed care staff for appropriate training section provided by Liverpool Primary Care Trust (PCT). According to research carried out by Mowe et al (1994), swallowing problem is showing up in 64 per cent of in-patience elderly (see Hickson, 2006). In addition, Gariballa et al (1998) argued that post Cerebrovascular Accident (CVA) patients with Dysphasia had a worse nutrition status then those patients without swallowing problems (see Hickson, 2006).
The author strongly believes that malnutrition caused by various factors combined together such as old age and health or mental health problem (Saunders, Smith and Stroud, 2010). In the UK, it was estimated that around 8 per cent of patients with chronic diseases living in the community are malnourished (Teo and Wynne, 2001). According to Hickson (2006), diseases-related malnutrition is usually associated with cancer, physical disabilities, endocrinology disorder and respiratory disease, gastrointestinal disorders, neurological disorders, sources of infection and other psychological factors such as depression and Dementia (Hickson, 2006 and Teo and Wynne, 2001). Medical factors increase the risk of patient to become malnourish through, for example, nausea or vomiting, diarrhoea or constipation, anorexia and malabsorption (Hickson, 2006).
Cultural factors or social (Vetta et. al. 1999) and food habits are also playing an important role in developing malnutrition as independent illness (Hickson, 2006). As example, an individual who had a long-term hospital stay or had no nutrition support while in the community would not used to have full nutritional meals. Moreover, individual who has been admitted to the author's care home used to take "fast" food or sandwiches at all the time while at home, instead of cooked meals. According to Hickson (2006), there are lifestyles and social risk factors for malnutrition in elderly people are lack of knowledge about food, nutrition and cooking, isolation and loneliness, poverty, inability to shop or prepare food (Hickson, 2006).
Dementia has a great effect on individuals' relationship with food (Alzheimer's Society, 2011). Dementia patients or patients with low mental status appeared to lost weight due to reducing self-feeding ability, acute sense of smell and taste that is depending on severalty and progression of disease (Teo and Wynne, 2001). Berkhout et al (1998) has confirmed that weight lost in demented patients is caused by patients' ability to feed them rather than by dementia as illness (Hickson, 2006).
According to Incalzi et al (1998), study carried out for in-hospitals patients found out that cognition is causing impairment to ability or desire to eat (see Hickson, 2006). Progressive dementia is usually associated with uncontrolled weight lost and changing eating habits (Claggett, 1989 see Hickson, 2006).
Nutrition screening and risk assessment
In 2007, RCN commenced "Nutrition Now" campaign, which has a wide response from members of public as well as members of multidisciplinary teams. The RCN Principles for Nutrition and Hydration were published in 2007. That principals aim to help of all health professionals' grades to improve nutrition and hydration of patience. This paper is highlighting three principles of nursing care: accountability, responsibility and management to improve the patience nutrition and hydration (RCN 2011).
Nutrition screening pathway, nutrition risk assessment are widely used which assist nursing staff to indentify the risk of malnutrition or/dehydration and appropriate actions to be taken. Risk of malnutrition screening should be a routine process in all healthcare settings (RCN and NPSA, 2009). In the author's care home as required all service users are being screened for malnutrition on the admission and once a month or more often if required, using Malnutrition Universal Screening Tool (MUST) as recommended by government bodies and Care Quality Commission (CQC) as registration body. Part of the admission documentation is to collect and record patience's food likes and dislikes. According to Saunders, Smith and Stroud (2010), MUST is reliable and valid screening tool in diagnostic or prediction of malnutrition (Saunders, Smith and Stroud, 2010). However, nutrition assessment was only done for patients who have been referral to their GPs following scoring, weight loss of 1 to 2 per cent per week, 5 per cent per month or 10 per cent over period of six months (Mitchell, 2003).
According to RCN and NPSA (2009), purpose of nutritional assessment is details identification of nutritional status and for special dietary plan to be formulated and implicated (RCN and NPSA, 2009). In the author's care home, dietician or dietician's assistant based on the information provided by staff nurse on duty normally carries out the nutritional assessment. As far as author concerns, nutrition assessment should be done by care home nurses as they are working in close contact with patients and their families on the daily basis, know better person's food likes and dislikes. However, special nutrition trainings are not always available to the nursing home staff. This could lead to complicated nutrition issues not to be addressed as quickly as they should be due to community dieticians waiting time is usually 6 weeks.
In the author's nursing home all necessary equipments are available such as weight scales and height measures. However, weight scales calibration has not been done which could lead to poor nutrition screening assessment (NPSA).
After completing the MUST, the author and colleagues will formulate the personalised care plan for each patient in order to meet nutritional requirements. Nutrition care plan could be based on the information or guidance provided by dietician or other health professions.
According to Hark and Morrison (2003), the nutrition needs of healthy older adults are mainly the same as for middle age adults (Hark and Morrison, 2003). The intake of food containing Calcium, Vitamin D, Folate, Vitamin B12 and B6 should be increased for the elderly population (Hark and Morrison, 2003). Protein intake recommendation is variable from 0.8 g/kg per day in the USA (Mitchell, 2003) to 0.75 g/kg in the UK (McKevith, 2009). However, according to Mitchell (2003), one established nutrition needs recommendation cannot be used for all ages' population (Mitchell, 2003). In addition, patient's lifestyle, height and weight should be taken in account (Mitchell, 2003).
