Promoting Frail Adults Nutritional Intake

The recognition of nutritional problems in older people is important as these are associated with poor prognosis but are potentially treatable. Any assessment of frailty has to include some key questions about diet, appetite and weight, as these can indicate specific problems related to nutrition as well as being markers of other underlying medical conditions.

However first and foremost, it’s important to identify the signs of malnutrition, which include the following:

  • Tiredness and low energy
  • Loss of appetite
  • Unintentional weight loss
  • Clothes, jewellery or dentures becoming loose over time

Malnutrition can affect every system in the body and results in increased vulnerability to illness and complications which can lead to an increase in the need for community services, more visits to the doctor, prolonged hospital
stays and in some cases, death. The main consequences of malnutrition are:

  • Fatigue and lethargy
  • Falls
  • Difficulty coughing, which increases the risk of chest infection
  • Heart failure
  • Anxiety and depression
  • Reduced ability to fight infection

Malnutrition is also associated with several psychological issues. Mental health problems such as depression and anxiety or a change in the cognitive status of a frail older person can result in a loss of interest in eating. If insufficient nutrients are consumed as a result of loss of appetite, a change in mood and energy levels will occur and a negative cycle of reduced calorific and nutrient intake may ensue. 

Given the current coronavirus pandemic, social isolation is also more prevalent than ever among older people particularly those who are frail and have been encouraged to sheild. Immobility can significantly reduce appetite in frail older people and eating alone can also lead to lower than required nutritional intake. This can also lead to a reduction in the nutritional quality of the food consumed. Less thought is also given to selecting the right food when we shop alone, as convenience and haste are deemed more important than a nutritionally balanced diet. Dietetic research also suggests that eating the right food in the right setting positively improves both mental and physical well-being.

Equally important is the additional element of dining with dignity and the visual appearance of food. For those that live with dysphagia, this can be extremely challenging, as the ability to enjoy eating communally can often prove problematic. The potential embarrassment and social awkwardness which can accompany the feeling of eating something completely different to everyone else can be hugely debilitating for some. Again this contributes to an increased risk of developing malnutrition due to a drop in  nutritional intake often accompanied by a reduction in the nutritional quality of the food consumed. 

Some frail older people also choose to add liquid to meals and foods when they are home-blending. Whilst this may help achieve the correct texture, it also increases the volume and, depending on the type of liquid used, potentially decreases the nutritional content. Access to ready-prepared texture modified meals can provide a solution. Not only is nutritional content carefully controlled in such meals great care is also taken to ensure the meals look appetising. When texture modified meals resemble the appearance of regular food as far as possible, it makes it easier for the person with dysphagia to enjoy eating with others. 

Due to the complex nature of malnutrition there are no blanket measures to prevent its occurrence. However, once the causes for each frail older person are recognised, there are steps which can be taken to manage, treat and prevent it.

So, once you’ve identified the signs, what are effective dietary solutions for malnutrition? If someone suddenly loses their appetite, becomes thinner, or steadily loses weight unintentionally it is important to speak to a GP or a dietitian. For some time now, the treatment for malnutrition has often included the prescription of oral nutrition supplements. However, for dietitians, the preferred first step to treating malnutrition is to encourage a ‘food first approach’ where possible. This is likely to focus on encouraging people to eat higher calorie and protein foods more often. 

The food first approach seems straightforward but increasing food intake for frail people with a smaller appetite can be challenging. Adding things like a slice of cake, cheese and full fat milk to one’s diet can all be beneficial, as these are energy dense foods. Smaller and energy dense meals are crucial when cobatting a reduced appetite.

Malnutrition remains one of the most common nutritional challenges among frail older adults in the UK. Healthcare professionals have a key role to play in the recognition and prevention of this challenging disease, as they often have close and regular contact with older adults in the community. Anyone who comes into close or regular contact with an older person has the potential to spot the signs and symptoms of malnutrition and weight loss is not an inevitable part of ageing. It is always worth asking frail older adults some gentle questions about their dietary intake because reduced appetite often marks a decline in their health. There are also screening tools that can be completed, the most commonly used one being the Malnutrition Universal Screening Tool (MUST). The MUST tool is often used to guide appropriate referral to a dietitian.

Whilst a ‘food first’ approach, often with additional use of oral nutritional supplements, is the cornerstone of treatment for malnutrition, there are several key social aspects to consider as well. Simple strategies like attending a local lunch club, encouraging eating with friends or family members or a visit from volunteers from services such as Age UK’s Befriending Service, can all have a positive impact on the amount an older person eats at mealtimes.

When it comes to preventing and treating malnutrition, we should all be thinking of both the clinical and social interventions that can help.

This piece has been based on an article on the British Dietetic Association (BDA) website by Emily Stuart, a Dietitian fo Apetito & Wiltshire Farm Foods.

Other resources from the BDA that you may find useful

There is a Managing Adult Malnutrition in the Community malnutrition pathway which also includes a pathway for the appropriate use of Oral Nutritional Supplements. See:

https://www.malnutritionpathway.co.uk/

The BDA earlier this year drew up an A4 leaflet listing a useful store of basic foods for older people who can’t easily get to the shops. Their ‘Older Peoples’ Store Cupboard Flyer’is available at the link given below.

https://www.bda.uk.com/resource/store-cupboard-flier.html

The full BDA guidance for managing malnourished adults in the community, including their Policy statement can be found at:

https://www.bda.uk.com/resource/the-management-of-malnourished-adults-in-all-community-and-all-health-and-care-settings.html

This guidance website also has 4 sections worth exploring near the top. Click on the links to Introduction, Discussion, Examples, Conclusion and References while you are there.

