Shailen Rao and Samantha Cudby Explain the Role of the Practice Pharmacist in Supporting the Management of Malnutrition in Frail Older People in Primary Care
Post-publication amendment: 10 February 2020
This article was originally printed in the December 2019 issue of Guidelines in Practice. The following amendments have been made to this online version:
- We have added a declaration of interest statement provided by Soar Beyond
- We have added a statement about the development of the Malnutrition pathway (reference 12).
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This article has been developed in association with Soar Beyond Ltd.
Malnutrition—specifically undernutrition—is more than just weight loss. It is a state in which a deficiency of energy, protein, and other nutrients causes adverse effects on the body, its function, and clinical outcomes, including:1,2
- impaired immune response and increased risk of infection
- impaired wound healing and increased risk of pressure ulcers
- impaired psychosocial and physical function
- increased disability, falls, and early institutionalisation
- increased risk of mortality.
The adverse effects of malnutrition lead to increased use of health services and associated costs, with the health and social care costs estimated to be three times more for a malnourished patient than a non-malnourished patient. Malnutrition affects more than 3 million people across the UK, mostly in the community,3 and national costs exceed £23.5 billion per year. This equates to around 15% of total public health and social care expenditure, which is set to rise as the population ages.2
Prevalence and Impact of Malnutrition
Malnutrition is most common in people aged over 65 years, particularly those living with disease and frailty.2 Studies show that up to 64% of frail older adults are malnourished, compared with just 2% of fit older adults, and the prevalence of malnutrition increases with the severity of frailty.4–6 The relationship between malnutrition and frailty is complex and both conditions underpin and perpetuate the other. They share central features of weight loss, reduced muscle mass, reduced strength and function, often related to a shortfall in protein intake, which is common in older age.7
Protein requirements increase with age due to an impaired ability to maintain and build muscle and increased demands in the presence of disease. Furthermore, physical activity, appetite, and dietary intake often decline with age. The combination of these effects results in a net loss of protein and reductions in weight, muscle mass, strength, and function.7
Although these physical declines are considered to be a natural part of the ageing process, underlying malnutrition may accelerate the rate of these declines and increase the risk of frailty four-fold.4,6 In turn, frailty may further compound malnutrition as associated issues with dexterity, physical function, and balance may pose barriers to accessing and preparing food, which further limits intake. Polypharmacy is also common among frail older patients8,9 and may worsen underlying malnutrition as a result of side-effects such as poor appetite, nausea, vomiting, constipation, diarrhoea, or low mood.
Despite its prevalence in frailty, malnutrition is under-reported and under-treated in primary care,2 perhaps because weight loss is seen as an inevitable part of ageing or disease. However, frailty is not inevitable, and malnutrition is a modifiable factor.8 Managing malnutrition in frail older patients is essential to promote positive clinical outcomes and save money.
Economic analysis shows that identifying and treating malnutrition can save at least £123,530 per 100,000 people per year, equating to £308,820 annually per average CCG in England,2 mostly through the appropriate prescribing of medical nutrition, including oral nutritional supplements (ONS). This has been highlighted as one of the highest potential cost savings from implementing NICE guidance (Clinical Guideline [CG] 321 and Quality Standard [QS] 2410), second only to NICE CG30 on Long-acting reversible contraception.2
Role of the Pharmacist in Malnutrition
While the management of malnutrition frequently involves a multidisciplinary approach, frail older patients often present first in a primary care setting and may experience long waiting times to be seen by a dietitian.
Practice pharmacists are well placed to support the whole primary care team to address a number of issues, including:
- inadequate systems for screening and identification of malnutrition
- lack of understanding among healthcare professionals about the importance of preventing malnutrition
- lack of confidence among healthcare professionals to manage and review patients with or at risk of malnutrition
- lack of implementation of key guidance and best practice
- lack of patient understanding about the importance of nutrition support.
NICE CG32 on Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition1 outlines key clinical and organisational priorities to help improve the management of malnutrition.1 Practice pharmacists should familiarise themselves with the guideline when managing malnutrition in practice. Effective management starts with screening and continues with appropriate nutrition support according to malnutrition risk. Practice pharmacists may have a key role in each of these stages of management.
