Nutrition in care homes and home care: Recommendations – a summary based on the report approved by the Council of Europe

doi:10.1016/j.clnu.2009.07.011

Clinical Nutrition

Volume 28, Issue 5, October 2009, Pages 492-496

https://doi.org/10.1016/j.clnu.2009.07.011 Get rights and content

Summary

Undernutrition in home care and care home settings has been acknowledged as a situation with various causes and significant consequences on both an individual and social level. A review article exposing this problem has been recently published. Consequently, scientific experts and other stakeholders were involved in formulating recommendations to tackle undernutrition and sensitize political authorities. The forum held in Brussels and its proceedings were considered as a baseline to interview stakeholders involved in care homes and home care in order to propose solutions on different levels. A full report including guidelines was sent and accepted by the Council of Europe, and can be used as a basis for implementing strategies on a national and international level.

A multidisciplinary approach is important to successfully tackle malnutrition on multiple levels: the patients, the health care workers (medical and non-medical), the public, policy makers and society stakeholders. Awareness for patients and caregivers is important; this can be obtained by information and appropriate training. Care home management and kitchen staff activities can be modified in order to promote nutrition. Policy makers should create legal frameworks to confront malnutrition as being a public health concern.

Undernutrition in home care and care home settings is a considerable problem and confrontation involves a multidisciplinary approach.

Introduction

As published previously, undernutrition is a state of nutrition in which a deficiency of energy, protein and other nutrients causes adverse effects on tissue or body form (body shape, size and composition), function or clinical outcome.¹ The focus of the forum organized by the Belgian Food and Health Plan on November 21–22 in Brussels 2007 was on undernutrition, concerning seniors in home care and care home settings. Proceedings of this forum were published as a review article in Clinical Nutrition.²

The Council of Europe is a political organization which was founded on 5 May 1949 by 10 European countries in order to promote greater unity between its members. It now comprises 47 member states. The work of the Council of Europe has led, to date, to the adoption of over 200 European conventions and agreements which create the basis for a common legal space in Europe and propose policy guidelines for national governments. With the help of the National Food and Health Plan (NFHP-B),³ a working group with leading experts from society, academia and authorities was created to identify the main causes of undernutrition and develop an action plan with recommendations to improve the situation. A full report including recommendations on nutrition in care homes and home care has been prepared by the Belgian delegation of the Committee of Experts on Nutrition, Food and Consumer Health and approved by the Council of Europe.3, 4 The report is available on the Council of Europe Online Bookshop.⁴

It is clear that tackling the problem of undernutrition in care homes and home care requires a multidisciplinary approach with different fields of action (Fig. 1). The objective of this action is to promote implementation of nutritional strategies at a European and national level by sensitizing political authorities.

Section snippets

Recommendations addressing underlying causes of undernutrition in care homes and home care

The most important causes of undernutrition are: insufficient intake of nutrients and loss of nutrients. Acute disease and disabilities have been identified as underlying problems, as well as a general decrease in food intake, sensation of hunger and thirst. Especially in the home care situation, many factors can contribute to the gradual decline of the nutritional status.2, 5

It is obvious that confronting undernutrition requires special attention to all confounding factors. Undernutrition is

Recommendations regarding consequences of undernutrition on outcome and quality of life

It has been well documented that undernutrition is linked to poor outcome. Undernourished patients have longer hospital stays, and present a 20-fold increase in complication rate. Moreover, morbidity is increased in these patients compared to well-nourished individuals with the same diseases.⁶ Furthermore, the nutritional deficits often persist for variable periods subsequent to discharge. Patients who remain undernourished at discharge have substantially increased rates of early hospital

Recommendation regarding consequences of undernutrition on health care costs

Undernutrition-related disease is an economic burden in most countries, although limited data are available.¹⁰ Therefore, preventive medicine should be one of the cornerstones of actions undertaken to reduce health care costs. Cost-effectiveness analysis, which should take into account social justice and equity-efficiency trade-off, is important to determine appropriate management. Prevention should probably start during hospitalization, by improving general food provision and offering medical

Recommendations regarding screening, assessing and treating undernutrition in care homes and home care

Screening is the first step in assessing and treating undernutrition. The following tools are proposed in a care home and home care setting: (1) Mini-Nutritional Assessment (MNA) as the first screening choice; (2) the Malnutrition Universal Screening Tool (MUST) can be second; and (3) Subjective Global Assessment (SGA) is considered as the optimal tool for further nutritional assessment. The choice of the screening tool may depend on national practices and practical considerations of the

Recommendations regarding the role and responsibility of health care workers and caregivers

A multidisciplinary approach is important to successfully tackle undernutrition on multiple levels: the undernourished person, the health care workers (medical and non-medical), the caregivers, the public, policy makers and society stakeholders.

