Abstract
Background: An estimated one third (1.3 million) of individuals affected by malnutrition in the United Kingdom (UK) are aged 65 years and above, with 93% of total malnutrition cases arising in the community. Malnutrition in the older population is complex, with an interplay of different risk factors affecting its cause as well as its treatment. Evidence suggests that there are significant challenges in the identification and management of malnutrition across healthcare settings, in part due to relatively limited access to dietitians and the lack of clarity around the roles of non-dietetic healthcare professionals (HCPs). While dietitians possess the specialist skills to provide nutritional interventions, they have one of the lowest workforce numbers in the NHS making it difficult to tackle the malnutrition burden alone. There is a clear need for improved opportunities for recognition of nutritionally vulnerable individuals and the implementation of multi-disciplinary management pathways.Aims: The aims of this thesis were to:
1. explore the nutritional care currently provided to nutritionally vulnerable older people in the community
2. establish whether non-dietetic healthcare professionals (HCPs) can provide effective nutritional care to nutritionally vulnerable older people and
3. to suggest potential strategies to improve the nutritional care of people accessing falls services.
Methods: This research project focused on the development phase of the MRC framework for the design of complex interventions through undertaking four studies.In the first stage,^(1) An observational, cohort study was undertaken from a subset of participants from an existing observational cohort study, NUTRICOM (The Impact of Nutrition Risk Status on Older People in the Community) and data from electronic health records (EHR) was collected and analysed to explore and describe the associations between nutritional risk status and the number of contacts in hospital and community settings, healthcare professionals and the documented nutritional care currently provided to nutritionally vulnerable older people in the community (2) A systematic review was conducted to identify and evaluate the current clinical trial evidence on the effectiveness of nutritional care interventions provided by non-dietetic HCPs on patient outcomes. The types of nutritional interventions provided, the professions delivering the interventions, and the settings the interventions are provided were identified. Additionally, the descriptions and completeness of nutritional were assessed using the TIDieR checklist. In the second stage, (3) A cross-sectional survey was conducted to identify current nutritional care practices within multi-disciplinary falls prevention services (4) Lastly, using data generated from studies 1-3, a qualitative study was conducted using semi-structured interviews to capture older adult service, users and HCP perceptions and experiences of nutrition services to explore current service provision, and to suggest potential nutritional care interventions for integration within multidisciplinary falls prevention services.
Results: In this project, the complex nutritional care needs of nutritionally vulnerable older adults in the community were identified and described.
In study 1: Results highlighted the numerous key contacts this cohort has with HCPs and healthcare services, and the missed opportunities for the detection and management of nutritional issues. During the study period, the group at high nutritional risk had higher risk of contact with hospital and community services and professionals than the group at low nutritional risk. Documented nutritional care appeared to be one-off and ad hoc rather than systematic, resulting in missed opportunities for identification and management of malnutrition. No association between the nutritional risk groups were demonstrated for nutritional documentation. Overall total healthcare contacts and documented nutritional care were greater in hospital contacts versus community contacts.
In study 2: Evidence for the potential role of non-dietetic HCPs to be effective in providing nutritional management to patients at nutritional risk was also identified. 18 eligible studies were included and interventions were grouped into three categories: feeding assistance, nutritional care plans and multi-factorial interventions. The very low and low-quality evidence highlighted mixed effects on outcomes. Assessment from the TIDieR checklist highlighted incomplete reporting of the nutritional interventions.
In study 3: Findings from 63 falls service respondents indicated a lack of policy on nutritional management within falls services in England and limited inclusion of routine nutritional care practices. Nutritional screening was a “one-off” procedure, with only 10% respondents reporting re-screening during contact with their service. The bulk of nutritional care was provided by physiotherapists or nurses.
In study 4: Findings from 14 multidisciplinary HCPs, 14 service users and one carer highlighted shared themes and improvement priorities among the HCPs and service users within outpatient and community falls services. These themes include ‘the patient is a complex story, but is nutrition part of it?’, ‘everyone’s job, but no one’s responsibility’, and ‘is the dietitian invisible?’. Intervention strategies addressing key barriers and for the integration of nutritional care the services were suggested by participants.
Conclusions: This thesis highlights the missed opportunities for identification and management of patients at nutritional risk and the need for innovative strategies to improve the detection and management of malnutrition in the community to alleviate the burden of management of malnutrition on dietetic services and “make every contact count”. The study, based on HCP and service user interviews provides a premise for the involvement of non-dietetic HCPs in the identification and first-line management of malnutrition. This thesis concludes by proposing nutrition intervention strategies for the integration of nutritional care in falls prevention services based on HCPs and older adult service users. Future research is needed to explore the feasibility of the suggested interventions in both multidisciplinary healthcare teams and older adults within falls prevention services.
| Date of Award | 1 Jun 2022 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Elizabeth Weekes (Supervisor) & Christine Baldwin (Supervisor) |