There are number of fundamental support of nutrition available at present such as enteral and parenteral nutrition support (Hark and Morrison, 2003). At this assessment only oral nutrition support (ONS) will be discussed. The aim of the nutrition support is to ensure an individual gets enough energy, proteins, macronutrients and micronutrients to meet patients' nutrition requirements (Saunders, Smith and Stroud, 2010). Saunders, Smith and Stroud (2010) argued that provision of regular meals with better nutrition content, wide menu choice and assistant with feeding should be enough to meet nutrition requirement and reduce nutrition risk (Saunders, Smith and Stroud, 2010).
Numerous studies show that nutrition support could reverse weight loss, only if underlying health conditions under control (Saunders, Smith and Stroud, 2010). However, not all patients react at the same way (Hickson, 2006). At what reasons care and treatment should take an account of individual needs and preferences (RCN and NPSA, 2009). In practice, knowledge of food preferences and past medical history, following personalised nutrition care plan, serving patients with small meals (Teo and Wynne, 2001) or using a small plate could encourage service user to finish all meal.
Currently some of the UKs' hospitals commenced to use red tray scheme for serving the meals to patients. A purpose of using red trays is to alert hospital staff that patience with red tray is at nutrition risk and need assistance or supervision with diet intake (Bradley and Rees, 2003 see Davis, 2007).
Protection of mealtime scheme is also widely spread across the UK. The purpose of this scheme is to create an environment for hospital patients free from hospital activities and unnecessary disturbance during a mealtime. In addition, this scheme is to assist nursing staff with concentration on the meeting nutrition need of hospital patients (NS, 2007).
People with Dementia could loss an ability to use cutlery that could lead to weight loss and malnutrition. Providing those patients with available finger food could improve nutrition status (Alzheimer's society, 2011).
Teo and Wynne (2001) argued that the possible benefits from using energy supplements in elderly patients have received little or no evaluation in clinical practice (Teo and Wynne, 2001). However, during the study carried out by Volkert et al (1996), it was found that patients consuming food supplement while in-patience and 6 months in community have develop positive nutritional status compare to group of patients without food supplements (see Teo and Wynne, 2001). The author has come across the situation then GP has refused to prescribe food supplement to one of the patience and recommended full fat milk instead. In addition, during controlled trial for six months in patients who have been discharged from hospital and prescribed ONS has no economic benefit. To compare, using ONS in community is costing more than using ONS in hospitals (Elia et al., 2005).
However, malnourished patients using could be at risk of re-feeding syndrome, which could results in death (Saunders, Smith and Stroud, 2010). Re-feeding syndrome is associated with water retention leading to fluid overload due to decay of potassium, magnesium, phosphorus and sodium in blood plasma (Mallet, 2002). Saunders, Smith and Stroud (2010) recommended that during re-feeding saviour malnourished patients potassium, phosphate and magnesium should be prescribed and thiamine (for patients with history of alcohol excess) (Saunders, Smith and Stroud, 2010).
The UK elderly population is rising, currently about 16 per cent of the population is above 65 (Hickson, 2006) and by 2050 over 30 per cent European population will be over 60 which will result in prevalence of malnutrition to rise (European Nutrition for Health Alliance, 2005).
Many changing associated with aging have been documented, however, how senescence leads to the health conditions, related to aging, is still unknown (Mitchell, 2003). It was found that ageing is leading to slow reduction of weight and modification in body composition. It is due to declines in bone, muscle mass and body cell mass. Bone mass reduced due to inadequate intake of Calcium and inadequate exposure skin to the sunlight to encourage production of Vitamin D (Sahyoun, 2002). In general, people are gaining weight until they 60th birthday and after gradually reducing weight, usually 10 per cent between 70 and 80 (Mitchell, 2003). Weight loss related to aging and malnutrition should be indentified during initial nutrition assessment.
In addition, community healthcare is facing many concerns. Firstly, malnutrition remains under-recognized problem facing patients, their families and health professions (Saunders, Smith and Stroud, 2010). Secondly, according to, Hark and Morrison (2003) argued that there are no single physical or biochemical screening tools could accurate predict the nutrition status in elderly (Hark and Morrison, 2003). Food prices are constantly rising and ONS are costing too much to the local PCT. In the author's opinion, providing service users with good quality food, offer choice of menu and snacks between meals are solution to fight malnutrition.
The significant role in education medical students and junior doctors in nutrition has widely recommended (Saunders, Smith and Stroud, 2010). However, inadequate knowledge in nutrition of nursing and care staff could increase risk of malnutrition (Saunders, Smith and Stroud, 2010). In the author's care home nutrition in elderly is not mandatory training for the care staff. Following this assessment, the author will provide relevant care staff with information on the nutrition in elderly service users. This could be achieved through supervision sections and face-to-face talks. Moreover, there it is possible, elderly population and their families should be informed about the latest nutrition recommendations related to their age, lifestyle and health conditions and should encouraged to apply those recommendations to individuals' lives (Sahyoun, 2002).