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Policies for elderly care in the UK

发布时间:2017-04-22
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AGEING SOCIETY

People are living longer, especially across the Western world. This has produced a corresponding increase in health care costs, because older people have a higher prevalence of degenerative and infectious diseases (Dietetics, 2006). Ageing has been implicated in obesity, diabetes, cardiovascular disease, and psychopathology (Hu et al, 2000; BNF, 2004). Currently, more than a fifth of the UK population is aged over 65 years, and this proportion will increase to around 30% across Europe by 2030 (BNF, 2001) Old age is characterised by a greater susceptibility to degenerative, infectious, genetic, and lifestyle-related illnesses. A Department of Health survey in the early 90s found that over 50% of the elderly have a chronic illness, 20% have trouble seeing, 10% are unable to walk (down the road, or up a staircase), and 50% of women and a quarter of the men aged >85 years lacked the ability to cook a meal (DOH, 1992). These difficulties continue to afflict the elderly today (BNF, 2003), hampering their ability to cater for their nutritional needs.

NUTRITIONAL PATTERNS

Malnutrition is a growing problem amongst the elderly (Smithers et al, 1998; BNF, 2001, 2002, 2003; Dietetics, 2006). Nutrition requirements become more critical with increasing age. Energy levels drop off sharply, causing an exponential reduction in BMR (basal metabolic rates). It is important for older people to remain active, consume adequate quantities of fat, fibre, carbohydrates, vitamins, and other micronutrients (BNF, 2002, 2004), and avoid alcohol. However, a recent DEFRA[1] survey of dietary practices in adults (DEFRA, 2004) revealed disturbing nutritional trends. Consumption of alcohol and dietary fat increased with aged, peaking between the ages of 50 to <65 (alcohol), and 65 to <75 (fat) (see Figure 1). Fruit consumption peaked between 50 to <65 years, then showed a decline through age 75. Energy intake from fat and cholesterol increased with age, while Iron and fibre intake seemed to stagnate throughout adulthood (see Figure 2).

Figure 1 Household Expenditure on Selected Foods by Age (DEFRA, 2004, p.61). X Axis represents the Age Groups, while Y Axis represents Pence per Person per Week.

Figure 2 Energy & Nutrient intake for Selected Foods by Age (DEFRA, 2004, p.62). The X Axis represents the Age Groups. The Y Axis represents Intake per Person per Day in Grams (Milligrams for Iron, Calcium, Cholesterol & Vitamin C). To fit the graph more conveniently, figures for Vitamin D and Potassium x 10, and Calcium /10. Figure for Cholesterol first converted to Grams, then x 10.

FACTORS IN MALNUTRITION

Older people are more vulnerably to malnutrition for various reasons (BNF, 2004; Dietetics, 2006; Furman, 2006). Firstly, medical conditions, such as osteoporosis and heart disease, may dictate what should or should not be eaten. Thus, for example while oily/fatty foods like margarine spreads, which are a good source of Vitamin D, may also be high in cholesterol and hence inappropriate for someone with cardiovascular frailties. Secondly poor dentition may hamper the ability to chew. Mobility constraints may prevent shopping for and preparation of food. Potential complications caused by drug prescriptions means that consumption of certain foods may not be recommended. Economic hardships can limit both the quantity and quality of food that can be purchased. Even the age-related deterioration in the senses (e.g. smell and taste) can affect food choice in the elderly (BNF, 2003). Changes in gut function can impair efficient absorption of nutrients by the body (Dietetics, 2006). Finally, as people age, they are more likely to be alone and homebound (e.g. due to illness). Suddenly, cooking and shopping at the local supermarket may become difficult, and many elderly people may find themselves heavily dependent on store cupboard food or ‘meals on wheels’. Consequently food policies have been developed in the UK specifically to cater for the nutritional needs of the elderly.

