A key challenge of caring for vulnerable patients is the prevention of malnutrition and dehydration. Malnutrition and dehydration are common but often go unrecognised and untreated.
More than 10 per cent of people aged 65 years and over are malnourished and 70 per cent of undernutrition in the UK is unrecognised. Malnutrition and dehydration were identified as underlying causes and contributing factors in the deaths of more than 650 care home residents between 2005 and 2009.
Malnutrition and dehydration greatly increase an individual's vulnerability to illness, clinical complications and death. Dehydration is one of the risk factors for falls in older people and is associated with pressure ulcers, faecal impaction and cognitive impairment.The clinical effects and consequences of malnutrition are wide ranging. Impaired immune response can weaken the ability to fight infection. Reduced muscle strength and fatigue can impede self-care and may result in falls. In bed-bound patients this can result in pressure ulcers and blood clots.
According to Malnutrition Pathway, disease related malnutrition costs the NHS more than £13 billion per year based on malnutrition figures and the associated costs of both health and social care. A saving of just one per cent of the annual health care cost of malnutrition to the NHS would amount to £130 million annually.
A report from Carers UK based on the experiences of more than 2,000 carers says that malnutrition can be a hidden issue. Carers may be unaware of where best to seek help, and can feel isolated and guilty that the person they are caring for is becoming malnourished, according to the report.
The state of services
Screening and planning for effective nutrition and hydration, coupled with quality food and beverage services and appropriate nutritional support are needed in all care settings. This includes considerations around enteral and parenteral as well as oral nutrition. Evidence collected by Age UK suggests that the reality falls short of what is needed. Concerns have also been raised about monitoring and reviewing processes in the administration of parenteral nutrition to ensure effectiveness and safety.
Identifying factors, targeting actions
Several factors reduce the effectiveness of services. These include lack of prioritisation of nutritional care, lack of awareness of the multiple impacts of malnutrition and hydration and the lack of trained staff.
Research literature from the University of Birmingham has noted the need to move from identifying concerns about nursing performance to targeting actions designed to alleviate contributing factors. This includes an understanding of the pressures of the healthcare environment and the demands of productivity and performance.
Nutrition and hydration present a specific set of challenges and need the attention and visible effort given to other patient safety issues. Early identification and intervention are essential.
Guidance documents and tools have been developed across the UK in response to these challenges. See the Nutrition – improvement actions page in this Clinical Topic for tools and approaches.