Recommendations regarding the organization and management of care homes

Although in most cases food is presented in sufficient quantity and quality, care homes have a high percentage of residents in a state, or at risk, of undernutrition (40–80%).12, 13, 14, 15 The main cause is the lack of statutory provisions regarding the quality and quantity of meals, monitoring nutritional state, and the lack of structural mechanisms for managing a food policy and staff qualifications. The second cause is – as is the case for hospitals – the lack of training of the staff,

Recommendations regarding home care

The family doctor and home care health care workers play a very important role in screening and treatment of undernutrition. Subsequently, identification and implementation of the most appropriate and feasible methods for screening and nutritional assessment are of major importance. Follow-up could be assured by providing a global medical record of each person, describing their nutritional status and personal history in a standard way and make it available to all caregivers. The best and most

Recommendation regarding awareness and education of the society

There is nowadays growing attention to promote more awareness of undernutrition in people themselves, in caregivers and in health care institutions. Attention is paid to adequate information, education, guideline implementation and registration. As a baseline, it is important to provide consumer information on healthy and balanced nutrition in a continuous and coherent manner, by using the most appropriate channels to reach the consumer, such as audiovisual media, general practitioners,

Recommendation regarding responsibilities of policy makers

It is clear that undernutrition should be put on the political agenda and targeted policies should be implemented. With regard to the above-mentioned strategies, national and regional health policy makers, as well as all related policy makers, should make sure that the proper legislative frameworks are set in place for the establishment of the necessary working groups and initiatives, so that simple and cost-effective screening methods, treatment plans and monitoring tools can be put in place.

Conclusion

A multidisciplinary approach is important in successfully tackling undernutrition at multiple levels: the patients and residents, the health care workers (medical and non-medical), the public, policy makers and society stakeholders (Fig. 2). Awareness, information and implementation are the key words to confront the problem.

A series of recommendations has been proposed in order to act on different levels. With regard to prevalence and causes, recommendations include promoting better nutrition,

Acknowledgements

The present report and recommendations on nutrition in care homes and home care have been prepared by the Belgian delegation of the Committee of Experts on Nutrition, Food and Consumer Health (Partial Agreement) (P-SC-NU) and approved by the Council of Europe Consumer Health Protection Committee (Partial Agreement) (CD-P-SC).

This report was conceived in the framework of the Belgian National Food and Health Plan (NFHP-B) by M. Arvanitakis,^a

