A care home is defined as "any home which provides accommodation together with nursing or personal care for any person who is or has been ill (including mental disorder), is disabled or infirm, or who has a past or present dependence on drugs or alcohol". The definition is intended to include residential care homes and nursing homes (OPSI, 2000).
Therefore service users of care homes are likely to be partially or fully dependant on other people, the care home has a responsibility of the nutritional wellbeing of the service users (Horne, 1994).
Many classify the age of 'elderly' to the over 65's in the developed Westernized world. These then can be as young elderly between 65-74 and also older elderly which are the over 75's (COMA, 1992).
1.1 The Elderly Population
It is well known that the elderly population is ageing, over the last quarter of a century the UK population of people aged 65 and over increased from 15 per cent in 1984 to 16 per cent in 2009; statistically this does not appear significant however this was a rise of 1.7 million people. Over the same period, the percentage of the population aged under 16 decreased from 21 per cent to 19 per cent. This trend is projected to continue. By 2034, 23 per cent of the population is projected to be aged 65 and over compared to 18 per cent aged under 16 (National Statistics, 2010). This shows that the number of people living longer is increasing; however the birth rate continues to fall.
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In 2001, a total of 527, 200 older people lived in care homes (CWT, 2004). However by 2010 in England alone, it is believed that at least 320,000 elderly people live in care homes and by 2030 this is said to increase to over half a million (POPPI, 2010). In this ageing population, it is reasonable to expect that demand for care home places will increase. However, government policies have been place so more emphasis will be provided to alternative forms of care in people's own homes in order to enable people to carry on living independently for longer (OFT, 2005). Therefore elderly people moving into care homes are likely to have an increased dependency on others and are likely to have other co-morbidities, which are unable to be managed in their own homes.
1.2 Nutritional Status of the Elderly
Nutritional status can be assessed in several different ways, including clinical considerations, physical state, dietary aspects, anthropometric measurements and also biochemical and haematological markers. Those with a poor nutritional status may be classed as undernourished or malnourished which can be defined as "a disturbance of form or function arising from the deficiency of one or more nutrient"' (Schenker, 2003). These nutrients include a depletion of energy where weight loss is a manifestation, when energy is depleted it is likely that other nutrients such as protein and micronutrients are also depleted. As energy intake is restricted weight loss is likely, therefore we are able to assess classification of under nutrition by our body mass index. You are able to be classed as underweight and therefore malnourished if your BMI is below 18.5 kg/m2.
According to the Caroline Walker Trust Foundation (CWT, 2004), being underweight in old age is a far greater risk to health than being overweight, therefore a nourishing balanced diet is essential to prevent malnutrition. Although the ageing process means activity decreases, therefore calorie requirements decreases, it is still essential for the body to have all nutrients that are recommended for adults, as without these a vicious circle of decrease muscle mass, lower activity and lower appetites can occur. Without sufficient diet elderly patients can become malnourished which may lead to further complications including impairments in physical and psychological health. This may include:
Impaired immune function
Delayed wound healing and the increased risk of pressure ulcers
Muscle wasting and weakness
It also may cause a general sense of weakness and illness, which impairs appetite and physical ability, which consequently worsens the state of malnutrition which is often a problem in healthcare settings such as hospitals and care homes (Thomas and Bishop, 2008).
It is believed that malnutrition affects the function and recovery of all bodily systems, increases the risk of infection, extents hospitals stays and also makes readmission more likely (Lean et al, 2009). This may be because malnourished patients generally have a lower muscle and tissue mass, poor wound healing, slower immune response, and also an increased risk of suffering from post-operative problems (NHS, 2009).
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Research by BAPEN discovered that in care homes, service users had an overall risk for malnutrition of 28%, those under 70 years of age had a 26% risk compared with a 32% risk for those over 80, this rose to 36% in the over 90s (BAPEN NSW, 2007).
In the last decade it is believed that mortality rates as a direct result of malnutrition were 2,300 and this rose to 2,656 people when care homes were included (Nursing Times, 2009). During 2007 and 2008 over eight thousand patients become malnourished in hospital in England (Blake, 2009). In care homes it is believed that approximately 15% of resident are underweight (Finch et al, 1998). Many people living in care homes are undernourished; this may be due to previous poverty, social isolation, personal or psychological problems, or due to the effects of illness or medication (CWT, 2004).
Studies have concluded that low energy intake and malnutrition is at a high incidence among elderly residents in nursing homes and also hospitals (Cederholm et al, 1993 & Thomas et al, 1991). It is important to note that people living in care homes have 100% of their meals provided by the home, therefore nutritional adequacy is essential to the maintain nutritional of the service users.
Ill health may often lead to a decrease desire for food and consequently nutritional intake. The body must also compromise for the increase demands of nutrition for tissue repair, also increased requirements for the body's defence mechanism. Changes include increased requirements for carbohydrates, fat and protein (Lames, 2009). Therefore it is essential for all care homes to provide a well balanced, nourishing diet.