Screening for Malnutrition in Frail Older People
NICE CG32 recommends the use of the Malnutrition Universal Screening Tool (MUST)1,11 to identify adults with, or at risk of, malnutrition. The MUST is a simple five-step process that calculates a patient’s overall risk of malnutrition (see Figure 1).
A quick-reference body mass index (BMI) chart and percentage unplanned weight loss chart are provided with the MUST toolkit. Alternative procedures are explained if a patient’s height and/or weight cannot be obtained.11
Screening with the MUST is a multidisciplinary responsibility and can be done by any healthcare professional. Practice pharmacists are usually responsible for addressing polypharmacy in practices and primary care networks, and malnutrition screening can be easily embedded in structured medication reviews. Practice pharmacists who are trained in using the MUST can promote effective screening in frail older patients by:
- undertaking MUST screening as part of medicines optimisation and polypharmacy reviews
- supporting training for the wider primary care team so that MUST screening can be undertaken by healthcare assistants, reception staff, and care home staff
- helping to ensure that MUST scores are understood and acted on with appropriate management, by supporting the implementation of evidence-based pathways.
Screening without appropriate management of malnutrition is neither clinically nor cost effective. To promote positive clinical outcomes and cost savings for the NHS, effective management must be implemented.
Managing Malnutrition in Frail Older People
NICE QS24 on Nutrition support for adults states that patients identified at risk of malnutrition should be managed across a range of healthcare settings.10 It is a multidisciplinary responsibility to support the first tier of malnutrition management with appropriate nutrition support. This encompasses a range of interventions including food-based strategies and prescription of ONS. Frail older patients at risk of malnutrition should receive appropriate nutrition support approaches to ensure management is clinically and cost effective.
A guide to managing adult malnutrition in the community,12 often known as the Malnutrition Pathway, was developed by a multidisciplinary consensus panel to support healthcare professionals to identify and manage patients at risk of malnutrition in the community. It highlights use of the MUST for effective identification of malnutrition risk and provides practical guidance on how to manage patients based on their level of risk. Used alongside NICE CG321 and NICE QS2410, the Malnutrition Pathway is a useful tool to determine the most appropriate management plan for patients.
Managing Patients at Medium Risk of Malnutrition
Patients at medium risk of malnutrition, that is, with a MUST score of 1, may be managed with food-based strategies to optimise dietary intake.12 The Malnutrition Pathway provides useful advice on food-based strategies including food fortification, meal pattern adjustment, and overcoming potential barriers to eating and drinking.12 Food-based strategies are best delivered by a healthcare professional with nutritional expertise, such as a dietitian. The practice pharmacist can help to ensure that food-based strategies have been implemented by checking the following during polypharmacy or medicine optimisation reviews:
- if food-based strategies have been discussed with the patient
- if appropriate first-line dietary advice resources have been offered to the patient, that is, the Malnutrition Pathway yellow leaflet Your guide to making the most of your food.13
While there is some evidence for managing malnutrition with food-based strategies alone, data on clinical outcomes or cost are limited. Care should be taken with these methods to ensure that requirements for all nutrients are met, including protein and micronutrients. The presence of disease or frailty may adversely affect patients’ appetite and the ability to access and prepare food and drinks. Dietary advice is only effective if it is feasible, acceptable, and acted on by the patient or their carer.12 Powdered ONS should also be considered for patients with a medium risk of malnutrition.12
Managing Patients at High Risk of Malnutrition
In patients at high risk of malnutrition, or when food-based strategies are inadequate to fully correct nutritional problems, ONS are indicated.1,12 They should be used alongside food-based strategies. The Malnutrition Pathway collates the evidence base for ONS, highlighting that ONS are clinically and cost effective because they:
- significantly increase nutritional intake, weight, and muscle mass
- increase physical function and quality of life
- reduce infections, delayed wound-healing, and pressure ulcers, antibiotic prescriptions, GP visits, hospital admissions and length of stay, and mortality.
