By Anne Wright, RD, Frances Ralph, RD, Rebecca McManamon, RD
In the UK, it is estimated that 1.3 million older people (aged 65 and over) are malnourished – with the majority (93%) living in community settings, including care homes.1 Upon admission to care homes, 35% of residents are malnourished.² Given the impact of COVID-19, rates of malnutrition in care homes could increase further due to the effect of the disease on nutritional status and early discharge of hospitalised patients.³
The UK Health and Social Care Act 2008 (Regulation 14) states that “nutritional and hydration needs of service users must be met”. Care providers must ensure that their service users’ nutrition and hydration needs are assessed and strategies are put in place to meet their requirements.⁴ The Care Quality Commission (CQC) can prosecute for a breach of this regulation, which reiterates the importance of meeting nutrition and hydration needs of care home residents.
This article discusses important macro and micronutrients, such as energy, protein, fibre and vitamin D, for care home residents. It also offers practical strategies for care home staff to help optimise nutritional status amongst their residents.
One small study in nursing home patients revealed that only 18% of residents consumed adequate protein and energy ( ≥ 1.2 g of protein/kg bodyweight and ≥ 85% of their energy needs).⁵ The same study found that patients using Oral Nutritional Supplements (ONS) were more likely to achieve an adequate protein and energy intake. Further research is required to assess dietary intakes in UK care homes.
Reasons for compromised oral intake in older people are varied, including:⁶ ⁷ ⁸
Fibre is not often prioritised in nutrition support advice due to the focus on meeting protein and energy requirements. However, a high-fibre diet has numerous benefits for older people, such as promoting regular bowel movements and reducing risk of diseases such as bowel cancer. ⁹
Recent National Diet and Nutrition Survey (NDNS) data found that most older adults (65 years and over) are not eating enough fibre. The average intake was 18.7g/day; two-thirds of the recommended daily amount (30g/day).¹⁰
Fibre is known to influence satiation¹¹, although interestingly, drinks supplemented with fibre are thought to have limited effects on reduced appetite.¹¹
The ageing process has been linked with a decline in gastrointestinal (GI) function, motility and absorptive capacity.¹² ¹³ As a result, constipation is common in older adults; one study found that up to 40% of care home residents experience constipation.¹⁴
Laxative prescriptions are common in care homes settings, with one-third of care home patients receiving inappropriate prescriptions.¹⁵ Overprescribing of laxatives contributes to polypharmacy, which is a significant problem in care homes¹⁶ and contributes towards frailty in older people.¹⁷
Dietary fibre supplementation is an effective way to manage and prevent constipation.¹⁸ A systematic review concluded that fibre supplementation increases stool frequency and decreases laxative use in long-term care residents, thereby alleviating the burden of constipation.¹⁹
Where possible, food-first measures should be implemented to increase fibre, energy and protein intakes in nutrition support patients. This should be introduced gradually alongside an increased fluid intake to reduce risk of gastrointestinal side effects.²⁰ ONS with added fibre is another useful strategy for optimising nutritional intake in older adults with constipation.
Fluid intake is another important factor to consider in bowel health. Up to 20% of older adults are dehydrated, especially those in long-term care establishments.²¹ Dehydration in older adults has been associated with pressure sores, confusion, poor cognition, urinary tract infections, increased risk of falls and unplanned hospital admissions.²² ²³ Furthermore, dehydration is one of the most common causes of constipation.²⁴
The importance of meeting a service user’s hydration needs is highlighted in the UK Health and Social Care Act 2008 (Regulation 14). Therefore, ensuring that residents are adequately hydrated should be a priority for care home staff (see table 1).
Vitamin D plays an important role in immunity and inflammation²⁵, bone and muscle strength, as well as having a protective role in reducing muscle loss.²⁶ Additionally, low levels of vitamin D are associated with increased risk of frailty.²⁷
UK guidance states that adults should consume a 10 microgram (400 IU) vitamin D supplement daily from October to March – for those with little or no sunlight exposure, Vitamin D should be taken throughout the year.²⁸ Current national lockdown restrictions have meant that care home residents have had limited sunlight exposure. Therefore, the government have provided a free four-month supply of daily vitamin D supplements for residents in residential and nursing care homes in England.²⁹
It is important that care home staff are provided with appropriate training, enabling them to support their residents in meeting nutrition and hydration needs. Education and guidance on all of the areas mentioned below (see table 1) should be provided internally and/or through local dietetic services. This information should also be embedded within internal nutrition and hydration policies. Additionally, care home staff should receive training on writing care plans that incorporate nutrition support actions.
Table 1: Strategies to optimise nutritional status in care home residents
|Strategy||Considerations for Dietitians and Care Home Staff|
|Nutrition risk screening - early detection of malnutrition||Staff should be trained in the use of nutrition risk screening tools such as MUST. They should also be familiar with the Managing Malnutrition Pathway resources, and appropriate use of ONS. ³⁰|
|Vitamin D supplementation||Vitamin D to be included in medication charts/rounds daily, as per Government recommendations.²⁸|
|Menu adaptation||Menus should be varied, offering tasty and visually appealing options to suit a wide range of dietary requirements (e.g., high-energy/vegetarian/fibre modified/gluten-free).³¹|
|Food fortification||Food fortification training for nutrients such as protein, energy and fibre should be provided for care home staff and/or chefs.¹⁹ ³² ³³|
Mealtime environments should be relaxing, with reduced clutter, contrasting colours and reduced background noise.³⁴
Offer a variety of foods on the plate as well as condiments on the table to improve residents' satisfaction with their meals and increase the quantities of food consumed.³⁵
|Nourishing drinks rounds||
Implementing regular nourishing drinks rounds has been found to significantly reduce urinary tract infections, hospital admissions and antibiotic use. ³⁶ ³⁷ ³⁸
Offer a variety of drinks to residents, alongside assistance and encouragement from carers.
Dietitians play an important role in training and supporting care home staff to meet the nutrition and hydration needs of their residents. A significant proportion of care home residents are at risk of malnutrition and have suboptimal intakes of energy, protein, fibre and fluid. Fibre is often an overlooked nutrient in this patient population, despite there being strong evidence to suggest that supplementation can help to manage constipation. ONS with added fibre is a useful strategy for optimising nutritional intake in older adults with constipation, thereby reducing use of laxatives and addressing the issue of polypharmacy in care homes.
Complete CPD questions on this resource