The Causes of Malnutrition among Elderly and How It Can Be Prevented
Introduction
Person-centred care does not have a single definition as it continuing to change and develop along with the patient's needs (Silva, 2014).) It is the role of the nurse and every medical staff involved in the care of a patient to include the patient in the decision making regarding their treatment and care. For an accurate identification and effective management of Malnutrition, nurse adequate knowledge and intervention is required for a good patient outcome. This study investigates the registered nurse's knowledge from the nursing home, hospital, home care, and palliative care.
Introduction to Person-Centred Care
Patient-centred care is focused on treating a person receiving care keeping their interest at heart. It is also referred to as person-centred care, linked to a person's health care rights (Santana et al., 2018). This aspect place the patient at the centre of everything in care provision by treating them with dignity, respect, sharing care between community and health care centres, tailoring this care to suit a patients' needs and helping these patients to identify new ways to get better. Every patient has a right to be treated with respect and dignity despite their gender, race or nationality (Haydon et al., 2018). To provide the best care to these patients, health care professionals should understand the care preferences of patients and respect them throughout the treatment process.
Another crucial part of patient-centred care is active patient involvement. Aspect involves patients collectively in decision making and health care planning to improve health care. Medical practitioners should share information with their patients and give them time to consider different options and ask questions on the same (Ekman et al., 2021). In situations where a patient is receiving multiple treatments, careful planning will enable the prioritization of treatments depending on the need. High-quality care in patient-centred care is based on open and effective two-way communication between patients and health professionals. These professional are expected to provide an in-depth explanation of care, available treatment options, prognosis, the potential side effects and the overall costs. A clear understanding of one’s treatment plan will help them make informed decisions about the care given to them (Nilsson et al., 2019). Lastly, patient-centred care should also incorporate safe environments that include personalized privacy and separate room treatments. Patient-centred care is more than how your health care professional treats you. It is about how governments and health services create and support policies to be used in health care.
Introduction to Malnutrition among Elderly and How It Can Be Prevented
In situations where a person's diet does not provide enough nutrients for optimal health, it is referred to as Malnutrition. Malnutrition is defined as a poor diet that does not contain a sufficient amount of nutrients leading to weight loss or a diet that contain more nutrients than recommended leading to obesity (NHS, 2020). World health organization (2020) has stated that malnutrition term has two broad groups of conditions which it covers. The first one is defined as under nutrition which includes low weight and low height, the second one is micronutrient deficiencies, this includes a diet which does not contain the important vitamins and minerals (WHO, 2020).
This condition is caused by inappropriate dietary choices that may be brought about by low incomes and different physical and mental conditions (Silva, 2014). When the body does not get enough food, there are delayed growths and low weight. Obesity is a possible condition that may result from Malnutrition. The common symptoms of this disorder are lack of appetite, or interest in food, irritability, lack of concentration, depression, loss of body weight and longer healing times for wounds (World Health Organization, 2020). Treatment of Malnutrition is possible; however the side effects of this condition may have long term effects for individuals with severe cases. Malnutrition may also be caused by severe mental conditions such as anorexia nervosa (McCormack and McCance 2010).
Digest disorders may also result into Malnutrition especially if the body does not absorb nutrients effectively. This digestive stomach conditions include, ulcerative colitis, celiac diseases, diarrhoea and vomiting (NHS,2020). Malnutrition is a risk factor for the elderly in the society. Older adults who are in hospitals or under institutional care are at more risk of developing Malnutrition. It is estimated that more than 30% of older adults are affected by malnutrition while at home while 20-60% of these adults are affected by this condition while in hospital care. (Silva, 2014) Malnutrition has devastating effects such as mortality and morbidity among the elderly which is an increasing cost in health care setting. Treatment of this condition majorly depends on a person’s general health as well as how severe the condition is (NHS, 2020). Consumption of high calorific, protein and vitamins foods helps in treatment of malnutrition cases. The best way to prevent Malnutrition is to eat health and well balanced diets such as fruits, vegetables, starch, milk and protein sources (NHS, 2019)This literature review has focused extensively on the major causes of Malnutrition and how the situation can be remedied. Different studies have been compared and contrasted on the same.
