The role of nutrition and oral nutritional supplements in the care of vulnerable or elderly frail adults

Question 1

What is malnutrition?

Answer 1

Malnutrition is the state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form and function.

Question 2

What is cachexia?

Answer 2

Cachexia is a multifunctional syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.

Question 3

What is sarcopenia?

Answer 3

Sarcopenia is the age-related reduction in skeletal muscle mass in the elderly, which is a natural part of the ageing process.

Primary sarcopenia has no specific etiologic cause that can be identified, while secondary sarcopenia is aggravated by extrinsic factors.

Question 4

How is sarcopenia diagnosed?

Answer 4

Sarcopenia is diagnosed by looking at muscle mass, muscle strength, and physical performance.

Question 5

Who is at risk of malnutrition?

Answer 5

Individuals at risk of malnutrition include those aged >65, particularly if living in a care home or nursing home, individuals with complex health needs, people with long-term conditions, and those who abuse drugs or alcohol.

Question 6

Name the causes of malnutrition

Answer 6

Physiological
Swallowing problems
Taste changes
Poor dentition
Dry mouth
Pain
Constipation
Medicine side effects
Impaired GI function
Hunger/thirst impaired

Social
Living/ eating alone
Little money
Bereavement
Difficulty shopping or cooking
Reliance on others

Increased nutritional needs due to:
Infection
Inflammation
Pyrexia (raised body temp.)
Healing wounds
Involuntary movements
Increased physical activity

Psychological:
Low mood/ depression
Dementia
Loss of interest in food
Poor appetite

Nutrient losses:
Malabsorption
Diarrhoea
Vomiting
Wound exudates (protein containing fluid)

Question 7

Name the consequences of malnutrition

Answer 7

Physiological

- Frailty 
- Reduced muscle and fat 
- Poor wound healing 
- Reduced mobility, weakness and fatigue 
- Increased risk of infection 
- Weak cough 
- More side effects from medicines 

Psychological

- Low mood/ depression 
- Confusion 
- Appetite further reduced  

Outcomes

- More falls and pressure ulcers 
- More hospital admissions 
- More GP visits 
- Require more prescriptions 
- Longer length of stay 
- Reduced quality of life  Increased mortality

Question 9

What BMI indicates malnutrition?

Answer 9

BMI < 18.5 kg/m²

Question 10

What is considered unintentional weight loss for malnutrition?

Answer 10

Unintentional weight loss >10% within the last 3-6 months

Question 11

What combination of BMI and weight loss indicates malnutrition?

Answer 11

BMI < 20 kg/m² and unintentional weight loss >5% within the last 3-6 months

Question 12

What eating condition indicates malnutrition?

Answer 12

Eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longer

Question 13

What physiological issues can indicate malnutrition?

Answer 13

Poor absorptive capacity, high nutrient losses, and/or increased nutritional needs from causes such as catabolism.

Question 14

What is the first step in treating malnutrition?

Answer 14

Managing factors affecting food intake

Question 15

What should be considered if a patient has swallowing concerns?

Answer 15

Has the patient been referred to Speech and Language Therapy?

Question 16

What should be considered if a patient has difficulty using cutlery?

Answer 16

Has the patient been referred to Occupational Therapy?

Question 17

What should be done if a patient is constipated?

Answer 17

Have laxatives been prescribed?

Question 18

What should be evaluated regarding medications?

Answer 18

Are there medicines causing problems that potentially could be stopped/rationalised?

Question 19

What should be prescribed if a patient has nausea or vomiting?

Answer 19

Is something being prescribed for this?

Question 20

What support might a patient need regarding food?

Answer 20

Do they need more support or meals from Wiltshire Farm Foods?

Question 21

What are the treatment aims for malnutrition?

Answer 21

Avoiding further weight loss, achieving BMI of 18.5 or 20 kg/m², wound healing, regaining lost weight.

Question 22

What dietary approach is recommended for malnutrition?

Answer 22

A food-based nutrient-dense diet

Question 23

What is a recommended eating frequency for a nutrient-dense diet?

