MALNUTRITION IN OLDER PEOPLE Introduction Marinos Elia NICE guidelines Typically for specific diseases e.g. specific drugs for specific diseases (malnutrition broad range of conditions) Clinical perspective rather than public health perspective (obesity guidelines expected in 2007 first time NICE methodology applied to public health evidence) NHS perspective (NICE is a special Health Authority) guidance primarily for health care workers generally less attention to those that do not access the health service (NB inequalities) and the public 1
AWARENESS OF HEALTH CARE WORKERS HEALTH CARE WORKERS D e t e c t e d U n d e t e c t e d OLDER MALNOURISHED AWARENESS OF PUBLIC Distribution of undernutrition in the UK hospital community 2
Proportion of illness spent in hospital (from onset to complete recovery) hospital community % with medium + high risk of malnutrition 20 18 16 14 12 10 8 Age effect, p<0.001 65 70 75 80 85 90 Age (years) 3
Risk of malnutrition (%) Low Medium High Medium +Hig Domicile: Free-living 87.6 6.9 5.5 12.4 Institution 79.5 9.4 11.1 20.5 Long-standing illness: No 91.8 4.2 4.0 8.2 Yes 83.8 8.6 7.6 16.2 Overall 86.2 7.3 6.5 13.8 Elia & Stratton 2005 % with medium + high risk of malnutrition 24 22 20 18 16 14 12 10 8 free-living residential 65 70 75 80 85 90 Age (years) p<0.001 4
% with medium + high risk of malnutrition 30 25 20 15 10 5 North of England South of England p<0.001 65 70 75 80 85 90 Age (years) 5
MEDIUM +HIGH RISK OF MALNUTRITION NORTH ENGLAND 19.4% CENTRAL ENGLAND 12.3% SOUTH ENGLAND 11.3% North v rest of England Central v rest of England South v rest of England P (trend) p<0.001 NS p<0.022 p<0.003 medium + high risk of malnutrition 65 y 9.2% 85 y 16.6% 85 y + residential 21.2% 85 y + residential + long standing illness 24.4% 85 y + residential + long standing illness + N. Engl 32.2% 6
Prevalence of vitamin C deficiency (>65y old) Elia & Stratton 2005 35 % with vit C deficiency 30 25 20 15 10 5 0 Mild deficiency (<11 umol/l) Severe deficiency (<5 umol/l) Northern Central Southern Northern England Central England Southern England Same geographical area (controlling for age and sex) Multiple deprivation score 25.0 p = 0.015 22.5 20.0 17.5 15.0 Low (n 581) Medium + high (n = 419) Malnutrition risk ('MUST') Stratton & Elia 2005 7
Utilisation of health care resources by malnutrition risk category Malnutrition risk group Low Medium High p< Hospital inpatients (12 mo) (%) 19 24 55 0.001 Hospital stays (12 mo) (n*) 1.02 1.39 1.47 0.04 GP visit (3 mo) (%) 57 72 84 0.001 GP visit (3 mo) (n*) 1.55 1.78 2.34 0.001 Regular clinic visit (%) 22 21 24 0.88 *geometric mean (Stratton et al 2001) Annual cost and incremental cost of medium + high risk of malnutrition ( MUST ) & associated disease in the UK 8 7 HANS + ONS OP visits GP visits 6 5 Community Community Long-term care Hospital billion 4 3 2 1 Hospital Hospital 0 Cost Cost BAPEN Health Econ. Group 2005 8
Annual cost of disease-related malnutrition in the UK* Elia et al (BAPEN Health Economic Group 2005) 8 7 6 other Long-term care Hospital billion 5 4 3 2 1 0 All subjects >65 y <65 y Malnutrition is undetected and untreated Hospitals inpatients >60% unrecognised (McWhirter & Pennington 1994) 70% unrecognised (Kelly et al, 2000) 62% unrecognised (Mowe et al 1991) Hospital outpatients 45-100% of patients unrecognised (Miller et al 1990); 57% in older outpatients (Wilson et al 2004) Nursing homes Almost 100% of patients unrecognised (26 US nursing homes) (Abbasi & Rudman 1990); Long-term care 50% unrecognised as underweight (CRAG, 2000) Community e.g. 15-50% of children with failure to thrive are unrecognised (Wright et al 1998; Bachelor 1990) 9
Change in practice required single organisation Other organisations/ agencies Control over Its activities Less control over activities of other organisations Disseminate Information - Malnutrition matters - What works - National toolkit - Standard indicators - Implication of complying/not complying Facilitate implementation Co-ordinated formal structures Perform Implementation (focus on existing structures rather than new ones) Local indicators National Regional Local Delivery Chain 10
Delivery chain Clear direction Clear responsibilities Greater efficiency Avoid duplication Sharing expertise/training material Use of same consistent indicators Multidisciplinary Funding and capacity building more coordinated Partnership encouraged Health Authority Hospital trust PCT (Director of Public Health) PARTNERSHIP Local Authority Education Social welfare Health (link with HA) Implementing strategy (include organisations) 11
When is a policy ready for implementation? Plan: Evidence: Are interventions, outcomes and operational infrastructure clearly defined? Is there good evidence that the interventions work? Assessment: Does policy include surveillance and audit of interventions? Resources: Are adequate resources available for implementing programme? Plan: Evidence: When is a policy ready for implementation? Are interventions, outcomes and operational infrastructure clearly defined? Is there good evidence that the interventions work? Assessment: Does policy include surveillance and audit of interventions? Resources: Are adequate resources available for implementing programme? 12
Vitamin deficiencies in older individuals (> 65 years; NDNS 1998) Free living Institutions* % % Thiamine 9 14 B 12 6 9 Vitamin C 14 40 severe 5 16 Folate 20 35 severe 8 16 * Registered residential homes (57%), nursing homes (30%); dual registration homes (9%) and other facilities (4%) DELIVERY CHAIN Sophisticated outcome-focused services, better tailored to the diverse and local needs of the public can rarely be achieved by one organisation alone Instead they require close partnership working together between different organisations at national, regional and local levels. These relationships ultimately linking the responsible ministers to the frontline health worker have become known as the delivery chain, echoing the business concept which refers to the network of systems, processes and organisations through which strategic objectives can be achieved. PSA 2006 13
DELIVERY CHAIN More sophisticated outcome-focused services, better tailored to the diverse and local needs of the public can rarely be achieved by one organisation alone Instead they require close partnership working between different organisations at national, regional and local levels. These relationships ultimately linking the responsible ministers to the frontline health worker have become known as the delivery chain, echoing the business concept which refers to the network of systems, processes and organisations through which strategic objectives can be achieved. PSA 2006 Delivery chain Clear direction Clear responsibilities Greater efficiency Avoid duplication Sharing expertise/training material Use of same consistent indicators Multidisciplinary Funding and capacity building more coordinated 14
Barriers Perceived to be unimportant (lack of evidence) Inadequate skills/infrastructure No ring fenced money/resources Breaking down barriers Highlight importance to patients and Trusts Training and education Establish infrastructure Reallocation (? new) funds/resources Annual cost and incremental cost of medium + high risk of malnutrition ( MUST ) & associated disease in the UK 8 7 HANS + ONS OP visits GP visits 6 Community Long-term care Hospital billion 5 4 3 Community 2 Hospital Hospital 1 0 Cost Cost Incremental cost BAPEN Health Econ. Group 2005 15
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