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Nursing staff must have sufficient knowledge in order to adequately prevent and treat malnutrition. However, only a marginal amount of information on this topic is available in the literature.
This paper provides a comparison of the malnutrition knowledge among nursing staff in Austria, the Czech Republic, the Netherlands, and Turkey and presents factors associated with the malnutrition knowledge of nursing staff.
A cross-sectional study was performed.
Nursing staff from different care settings in Austria, the Czech Republic, the Netherlands, and Turkey participated in the study.
The KoM-G 2.0 (Knowledge of Malnutrition – Geriatric) questionnaire was used for data collection.
In total, 2056 participants from different care settings took part in the study. Between 11.7 % (Turkey) and 32.5 % (Austria) of the participants had high levels of malnutrition knowledge. The country itself was the factor most strongly associated with malnutrition knowledge. The nurses' educational level and specialised training of nursing staff were also significantly (p < 0.001) associated with malnutrition knowledge. Questions about “factors that should be considered during older persons' food intake” were most frequently answered correctly, while questions about “different aspects of nutritional screening” were less often answered correctly in all four countries.
This study was one of the first to describe the rather low level of malnutrition knowledge among nursing staff in different countries. The country itself was identified as the factor most strongly associated with the nurses' knowledge of malnutrition, while the nursing staff's basic education as well as further training were also detected as significant factors. These results indicate that it is necessary to extend and improve (academic) nursing education and to offer specialised training programmes which may improve nutritional care across country borders over the long run.
Institutional Factors Associated with Residents’ Malnutrition in Nursing Homes: A Cross-Sectional Study
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Malnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents’ malnutrition.
Subanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.
This study included 76 nursing homes with a total of 5047 residents.
Malnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.
The prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).
Having a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents’ malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.
Critical review of French training courses on nutrition for professionals in gerontology
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Dans un plaidoyer pour améliorer le statut nutritionnel des seniors, Dorothée Volkert en 2013 insistait sur la nécessité de former les professionnels médico-sociaux. Dans la lignée de ces recommandations, notre objectif est d’inventorier et d’analyser les formations proposées en France sur l’alimentation des personnes âgées à destination des professionnels du « cure », en charge de la santé des seniors (médecin, infirmier, diététicien…) et du « care », en charge de l’accompagnement des seniors dans leur vie quotidienne (auxiliaire de vie, aide-ménagère, cuisinier et directeur d’institution…). Cinquante-huit formations ont été identifiées. Il s’agit essentiellement de formations courtes (62 % durent 2 jours ou moins) dispensées dans le cadre de la formation continue (76 %). La plupart des formations abordent les besoins nutritionnels des seniors et/ou la dénutrition, constituant ainsi un levier important pour sensibiliser les professionnels à ces thématiques. L’analyse sémantique du contenu des programmes a néanmoins permis d’identifier des pistes pour enrichir l’offre de formation : cibler davantage les professionnels accompagnant les seniors à domicile, prendre davantage en compte l’hétérogénéité de la population âgée et aborder davantage les aspects sensoriels et psychosociaux des repas.
In a plea to improve the nutritional status of older people, Dorothee Volkert (2013) insisted on the need to train healthcare professionals. In line with these recommendations, our objective was to identify and analyze the training courses offered in France on older people's diet for both “cure” providers, in charge of seniors’ health (physician, nurse, dietician…), and “care” providers, in charge of assisting seniors in their daily activities (caregiver, cook, manager of nursing homes…). Fifty-eight courses were identified. These were mainly short courses (62% lasted 2 days or less) provided as part of continuing education (76%). Most of the training courses present the nutritional needs of the older people and/or the undernutrition issue, thus constituting an important lever for raising the awareness of professionals on these important topics. However, the semantic analysis of programs raised proposals to enhance the training offer: increasing targeting of professionals working with older people living at home, taking greater account of the heterogeneity in the aged population and being more focused on the sensory and psychosocial aspects of meals and not only on nutritional aspects.
Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions
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Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.
Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)
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To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting.
Observational, multicenter, prospective, pragmatic study.
This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions.
The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months.
Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up.
A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m², interquartile range 18.3–21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m²) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found.
Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.
Direct health care costs associated to neurological diseases and different degrees of malnutrition
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Citation Excerpt :
The prevalence of hospital malnutrition is high and leads to increased healthcare costs. The importance of addressing malnutrition in post-hospital phases has been highlighted and recommendations have been made for tackling malnutrition as a public health problem [8]. Malnutrition in home-based care is a major problem and dealing with it requires a multidisciplinary approach [9].
Home-based care and oral supplemental nutrition may be an efficient way of managing health resources, freeing up hospital resources and improving patient care and quality of life. For some conditions, such as neurodegenerative diseases and acute neurological conditions, adequate nutritional control of patients at the time of discharge, with home monitoring by a home hospitalization unit (HHU), coupled with the introduction of necessary and appropriate oral nutritional supplements for each patient, is a good strategy for ensuring the efficiency of health resources. The aim of this paper is to analyse the direct health costs, considering home care and oral nutritional supplement, of patients with newly diagnosed neurological diseases and at risk of nutritional problems.
A study was designed to measure direct health care costs of patients with neurological related diseases according to their different nutritional needs. The sample for this study consisted of all patients (n = 100) of the Elda University Hospital in Elda, Spain, with newly diagnosed neurological pathology and suspected malnutrition at hospital discharge during a six months period. These patients were included in a home base care program and given oral nutritional supplements afterwards. The nutritional intervention consisted in giving nutritional supplements according to nutritional patients’ needs through a home-based care unit. Nutritional needs could comprise from protein-calorie malnutrition to at risk of malnutrition. Descriptive health care costs analysis was carried out accounting for the nutritional status. Costs are expressed in 2018 euros and for a total time horizon of one year, six months of classical inpatient care and six months of home care monitoring with a nutritional intervention.
Mean direct health care cost for neurological patients in the six months of classical inpatient care was €8309.30 and, the direct healthcare cost of treating these patients according to their nutritional needs from a home care unit was €2970.18. The subgroup of patients that most benefited from the nutritional intervention and monitoring from the home care unit were those who were in a state of protein-calorie malnutrition or at risk of malnutrition. Under the log transformation of the variables, the Shapiro–Wilk test showed significant differences in mean costs at the 5% level for the two time periods for those suffering from protein-calorie malnutrition or at risk of malnutrition.
It is important to measure and economically quantify the direct health care costs of patients with neurological diseases in order to be able to evaluate different hospital and home-care interventions according to different nutritional needs. Oral nutritional supplements and monitoring by the hospital home care unit could be associated with saving money when patients have protein-calorie malnutrition or at risk of malnutrition. Therefore, direct health costs information is needed to future evaluate these different management interventions.

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ReviewNutrition in care homes and home care: Recommendations – a summary based on the report approved by the Council of Europe

Summary

Introduction

Section snippets

Recommendations addressing underlying causes of undernutrition in care homes and home care

Recommendations regarding consequences of undernutrition on outcome and quality of life

Recommendation regarding consequences of undernutrition on health care costs

Recommendations regarding screening, assessing and treating undernutrition in care homes and home care

Recommendations regarding the role and responsibility of health care workers and caregivers

Recommendations regarding the organization and management of care homes

Recommendations regarding home care

Recommendation regarding awareness and education of the society

Recommendation regarding responsibilities of policy makers

Conclusion

Acknowledgements

Clin Nutr

J Nutr Health Aging

Clin Nutr

Am J Med

Scientific criteria for defining malnutrition

Malnutrition in institutionalized elderly: how and why?

J Am Geriatr Soc

Review
Nutrition in care homes and home care: Recommendations – a summary based on the report approved by the Council of Europe