A survey explored patients’ views of their nutritional status on arrival in hospital and how this might change during their stay
In this article…
- Problem of malnutrition in older people
- Results of an audit exploring patient and family perceptions of malnutrition
Harriet Gordon is consultant gastroenterologist; Carolyn Best is nutrition nurse specialist; Jill Summers is senior dietitian; all at Royal Hampshire County Hospital, Hampshire Hospitals Foundation Trust.
Gordon H et al (2014) Patient and family views of nutritional status. Nursing Times; 110: 17, 13-14.
Providing adequate food in hospitals remains a concern for those involved in healthcare as well as patients and relatives. We conducted a small-scale survey to explore relatives’ and patients’ perceptions about the risk of developing malnutrition in hospital and to gauge whether further more in-depth audit was required.
5 key points
- Around 10% of older people living in the community in the UK are malnourished
- Malnutrition is associated with a poorer clinical outcome and longer length of hospital stay
- Many older people are unaware that they are at risk of malnutrition
- Older people who live alone are more likely to have increased health risks than those living with, or close to, family
- Relatives expect patients’ nutritional state to improve while in hospital
Malnutrition is under-recognised and undertreated in the UK. Public expenditure on disease-related malnutrition in 2007 was estimated to be in excess of £13bn per annum, about 80% of which was in England (Elia and Russell, 2009). It is suggested that 10% of older people living in the community in the UK are malnourished and, of that number, 70% of cases are unrecognised and untreated (European Nutrition for Health Alliance, 2006).
Malnutrition is a particular problem for older people who are ill and is associated with a poorer clinical outcome and longer length of stay in hospital (Elia and Russell, 2009; Stratton et al, 2003). It has been reported in 25% of patients on admission to hospital; this increases to 31% in those over the age of 65 (Russell and Elia, 2011).
A Patients Association (2011) report pointed out that many older people are unaware they are at risk of developing malnutrition and do not know how to reduce their risk or where they can go for help and advice. It also noted that health professionals often miss opportunities to assess and intervene when presented with patients who are underweight or malnourished, not only in hospital but also in GP surgeries or during contacts in community settings.
In the UK the population aged 65 years and over was 10.8 million (17% of the total population) in mid-2012 (Office for National Statistics, 2013); of these, over 3.8 million live alone (Age UK, 2014). There is a perception that older people who live alone are more likely to feel socially isolated and have increased health risks than those who live with, or near to, family (Cornwall and Waite, 2009). One report suggests mortality rates increase up to four-fold in older people who are socially isolated compared with those who have extended social or family ties (Fratiglioni et al, 2004).
It is not uncommon to see stories in the national media or from patient-focused organisations, families or carers about poor nutritional care in hospitals (Patients Association, 2011; Francis, 2010). However, there are fewer reports on older patients’ perspectives of their nutritional care in hospital. To explore this and gain an understanding of the expectations of older patients in hospital and their family/carers we undertook a survey about patients’ nutritional status on arrival in hospital and how they thought this might change during their stay.
As part of their training programmes we helped a multiprofessional group of students (including nursing, physiotherapy and pharmacy students) to undertake the survey using a pre-agreed questionnaire for patients (Box 1) and an adapted version for relatives/carers. In total, 105 participants were included (57 patients and 48 relatives/carers). Patients aged over 65 who had been in hospital for more than 24 hours, and their family members or carers, were invited to participate. Patients were excluded if they could not answer questions independently or coherently.
Patients and relatives were approached and questioned separately to minimise any influence they might have on each other.
Length of stay for patients varied: 22 (39%) had been admitted to hospital within the previous seven days; 15 (26%) had been in hospital for 8-14 days; nine (16%) for 15-30 days and 11 (19%) for over 31 days. Thirty-four (60%) normally lived alone, while the remaining 23 (40%) lived with or close to family members; when the two groups’ perception of their own nutrition status was compared, no difference was identified.