Oral nutritional supplements achieve these outcomes without affecting appetite or dietary intake. The evidence base shows that these outcomes are typically achieved with 2–3 months’ supplementation (1–3 ONS servings per day), although this may vary depending on individual clinical need.12
A wide range of ONS are available on prescription including milkshake, juice, yoghurt, and savoury styles; liquid, powdered, pudding, and pre-thickened formats; high-energy, high-protein, fibre-containing, and nutritionally complete types; volumes ranging from 125–237 ml; and various flavours to suit a wide range of needs.12 Practice pharmacists may not feel confident in deciding which type of ONS is most suitable for their frail older patients, so during medicines optimisation and polypharmacy reviews it is important to consider patient-centred factors, which may affect adherence and suitability. For example, frail older patients:
- with malnutrition or at high risk of malnutrition have increased protein requirements and are likely to have poor protein intake
- may have long-standing poor appetite and intake and may, therefore, struggle with large ONS volumes
- may have poor dexterity, physical function, and balance, which may pose a barrier to reconstituting powdered ONS.
Practice pharmacists may also be unsure about the most appropriate time to stop ONS, but it is important to get this timing right to ensure that prescription is clinically and cost effective. If ONS are initiated without follow up, review, and exit strategies, this may compound pre-conceptions of overprescribing, product wastage, and local prescribing restrictions. However, if ONS are initiated appropriately, prescribing is clinically and cost effective. Therefore, when reviewing frail older patients who are prescribed ONS, the practice pharmacist should consider:
- the aim of treatment with ONS (e.g. weight maintenance, weight gain, increased strength, or improvements in activities of daily living)
- the patient’s requirements for ONS:
- short term following recent hospital discharge (initially 6 weeks’ treatment according to clinical condition/nutritional needs)12
- long term due to chronic conditions such as frailty (initially 12 weeks’ treatment according to clinical condition/nutritional needs)12
- if a realistic goal has been set and achieved
- how the patient will be monitored, how often, and by whom
- if specialist referral to a dietitian is required
- when and how the ONS prescription will be discontinued (e.g. will the patient require ‘weaning off’ ONS to ensure the difference can be made up with dietary approaches?).
Soar Beyond’s i2i Network faculty has developed a simple process outlining best practice in the management of frail older patients who are receiving ONS: the GREeat framework (see Figure 2). Nutritional goal-setting on initiation of ONS is key and should be entered on the clinical system so that it is read-coded and recorded for future review points. Patients should be reviewed within an appropriate timeframe, including checking adherence. Ongoing care is dependent on whether goals have been achieved.
A number of resources are available to support practice pharmacists and other primary care professionals to manage malnutrition in frail older patients:
- the MUST11
- the Malnutrition Pathway resources:
- A guide to managing adult malnutrition in the community12
- Ten top tips for implementing the malnutrition pathway: pharmacists14
- the i2i Network faculty programme (www.i2ipharmacists.co.uk)
Malnutrition is costly and common, particularly among frail older adults. To promote positive clinical outcomes for frail older patients, and cost savings for the NHS, malnutrition must be proactively identified and effectively managed. ONS are an evidence-based approach to the effective management of malnutrition, with proven clinical and cost benefits. Practice pharmacists are well placed to ensure malnutrition screening and management of frail older patients by embedding these processes in everyday practice. During polypharmacy and medicine optimisation reviews, practice pharmacists should screen for malnutrition. They should support the implementation of appropriate processes and multidisciplinary training throughout their multidisciplinary team. Practice pharmacists also have a key role in ensuring that appropriate management plans for frail older patients at risk of malnutrition are implemented, by considering patient goals, patient-centred factors affecting adherence and suitability, and appropriate review and follow-up processes. Effective screening and management are a multidisciplinary responsibility and are essential to reduce both the clinical and the economic burden of malnutrition in frail older patients.
Clinical Pharmacist and Care Home Pharmacist
Managing Director, Soar Beyond Ltd (providers of i2i Network)
|Key Points for Practice Pharmacists|
HCPs=healthcare professionals; MUST=Malnutrition Universal Screening Tool; ONS=oral nutritional supplements