The British Geriatrics Society also have a brief chapter from their resource ‘End of life care in Frailty’ on Nutrition which you may find useful.

https://www.bgs.org.uk/resources/end-of-life-care-in-frailty-nutrition

The role of nutrition in the cycle of frailty diagram you will see on the page is interesting and worth considering.

Mental Well-being in Later Life

Much of the literature on Frailty has focused on physical health, however mental health including cognition, sleep, social interactions and positive aspects like well-being are just as important.

In 2014 in the UK general population about 300 in every 1,000 people experienced mental health problems. Of those 300 people, 230 visited a GP and 102 were diagnosed as having a mental health problem. For people with frailty who are at higher risk of mental ill-health, these figures will to be higher. National Surveys of NHS patients indicate that approximately 91 per cent of people with a mental health problem are treated within the primary care system, meaning that very few are referred to specialist mental health services. Figures also suggest that at least 25% of individuals with symptoms of mental health conditions such as depression and anxiety do not report them to their GP. People living with frailty will behave similarly. There is also an assumption by some that mental health problems are a ‘normal’ aspect of ageing, but most older people don’t develop mental health problems, and they can be helped if they do.

Healthcare professionals in the community are ideally positioned to make a difference. Age UK has identified key steps that every healthcare professional can take:  

  • Remember that mental health is just as important as physical.
  • Try to get into the habit of asking about the emotional well-being of the people you see. 
  • Look out for signs that your patients are struggling with their mental health. 
  • Start the conversation. It can seem awkward bringing up mental health but older people do say that they want to be asked and find talking useful.    
  • Think about language. Older people can be put off by terms such as mental health and depression. Try to use more informal language. 
  • Remember mental health problems are not inevitable. With the right support older people can recover. 

We have looked at two of the biggest causes of mental illness in frail older people already. See the earlier post on Loneliness which is at http://frailtymatters.uws.ac.uk/2019/12/04/the-value-of-social-support/ and our post about Dementia which is at http://frailtymatters.uws.ac.uk/2020/02/27/dementia-some-guidance/

One of the main issues we have not examined relating to mental health is DEPRESSION. It has been estimated that 1 in 4 older people have symptoms of depression that require treatment, but fewer than 1 in 6 older people will seek help. Care home residents are also at an increased risk of depression. Depression in later life can be a major cause of ill-health and can have a severe effect on physical and mental well-being. Older people are particularly vulnerable to factors that lead to depression such as bereavement, physical disability, illness and loneliness. Depression in older people can be treated effectively through talking therapies and antidepressants. See the NICE Clinical Knowledge Summary on Depression mentioned below. Effective interventions to prevent depression in older people include reducing loneliness and isolation through encouraging learning, physical activity and any form social interaction including volunteering. Many of these are difficult at this time but a useful guide to ‘Keeping Well at Home’ which was devised for all older people whose interactions are restricted currently because of COVID-19 has been produced by the Healthy Ageing Research Group at Manchester University. You can download the booklet at http://documents.manchester.ac.uk/display.aspx?DocID=49104

There is limited guidance from the Royal Colleges for those in primary care on what to do to maintain older people’s mental well-being but there is NICE guidance that you can refer to. NICE Guideline 32 is all about mental well being and independence in older people and there is also a NICE Quality Standard 137 which is on the same topic. You can look at the NICE flowchart and download both documents at

NICE (2020) Mental wellbeing and independence in older people overview: Interactive Flow Chart

You might also find the following NICE Clinical Knowledge summary on Depression useful. https://cks.nice.org.uk/topics/depression/

England (2014), writing for the Royal College of GP’s has stated that community practitioners need to take responsibility for coordinating and signposting to services beyond health care, in particular social care, housing and benefits to effectively tackle mental well-being in older people. The more collaborative form of working integrated care heralds will move community staff from gatekeepers to that of navigators. Community healthcare workers need to take responsibility for co-ordination and signposting to services beyond health care and builds bridges with many community services, patients’ families and their communities, if improving the mental welfare of our older people is the goal.

If you want to know more about this topic an intersting report to read is by Lee, M. (2006) Promoting mental health and well-being in later life: A first report from the UK Inquiry into Mental Health and Well-Being in Later Life. London, Age Concern & Mental Health Foundation. 

The report highlights discrimination; participation in meaningful activity; relationships; physical health and poverty; as important parts of promoting mental health and well-being that also need to be considered

Welcome Back!

We would never have believed in early April when we last posted a blog item that it would take until the 19th of October to resume our coaching and teaching programme. It’s been a very strange and unique year and one that we are never likely to forget. We hope that you have all stayed well throughout the pandemic and our hearts go out to any of you who have had your lives or the lives of your family members affected by COVID-19.

Last month you would all have been sent a copy of our new plans for the coaching and teaching programme and we look forward to seeing you all again on Microsoft Teams on Thursday the 22nd of October between 3-5pm. We hope we have picked a time when most of you can be available.

From the timetable you will be able to see that new materials on the Blog should appear every Friday for 6 consecutive weeks. Please be patient with us if they don’t appear early, the intention is to have them available and posted by the commencement of each new week. Alongside the Blog it is our intention to include a number of podcasts/videocasts in line with topics that we are covering that week or that we have previously covered. If possible they will appear within the Blog posts for that week but they may have to be posted as separate items.

In the meantime we hope you #staysafe

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