In 1998 the National Diet and Nutrition Survey was commissioned by the Ministry of Agriculture, Fisheries and Food and the Department of Health to create the largest and most detailed survey on the older population of the UK, and covered the population living in the community as well as in institutions. The survey included interviews about the population's backgrounds, questionnaires to assesses mood and depressions, a weighed food intake, bowel movements, anthropometrics measurements, blood biochemistry and urine samples to assess nutritional status and interviews on oral health (Smithers et al, 1998).
According to the National Diet and Nutrition Survey, energy intakes for those living in institutions were close to the EARs whilst in the free living group energy intakes were lower, whilst protein was above EARs in both groups. NMES provided over 18% of energy, which is above the COMA recommendation of 1991. Average daily intake of non-starch polysaccharide (NSP) ("dietary fibre") was below the daily intake of 18g recommended by COMA for both groups (Department of Health, 1991). Total fat intake was close to the COMA recommendation of 35%. The study also analysed vitamin and minerals from food sources and found most were above RNIs. In the institutionalized elderly they found low intakes of riboflavin and folate, and also low biochemical status was indicated in approximately 40 per cent of the group for vitamin C, folate and riboflavin, and around 10 per cent for thiamine. Average intakes of Vitamin D were also low. Intakes of magnesium and potassium were low between 9 - 42 per cent of the institutionalized. Iron, zinc, calcium and iodine were low in up to 13 per cent in the elderly in institutions. Around 10 per cent of the free-living group had haemoglobin concentrations below the WHO defined level for anaemia (13.0g/dl for men and 12.0g/dl for women). This was even higher institution group, at 52 per cent of men and 39 per cent of women. Up to 11 per cent of both groups had low serum ferritin concentrations, indicating low iron stores (Smithers et al, 1998).
Read et al (1998) concluded a study on catering for older people, where they analysed weekly menus from care homes and compared to the UKs DRVs for men and women over 50 years, they concluded that if service users ate all the food supplied by care homes they would receive an adequate amount of energy, protein fat B vitamins, Vitamins A and C, calcium and iron. They also concluded that the menus did not provide adequate amounts of vitamin D, starch or fibre, and the menus provided higher amounts of salt and sugar that was recommended (Read et al, 1998). However this study did not take into account the amount of food the service users consumed, this meant although the menu was providing sufficient energy and some nutrients, if all meals were not consumed the service user may not have been receiving adequate amounts of energy and other nutrients.
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Various studies have analysed care home food, including a study by Suominen (2004), which concluded residents were meeting energy requirements and also protein, they study suggested the need for improvements in micronutrients e.g. Vitamin D, Vitamin E and also Folic Acid. The study assessed energy and nutrient content of all recipes of food served over a 14 day period, food portion sizes were only estimated and then all data was entered into a nutritional analysis program to calculate energy and nutrient content. It is important to note that this study did not use the Caroline Walker Trust Guidelines in which case the results may have had variations, this study also concluded that residents were not meeting the nutritional requirements of fat, as the food provided to the service users was not completely consumed.
Research by Olin et al. (2003) concluded that energy dense foods regardless of the portion size increased total energy intake of elderly residents in care homes. This was supported by Suominen (2004) who concluded that it may be possible to have enough nutrients from food served at care homes although concluded the amount eaten would not meet some requirements.
Other studies have concluded that nursing homes residents also receive less energy, calcium and also fibre (Nowson, 2003). Schmid et al, (2003) also concluded that energy intakes were poor in care homes residents, also discovered that only 40-50% of the recommended intake of vitamin and minerals were being consumed. Berener et al (2002) showed that vitamin and mineral including dietary fibre intakes were low. The following study discovered that nutritional status of the elderly declined once admitted to an institution although this could be prevented with smaller portion sizes and increased energy, protein and micronutrient density (Allison, 2002). This concluded that analysing portion size should also be assessed, because although food served may provide sufficient energy and nutrients it may not be realistic for the service user to consume all food provided.
Blades et al (2002), gathered information on various surveys including a study by the Ministry of Agriculture Fisheries and Food with the Department of Health and concluded that elderly residence in care homes were at high risk of being anaemic, and also have a lower vitamin C and vitamin D status compared to elderly the same age living in their own homes.
It was studied by Leslie et al (2006), that despite adequate food provision, under nutrition was prevalent in care homes and was left untreated. The studied discovered that food provision satisfied the DRVs for energy, fat, carbohydrate, protein NSP, thiamine, riboflavin, niacin, vitamin C and A, calcium and iron. However did not provided sufficient vitamin D. The three day weighed food intake showed that mean energy intakes were below the current estimated average requirements, however vitamin C and iron met the recommended DRVs, the consumption of other macronutrients were below recommendations (Leslie et al, 2006).