There are many factors that contribute to Malnutrition in elderly people, in United Kingdom (UK) it has been estimated that people the age of 65 years old and over are malnourished (Age UK, 2012). Good nutrition has many benefits on an individual; it contributes to a healthy development and ageing, good nutrition canlower the risk of developing disease such stroke, heart failure, diabetes or memory problem (Pray, 2010). Elderly people tend to develop an eating disorder which includes the refusal to eat; this can lead to weight loss or malnourishment that can have a negative effect on their health or treatment (Oxford Academic, 2021). Nurse can improve nutrition in elderly patientsbyeducating them on the importance of good n utrition and by putting patient on food record chart (Nursing Time, 2002).
It has been estimated that one million of elderly people are at risk of malnourishment and other are malnourished in the UK, 1 in 10 people at the age of 65 years and over are malnourished, despite all the intervention to combat nutrition issue among elderly people, Malnutrition still a big issue the UK(Malnutrition Task Force, 2021). The most common cause of malnutrition issue among elderly people who are admitted to the hospital is eating disorder which includes the refusal to eat and lead to weight loss. Physical, social and psychological effect can have an impact on a person eating habit, elderly people tend to suffer from loss and grief of a relative such as parents, spouse and children or a friend, grief can be experienced in a form trauma or loss and some elderly people tend to turn their back to foodas they find comfort in it, and other tend to restrict calories or refuse to eat (Aziz, Rafferty and Jurewicz, 2018). Public Health England (2017) has stated the importance of tackling Malnutrition, Malnutrition has negative effect on every part of the human body, it contributes to a long-lasting health condition, Malnutrition can also affect the individual ability to fight infection which can put them at risk of developing pneumonia, in older people malnutrition increase the risk of falls due to the decrease in their mobility caused by poor dietGOV.UK. 2017.
The Five Year Forward View which was developed in October 2014, their aim is to outline the challenges and issues that the NHS face and set goals on what needs to be changed (England.nhs.uk, 2014). Food for life programme has outline ways in which they will support to the NHS Five Year Forward View, to tackle Malnutrition among elderly people, The Food for Life Better Care Programme is a programme that was designed to tackle Malnutrition among elderly people from hospital, care home and community and to improve nutrition by providing older people with good food provision and communal dining (Foodforlife.org.uk, 2014). However BAPEN (British Association for Parenteral and Enteral Nutrition) a charity that began in 1992 to raise awareness of the impact that Malnutrition has on an individual and how it can be prevented has stated that, the latest data shows that many patients whether older or young from hospital, health care and care homes have not been receiving any support from any form of nutrition support, and malnutrition issue still going under-identified and untreated (Bapen, 2018).
However a research that has been done on the screening tool that is used to identify elderly people with Malnutrition has found that malnutrition screening tool has not been used in the primary care as recommended during the routine check and weight loss has been misbelieve as a process of ageing in elderly people, a tool named The MUST which was developed by BAPEN can be used to identify patient current weight status, any unintentional weight loss and any nutrition intake effect caused by acute disease, this tool is proven to reduce the clinical risk factors which is linked with Malnutrition compare to the body mass index (BMI)which is not adequate(Murphy, Mayor and Forde, 2018). Food record chart is a chart that is used in practice to document the quantity of the food and drink that the patient has had during the day starting from the breakfast to the last meal in order to plan their treatment especially patient who are at risk of Malnutrition. (Contributor,2002) however the information documented on the food record chart tend to be inaccurate as it is often documented as for example patient ate a big or a small bowl of cereal, or inaccurate information from the patient and this does not provide sufficient information as required.
The main objective of this study is to assess the main causes of Malnutrition among the elderly in the society and devise prevention and treatment strategies. This paper also focuses on different studies conducted on Malnutrition by comparing and contrasting the main themes identified in this study. This study also aims at reducing the prevalence of Malnutrition to other vulnerable groups such as under-fives, pregnant and lactating mothers. It also aims at improving nutritional status of the most vulnerable groups in the management of infectious diseases. This literature review assesses the main causes of Malnutrition among the elderly and how it can be prevented. Papers used in this review clearly informs the topic of research and have been able to determine that there are different causes of Malnutrition and associated risk factors that may present long term or shorter side effects depending on the severity of the disorder.