Of the 57 patients who participated, 43 (75%) did not consider themselves to be in a malnourished state on admission to hospital. The remaining 14 (25%) did consider themselves to be malnourished, although the severity of malnourishment was not explored specifically. By comparison, only seven (15%) of family members/carers thought their relative was malnourished on admission to hospital; the remaining 41 (85%) considered their relative’s nutritional status to be within normal range.
Of the patients who considered themselves malnourished before admission to hospital, eight (57%) thought their nutritional status would be unlikely to alter while they were an inpatient, while four (29%) thought it was likely to improve; only two (14%) thought it was likely to deteriorate further in hospital.
Only one (2%) of the patients who did not consider themselves malnourished thought their nutritional status was likely to deteriorate in hospital; 30 (69%) thought it was likely to remain the same, while the remaining 12 (28%) thought their nutritional status would improve slightly.
When questioned about the level of assistance needed to eat their meals only seven patients (12%) said their nutritional intake would improve when they were helped to eat their meals in hospital; however, the number of patients whose nutritional status was likely to improve if they received such help rose to 11 (19%) when family members’/carers’ views were taken into account. To explore this further we looked into the proximity of these 11 family members/carers to their relative: six (55%) lived away from them; four (36%) lived close to, or with, their relative; and one family member did not answer this question.
The aim of the audit was to explore patients’ and relatives’ perceptions of the risk of developing malnutrition in hospital in view of recent high-profile media reports, and to gauge whether further more in-depth audit was required.
We aimed to explore whether family members who lived further away from their relatives where more or less likely to report concerns about the nutritional state of their relative before and after admission to hospital. However, this did not appear to be the case as there was little difference in reporting between those relatives/carers who lived with, or close, to patients and those who lived farther away.
All family members/carers who thought their relative was malnourished before admission to hospital stated they expected their relative’s nutritional status to improve while in hospital as their meals would be cooked for them and they would receive help and encouragement.
Our results demonstrate that patients were more likely to state they were in a poor nutritional state than relatives. However, relatives were more inclined to expect patients’ nutritional state to improve while in hospital. There was no clear difference in expectations between patients living with, or close to, relatives/carers and those living alone.
This audit has a number of limitations, in particular the level of information asked of participants. The audit was undertaken to gauge an insight into the perceptions of patients and their relatives and to ascertain whether there were issues in our area that needed to be addressed.
This survey explored whether the perceptions and expectations of patients and their relatives were influenced by the proximity in their living arrangements. This did not appear to be the case. It has highlighted that expectations of relatives and patients need to be managed on arrival in hospital and ideally matched with accurate nutritional assessment. Better communication is needed to ensure all involved have a clear idea of relatives’ expectations about the patients’ capabilities to eat independently in hospital.
Based on these results it would be useful to undertake further investigation into whether perceptions of nutritional status on admission to hospital match actual nutritional status, and to examine whether the type of ward or presenting illness has an impact on nutritional status and the level of supportive nutritional care required in hospital.
Age UK (2014) Later Life in the United Kingdom. London: Age UK.
Cornwall EY, Waite LJ (2009) Social disconnectedness, perceived isolation, and health among older adults. Journal of Health and Social Behaviour; 50: 1, 31-48.
Elia M, Russell C (2009) Combating Malnutrition: Recommendations for Action.
European Nutrition for Health Alliance (2006) Malnutrition Among Older People in the Community: Policy Recommendations for Change.
Fratiglioni L et al (2004) An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurology; 3: 6, 343-353.
Office for National Statistics (2013) Annual Mid-year Population Estimates, 2011 and 2012.
Patients Association (2011) Malnutrition in the Community and Hospital Setting. tinyurl.com/mal-nutritional-hosp-comm
Russell CA, Elia M (2011) Nutrition Screening Survey in the UK and Republic of Ireland in 2010. tinyurl.com/BAPEN-UK-ROI-survey
Stratton RJ et al (2003) Disease-Related Malnutrition: An Evidence-Based Approach to Treatment. Wallingford: CABI Publishing.