Pharmacy In focus 114

ELDERLY

care plan. (Last year, BAPEN launched the first Malnutrition Self-Screening Tool, which is designed for use by individuals and/or their carers, who are concerned about malnutrition.)

MUST is a five-step, point-of-care measurement tool, which features patient experience questions and takes approximately five minutes per individual, data is instantly available to pharmacy teams and allows improvements in nutritional care to be delivered while the patient is still in consultation with you. The BAPEN tool is available at www.data.bapen. org.uk.

Level of malnutrition risk

MUST assesses a patient’s level of malnutrition in three categories:

BMI score: >20kg/m²

18.5-20kg/m² <18.5kg/m²

months) <5%

5-10% >10%

Score 0 Score 1 Score 2

Weight loss score (Unplanned weight loss score in past 3-6

Score 0 Score 1 Score 2

Acute disease effect score (unlikely to apply outside hospital)

If a patient is acutely ill and there has been or is likely to be no nutritional intake for more than five days – Score 2

TREATMENT OF MALNUTRITION Low risk = score 0 • Routine clinical care

• Review/repeat screening, ie, monthly in care homes, annually in community

• If BMI >30kg/m² (obese) treat according to local policy/national guidelines

Medium risk = score 1 • Observe

• Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small, frequent meals and snacks, with high energy and protein food and fluids

• Powdered nutritional supplements to be made up with water or milk are available

• Review progress/repeat screening after 1-3 months according to clinical condition, or sooner if the

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• If improving continue until ‘low risk’

• If deteriorating, consider treating as ‘high risk’

High risk = score 2 or more • Treat

• Dietary advice to maximise nutritional intake. Record intake for 3 days, encourage small, frequent meals and snacks, with high energy and protein food and fluids

• Prescribe oral nutritional supplements (ONS) and monitor

• On improvement, consider managing as ‘medium risk’

• If no improvement or more specialist support is required, refer to Dietitian

MANAGEMENT OF MALNUTRITION

In most cases, malnutrition is a treatable condition that can be managed using first-line dietary advice to optimise food intake and oral nutritional supplements (ONS), where necessary.

Once the risk score is ascertained, it’s a matter of the pharmacist agreeing goals of intervention with either the individual or their carer.

Goals should be set to assess the effectiveness of any intended intervention, for example, preventing further weight loss, maintaining nutritional status, optimising nutrient intake during acute illness, healing of wounds or pressure ulcers, or improving mobility.

The disease state and treatment also have to be considered, with the goals of intervention adjusted accordingly.

Management options can include: good food, assistance with eating, addressing social issues, ensuring ability (physical and financial) to shop and prepare food; texture modification; dietary advice to maximise nutritional intake (also known as ‘food first’) and ONS to complement dietary strategies in order to support individuals to meet their nutritional requirements.

DIETARY ADVICE TO OPTIMISE ORAL INTAKE (‘FOOD FIRST’) Everyday foods such as cheese and full-fat milk should be added to the diet to increase energy and protein content without increasing the volume of food consumed. Further

52 - PHARMACY IN FOCUS

guidance and advice can be obtained from local dietitians.

Small, frequent meals and snacks, with food and fluids which are high in energy and protein.

Powdered nutritional supplements are available.

Care should be taken when using food fortification to ensure that requirements for all nutrients including protein and micronutrients are met. Consider a multivitamin and mineral supplement.

Acute and chronic disease may adversely affect appetite and the ability to source and prepare meals and drinks. Dietary advice can only be effective if acceptable and feasible to the individual.

ORAL NUTRITIONAL SUPPLEMENTS (ONS) TO OPTIMISE ORAL INTAKE ONS are typically used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements. They not only increase total energy and protein intake, but also the intake of micronutrients.

ONS come in a range of styles (milk, juice, yogurt, dessert, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre-containing, low volume), energy densities (1-2.4kcal/ml) and flavours. They provide energy along with other essential macronutrients and micronutrients.

Most ONS provide -300kcal, 12g of protein and a full range of vitamins and minerals per serving.

The majority of people requiring ONS can be managed using standard ONS (1.5-2.4kcal/ml): these are often used for people who are frail, elderly or with diagnoses of dementia, COPD or cancer.

SUMMARY

While an individual’s clinical condition may require the services of a multi- disciplinary team, such as a dietitian, GP or occupational therapist, there’s no doubt that community pharmacy can play a major role in raising the awareness of malnutrition – particularly in the elderly - assisting in identifying it and encouraging action to overcome it. •

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