Statistics
Malnutrition issue has a great financial burden on NHS, it has been estimated that one adult in 20 or three million of adults are being affected by Malnutrition, and this cost the NHS £20 billion every year (Stuart, 2020). The rates of Malnutrition in UK has doubled compared to 2020, as in 2006 Malnutrition was estimated to cost around £7.3 billion a year in the UK, care home was a risk factor for elderly as an estimation of up to 90,000 elderly people were at risk of Malnutrition, this had an impact on the length of hospital stay and mortality rates (SCIE, 2009). Due to the increase in life expectancy of both male and female, nutrition in elderly people has become a focus of investigation, it has been reported that from 2017 to 2019, life expectancy of a male was 79.4 years and for a female 83.1 years in the UK (Office for National Statistics, 2020). A healthy diet plays a huge role in preventing or delaying the health problems risk that comes with the increase in life expectancy. During the investigation, the investigators have found that 60% and 80% of patients in European hospitals are malnourished, 15% of these patients were elderly patients (Corcoran et al., 2019). The Care Quality Commission (CQC) has reviewed the dignity, privacy and nutrition in the hospital and care homes and the report was published in March 2013, during the inspection the inspector found that 83 per cent of 500 care homes met the elderly nutritional needs by taking into account people food preferences such as the food they like or dislike, however other people did not receive support during mealtime, the inspection was also carried out at the hospital looking at the same issues and found that despite the poor care in the patients nutritional needs, the percentage of the nutritional needs met was 88 per cent compared to the care home(Care Quality Commission, 2013). Poor nutrition or a lack of eating for two or three days can cause a person to become malnourished and lead to weight loss, however these sign goes unrecognized until Malnutrition seriously affect the individual health, well-being and lead to financial burden on NHS, as it is often overlooked as an underlying cause of poor health among elderly people, BAPEN has found that treating a malnourished person is more expensive which is two to three times expensive compared to a patient who is not malnourished(Malnutrition taskforce, 2017). The cost that Malnutrition could be decrease by implementing the NICE guidance into practice, the management of Malnutrition such as early identification and treatment can save up to £123,530 per an estimation of 100,000 people and reduce the use and cost of health care (Bapen , 2018). A healthy nutrition is a fundamental part of an individual at any stage of their life whether old or young, especially vulnerable people however a data shows that 1 in 3 people admitted to the hospital are malnourished which is caused by many different conditions such as disease, or aging(NHS England, 2015). NICE has set standard which cover the best practice that must be implemented into everyday practice, this quality standard covers all healthcare settings providing care to patients who are malnourished or at risk of Malnutrition, and patients on nutrition support which include parenteral nutrition and enteral nutrition. NICE has set 5 statement and each statement contain the quality of care that need to be implemented into practice, statement 1 is about screening as screening can be a useful tool to identify patients at risk of Malnutrition, statement 2 is about creating a management care plan and the fourth statement is providing people who are at risk of Malnutrition or malnourished and their careers with training to monitor and manage their nutrition need(NICE, 2012).
Summary of Search strategy
The topic of the causes of Malnutrition among elderly and how it can be prevented is a bit broad and requires a lot of research. Articles and journals from PubMed, Google scholar, MEDLINE, FINNA and CINAHL were used in informing this research. These sources had rich databases that were scientifically published. Literature review was highly preferred as a data collection method as it focused on collecting data from peer reviewed sources. Eligible published literature used in this research was obtained using the preferred reporting items for systematic reviews and meta-analyses. Key words such as ‘malnutrition’ ‘OR’, causes of malnutrition ‘AND’, ‘Prevention of malnutrition’ ‘OR’ were used. These Boolean expressions were used to combine these key words for research. Articles that primarily focused on causes of Malnutrition among the elderly were used primarily to inform this research. The inclusion criteria were restricted to English articles located in the UK. The excluded articles were those that were limited in opening and needed subscription fee to access. Articles that were not in English and published outside UK were omitted from the study. The inclusion and exclusion criteria helped in channelling the focus of this study towards achieving the main objective of this literature review. The findings of this research were examined using thematic analysis. Reviews that were identical and informed the research question were analyzed. Data from 8 sources was closely examined to identify the common themes and topics under study. The list obtained from critical evaluation is compiled to allow for naming of each theme to establish an introduction of this research question.