In conclusion to this research it is evident that there is malnutrition in care homes and that the care homes are not meeting the recommended standards. This ranges from home to home and deficiencies may be present in some care homes but not in others. It is unclear if the nutrient deficiencies are a direct cause of the food provided or because of poor appetite and poor consumption of meals or if food portion sizes are appropriate for the service user. In which case, analysis is required to identify if the food served at nursing homes meet the recommended standard, all nutrients are considered for analysis as various studies identify various deficiencies, also it will be assessed if food portion sizes are suitable for the service user, and if these provide sufficient energy and nutrients to prevent malnutrition.
3.0 Initiatives and Guidelines to tackle Nutrition in Care Homes
3.1 National Minimum Standards
According to the National Minimum Standards for Care Homes for Older People, the service users must receive a wholesome appealing balanced diet in pleasant surroundings at times convenient to them. This requires the service user to receive a varied, appealing, wholesome and nutritious diet; meals must be suited to the individual and are available at flexible times. Service users must be offered three full meals per day one of which musty be cooked, and these must be served at intervals of no more than five hours. Also the National Minimum Standards require hot and cold snacks to be available at all times, and also a snack should be offered in the evening and the interval between this and breakfast the following morning should not be more than 12 hours. All food served must be appealing and attractive including, texture, flavour and appearance to maintain appetite and nutrition. A menu must also be in place, this must be changed regularly, and the menu must be provided in written or other formats to suit capacities of all service users (DoH, 2000).
The National Minimum Standards do not provide specific information on meals and nutrients and refer to the Caroline Walker Trust as guidelines.
3.2 Dietary Reference Values
In 1987 the Committee on Medical Aspects of Food Policy (COMA) revised the Recommended Daily Intakes (RDIs) and Recommended Daily Amounts (RDAs) for food energy and nutrients for people in the United Kingdom to create the Dietary Reference Values, the panel created a reference for 40 different nutrients for groups of people depending on their age within the UK (DoH, 2007).
3.3 Caroline Walker Trust
The Caroline Walker Trust believes that community meals are part of the vital components of community care. They believed that the nutritional standards of food are crucial for the wellbeing of service users (Read et al, 1998). The COMA reported the Dietary Reference Guidelines for older people in 1991; the Caroline Walker Trust adapted these as they believed they were insufficient for care home residents, where they then produced the publication Eating Well for Older People in 1995, where it has been used for practice guidelines for those that work in care homes (CWT, 2004). It was said that these should become the minimum standards of food prepared for service users of care homes (Read et al, 1998).
The publication Eating Well for Older People cover several topics including why nutritional guidelines are needed in care homes, also provides exact nutritional requirements and guidelines as well as recommended portion sizes for food prepared for older people. It also provides example menus and ways of exciting the appetite. The National Minimum Standards for care homes refer to the CWT 1995 as further guidelines for meal provided in care homes.
3.4 The Food Standards Agency
The FSA produced Guidance on Food Served to Older People in Care homes in 2007, they produced these guidelines a supporting document for the wide range of standards available for care homes. The publication was aimed at healthy elderly, which do not have any illness or disease.
The guidelines advise care homes that food provision should meet the average population requirements, they also aim there guidelines on the FSA Eatwell Plate. The guidance are specifically aimed for older people (i.e. >75s) living in care homes with no co-morbidities, however the NACC believed that these were inappropriate as they were aimed at healthy adults over 75s, which are rarely found in care homes (Cross et al, 2009).
Also the FSA do not cover the wide range of nutrients as the CWT, the FSA only provide the vitamin and mineral recommendations for riboflavin, potassium, magnesium, iron and zinc, where the CWT standards also cover DRVs for B vitamins, Vitamin C & A as well as calcium with the exclusion of magnesium.
From reviewing the guidelines the CWT standards are more dependable than the FSA as they provide guidance on a wider range of nutrients as well as recommendation on portion size, however from researching previous literature they also identify magnesium is a mineral that is low in care home food, therefore the DRV for magnesium will be added to the CWT guidelines.
It is clear that the population is aging; more elderly people with co-morbidities are increasing, which is increasing the number of care homes service, users. The prevalence of malnutrition is remains evident in the care home setting. From studies it is clear that several nutrients are deficient in elderly people in care homes including service users depleted of energy but also depleted of vitamin and minerals. It is unclear the direct cause of malnutrition, where the cause could be food served may not contain adequate nutrients, or portion sizes are too large for service users, therefore inadequate amounts are consumed. From this research it is clear that further investigation is required in care homes to identify the direct cause of magnetron, and also further education for care home staff to tackle malnutrition.
Table 1 Guidelines providing figures for the recommended nutrient content of an average day's food for on older person over a one weeks period
Women aged 75 and over: 1810kcals
Men ages 75 and over: 2,100kcals
35% food energy
Women aged 75 and over: 70g
Men ages 75 and over: 82g
Starch and Intrinsic and Milk Sugars
39% food energy
Women aged 75 and over: 188g
Men ages 75 and over: 218g
11% of food energy
Women aged 75 and over: 53g
Men ages 75 and over: 62g
Women: 600 micrograms
Men: 700 micrograms
Not more than 2,400mg sodium (6g salt)
Adapted from CWT, 2004