Answer 23

A nourishing meal, snack, or drink every 2-3 hours

Question 24

What can stimulate appetite?

Answer 24

Appetiser (fresh air, light exercise)

Question 25

What types of food options are recommended?

Answer 25

High protein, high energy food options

Question 26

How can food and drinks be enhanced?

Answer 26

Fortify food and drinks with nutrient-dense enrichers

Question 27

What should be allowed regarding food preferences?

Answer 27

Allow favourite foods at any time of the day

Question 28

When should meals be encouraged?

Answer 28

Make the most of times when appetite is better

Question 29

What should be considered regarding the eating environment?

Answer 29

Encourage meal times with others where possible

Question 30

What is a method for enhancing food?

Answer 30

Food fortification

Question 31

What are some examples of homemade nourishing drinks?

Answer 31

Homemade nourishing drinks can include smoothies, protein shakes, and fortified beverages.

Question 32

What are high protein/high calorie snacks?

Answer 32

High protein/high calorie snacks include items like nut butters, cheese, and protein bars.

Question 33

What are oral nutritional supplements?

Answer 33

Oral nutritional supplements are products designed to provide additional calories and nutrients.

Question 34

What are the benefits of oral nutritional supplements?

Answer 34

They significantly reduce mortality, reduce complications, and improve weight.

Question 35

What functional benefits do oral nutritional supplements provide?

Answer 35

They offer better energy and protein intakes in supplemented patients in all trials.

Question 36

How are oral nutritional supplements perceived by patients?

Answer 36

Oral nutritional supplements are generally acceptable to patients.

Question 37

What is important to do with oral nutritional supplements?

Answer 37

It is important to review and monitor their effectiveness.

Question 38

What are the ACBS criteria for Oral Nutritional Supplements (ONS)?

Answer 38

1. Short bowel syndrome 2. Dysphagia 3. Intractable malabsorption 4. Pre-operative preparation of under malnourished patients 5. Inflammatory Bowel Disease 6. Total gastrectomy 7. Bowel fistulae 8. Disease related malnutrition (chronic/acute) - can be evidenced by MUST

Question 39

What is the MUST score requirement for considering ONS?

Answer 39

Individuals must have a MUST score of 2 or more (HIGH risk) if weight has decreased after one month of FOOD first advice.

Question 40

What is the prescription guideline for ONS?

Answer 40

Prescribe 2 x 1st line ONS daily. Trial for 2 weeks in a variety of flavours, check acceptability, and try other types and flavours if necessary before issuing a monthly prescription.

Question 41

What should be considered when prescribing ONS?

Answer 41

Always consider local guidelines.

Question 42

What do ONS supplements contain?

Answer 42

Supplements contain energy, protein, vitamins, and minerals. They come in a variety of makes and flavours.

Question 43

What should be recorded on initiation and repeated monthly?

Answer 43

A weight should be recorded on initiation and repeated a minimum of 3 monthly.

Question 44

What indication should be documented?

Answer 44

An ACBS indication should be documented.

Question 45

What is a MUST score?

Answer 45

A MUST score should be assessed; if so, what is it?

Question 46

What advice should be given first?

Answer 46

Food first advice should be given.

Question 47

What should be set for treatment?

Answer 47

An aim of treatment should be set.

Question 48

What should be prescribed?

Answer 48

Supplements should be prescribed.

Question 49

What should be trialled if appropriate?

Answer 49

A powdered supplement should be trialled if appropriate.

Question 50

What should be considered for cost-effectiveness?

Answer 50

A more cost-effective formulary alternative should be considered (i.e. Nutricrem vs Forticreme).

Question 51

What is the minimum prescribed dose?

Answer 51

The patient should be taking in a prescribed dose, i.e. a minimum of 1 serving daily.

Question 52

Who is responsible for the supplement review?

Answer 52

Identify who initiated the supplement and who is responsible for its review (i.e. Community Team, Dietitian, GP, etc.).

Question 53

What should be monitored for specialist products?

Answer 53

More specialist products being prescribed (e.g. Calogen Extra, Altrashot, Prosurce, Modulen IBD) should be monitored appropriately. Is dietetic referral appropriate?