Literature review
Forss, K. Nilsson, J.and Borglin, G. (2018) undertook a qualitative study on the participation in nutritional care for elderly people in the nursing homes, the study stated that nutritional care for elderly people has been seen as a low priority by nurses, however good nutrition contributes to the aging process. The aim of this study was to illuminate the view that the nurses have on an elderly person participating in their nutritional care, the study collected data through interview and the participants consisted of four elderly people from the age of 65 years and over, which one was a male and three females, the four older people had to meet the requirement such as they have to be 65 years old or over, as the study took place in Sweden the participants must be able to speak and understand Swedish and be cognitively intact. and eight registered nurses working indifferent accommodations(SjögrenForss, Nilsson and Borglin, 2018).
The study has found that older people were offering poor information quality concerning their nutritional care and elderly people were not involve in their nutritional care as registered nurses did not find it important to involve them and inform them about the outcomes of a nutritional assessment(SjögrenForss, Nilsson and Borglin, 2018). Their reason for not involving elderly people in their nutritional care were lack of time, older persons not showing any interest in their nutritional care and trouble understanding the cause of the older persons malnutrition(SjögrenForss, Nilsson and Borglin, 2018). The study concluded that despite all the factors and barriers making it difficult to involve older people in their nutritional care, the registered nurses should understand the importance of involving them in their care (SjögrenForss, Nilsson and Borglin, 2018).
A study has been done on the intervention to prevent and to treat Malnutrition in elderly people, the aim of this study was to evaluate how these intervention and treatment contributed to the patients’ outcome (Cate et al., 2020). As Malnutrition can worsen an elderly person health problem, it is the role of the nurse to improve the patient nutritional care, randomized controlled trials and the Cochrane tool was used as a method during this research to assess the risk of bias (Cate et al., 2020). The research included a total of 21 studies which 14 of the studies has identified a higher risk of bias, the study has found that the nurse played a role in treating and preventing Malnutrition by providing oral nutritional supplements, food fortification and provided older people who were at risk of Malnutrition with education and dietary counselling (Cate et al., 2020). The study concluded that although the study has identified four effective interventions in elderly nutritional care, there is still a need of a highly quality research in the nurse nutritional care(Cate et al., 2020).
This study found similar aims and outcomes of Bassola, B. Tommasi, V. Boneetti, L. Bauer, S. and Lusignani, M. (2020) both studies used different method to measure the registered knowledge regarding elderly people nutritional needs and whether the nurses had knowledge on the intervention which can help in treating and prevent Malnutrition, however the result from Bassola, B. Tommasi, V. Boneetti, L. Bauer, S. and Lusignani, M. (2020), study is more accurate as the questionnaires tool had to be evaluate and marked by medical expert who had experiences on elderly nutritional need and care.
Hazzard. E, Barone. L, Mason. M, Lambert. K, McMahon. A, (2017) carried out a study on patient-centred dietetic care in elderly malnourished patients, governing organization recommend an implementation of person-centred approach to be prioritized in the vulnerable malnourished older patients to improve the outcome of their treatment. The aim of the study is to identify the quality of dietetic services of the malnourished elderly patients, 56 older people who were 28 males and 28 females aged 81 years completed a survey to identify the quality of malnutrition assessment from the dietician. The study found that patients and their family were involve in their care, there were an improvement in patient weight and there was a high-quality dietetic care set in place for malnourished patients.
This study found similar aim which was involving elderly persons in their nutritional care and decision, however Hazzard. E, Barone. L, Mason. M, Lambert. K, McMahon. A, (2017), study had good outcome compared to Forss, K. Nilsson, J. and Borglin, G. (2018) study as dieticians are specialized in patients nutrition care as their focus is to improve the patients nutrition needs, as it has been mentioned from Forss, K. Nilsson, J. and Borglin, G. (2018) study the reason for not involving elderly persons in their nutrition care is lack of time.
Frank, M. Sivagnanaratnam, A. and Bernstein, J. (2015) carried out a study on the nutritional assessment a MUST tool in older people care, the MUST is a malnutrition screening tool that was launched in 2003, each score of the MUST screening tool has its own recommended intervention. 64 elderly patients from Watford general hospital were included in this study, the study found that 73 per cents of patients had a completed assessment of the MUST documented, 70% score were accurate and for the remaining of the patients the MUST score was miscalculated leading to confusion (Frank, Sivagnanaratnam and Bernstein, 2015). The study has found that lack of an appropriate training among the healthcare staff is the cause of errors when calculating the MUST score, incorrect estimation of weight loss was also classed as the contributor to the errors (Frank, Sivagnanaratnam and Bernstein, 2015). The study concluded that the MUST score is an important screening tool that can identify early sign of Malnutrition, the errors from calculating the score of the MUST came from not knowing patient previous weight (Frank, Sivagnanaratnam and Bernstein, 2015).
Zhou, J. Wang, M. Wang, H.and Chi, Q. (2015) carried out a study to compare two nutrition assessment tools in elderly inpatients in China, the aim of this study was to study and compare two nutritional assessment which are Mini Nutritional Assessment and Nutritional Risk Screening 2002 which are used in elderly patients who have been admitted in surgical ward (Zhou J, Wang M, Wang H, Chi,Nutr 2015). 142 elderly patients participated in this study, Mini Nutritional Assessment and Nutritional Risk Screening assessed the participants within 48 hours of admission (Zhou J, Wang M, Wang H, Chi, Nutr 2015). The result found that the risk of Malnutrition among elderly people were higher especially in older persons with digestive disease, the study found that Mini Nutritional Assessment more suitable tool for assessing elderly patients nutritional needs compared to and Nutritional Risk Screening tool (Zhou J, Wang M, Wang H, Chi, Nutr 2015).
This study found similar aim and outcomes to the Frank, M. Sivagnanaratnam, A. and Bernstein, J. (2015), as they both looked at the accuracy of the malnutrition screening tool, the study of the MUST tool has highlighted the factor that was contributed to a miscalculated score, however Zhou, J. Wang, M. Wang, H. and Chi, Q. (2015), study has highlighted a health condition which is digestive disease that was contributing to the risk of Malnutrition.
Hestevik, C. Molin, M. Debesay, J. Bergland, A. and Bye, A. (2019) carried out a study on the experiences of healthcare professional in elderly nutritional care, recent studies identified barriers and inadequate training in elderly nutritional care, the aim of this study is to explore the experience of healthcare professional in providing nutritional care to elderly patients in care home and in acute geriatric hospital. The study interviewed 23 healthcare staff from home care and acute geriatric and found that the healthcare professionals experienced difficulties in meeting the care of the patients with complex nutritional problems, there were not enough time to individualize nutritional care for elderly patients, however the study concluded that healthcare professionals needed to be provided with important knowledge and policy makers on how the elderly persons nutritional care can be improved(Hestevik, Molin, Debesay, Bergland, and Bye,2019).
Marples, O. Baldwin, C.and Weekes, E. (2017) carried out a study on the effect of healthcare staff training regarding patient nutritional care and patient outcomes, the aim of this research is to study whether the implementation of nutrition training in healthcare settings can help tackle Malnutrition. The study used training strategy as a method which included behavioural, psychological and cognitive training strategies, the study found that healthcare staff who took part in cognitive training strategies reported to have higher knowledge compared to those who did not participate in the training(Marples, Baldwin, and Weekes,2017). However, one study that was undertook by residential care homes nurses reported no difference in knowledge as a part of nutritional training, this study concluded that improving the staff attitude toward nutrition can result in more comprehensive actions toward Malnutrition, however factors such as the quality and duration of educational input or training and care setting can affect the training efficacy (Marples, Baldwin, and Weekes,2017).
This study found similar aim from Hestevik, C. Molin, M. Debesay, J. Bergland, A. and Bye, A. (2019) study, as both study focus on the healthcare professional training as adequate knowledge and training can help in tackling Malnutrition among elderly people, however Marples, O. Baldwin, C. and Weekes, E. (2017) training strategy used a method that did not only collect data but also improve the participants knowledge regarding patient nutritional needs and care.
Conclusion
Malnutrition is a major international crisis and a United Kingdom health problem which has been unrecognized with limited research on the same. There different causes of Malnutrition such as poor diet and low income as well as physical and mental issues that have been critical evaluated in this review. There are evidence based guidelines which have been recommended in the management of Malnutrition in adult patients across the continuum of care. From the 8 studies assessed, it can be deduced that there different causes of Malnutrition related to dietary and mental issues. Inappropriate dietary choices, low incomes physical and mental conditions have greatly contributed to malnutrition cases in the elderly people in home or hospital care. In severe and extreme cases it can lead to mortality or long lasting side effects. Patient centred care is encouraged in this case scenario to improve the quality of care provided to these patients.
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