Existing food policies[2] in Britain essentially amount to providing the elderly with sufficient advice and information to enable them “make” the right food choices (FSA, 2005, 2006). The Food Standards Agency has outlined specific nutritional guidelines for old people (FSA, 2006). These include eating plenty of food rich in starch and fibre (e.g. bread, rice, cereals), iron-rich foods (e.g. red meat, eggs, lentils, oily fish), foods/liquids rich in Vitamin C (fruit juice, citrus fruit, peppers, tomatoes), foods, rich in folic acid (e.g. brown rice), and calcium rich foods (e.g. milk, cheese). The FSA also recommends Vitamin D supplements (especially for persons of Asian origin, who rarely venture outdoors, and eat no meat or fish). Consumption of Vitamin A, potassium, and salt should be moderate. In their Strategic Plan 2005-2010 Putting Consumers First, the FSA (2005) places considerable emphasis on choice. Their policy is to promote healthier food choices by providing better information (e.g. improved nutrition labelling, allergen labelling), regulating food supplements/health claims based on sound evidence, and protecting against food fraud. In addition to FSA nutrition recommendations (FSA, 2006), Government departments, such as the Department of Health (DOH), and professional bodies, notably the National Institute for Clinical Excellence (NICE), also issue specific guidelines for promoting nutrition in the elderly in specific clinical and community settings. These are considered below.

Care/Nursing Homes

Since a significant proportion of the elderly population reside in care homes, general regulations for care homes – which include nutritional standards – have been published by Department of Health (DOH, 2001), the Care Standards Inspectorate for Wales (CSIW, 2004), and the Scottish Commission for the Regulation of Care (SCRC, 2005). Guidelines for Northern Ireland are espoused in the Residential Care Homes Regulations (NI) 2005 (Statutory Rules for Northern Ireland, 2005). The Scottish Office Department of Health (SODOH, 1997) published the Nursing Home Core Standard, which provides nutritional guidance for nursing/care homes. These bodies all specify mandatory standards relating to meal times, meal content, and menu choice, consistent with nutrition specifications of the Food Standards Agency (FSA, 2005, 2006) and NICE (2006).

Hospitals

Hospitals in England and Wales are guided by NICE nutritional guidelines, which although not specific to older patients, are applicable to any adults who are malnourished or at risk of malnutrition (NICE, 2006). The British Dietetic Association published Standards of Care for Older Adults in Hospital as early as 1993 (BDA, 1993), which includes nutritional guidance. The Scottish Nursing Home Core Standards for Nutrition (NHCSN) provide a practical guide for staff working with elderly patients in hospitals. In 2002 The National Nursing, Midwifery and Health Visiting Advisory Committee (NNMHVAC) (Scottish Executive, 2002) set up a working group to consider the nutritional needs of older patients in Scottish Hospitals, using the Nursing Core Standards (SODOH, 1997). Overall, it is a recommended that patients’ nutritional needs are adequately addressed through nutritional screening, dietary assessment (patients at risk, dietary preferences, poor intake level), dietary intake (e.g. hygiene, meal ordering system, menu design etc), and staff training/monitoring. Nutritional screening is now mandatory in Scottish Hospitals (Scottish Executive, 2002). In Northern Ireland individual Hospital Trusts are responsible for developing and implementing their own guidelines.

Own Home

NICE guidelines are also applicable to the home (NICE, 2006, p.4). Health care professionals are required to undertake monitoring both in the hospital and community. They are expected to train patients and carers to recognise changes in their nutritional needs, and take appropriate action. Additionally, the FSA has published ‘Ages and Stages – Eat Well’, a self-help guidance that on what to eat (foods rich in starch, fibre, iron etc), and vitamin/salt intake (FSA, 2006). These standards are applicable across England, Wales, and Scotland[3].

Homebound

In England, Scotland and Wales, it is the Local Authorities that provide nutritional support for homebound elderly people, for example meal provision (e.g. home delivered hot/frozen meals, help with shopping) and assessment (identifying people at risk of malnutrition). In Northern Ireland it is the Health Boards that provide these services.

Other Developments

In 2005 the Health Ageing Action Plan was published by the Welsh Assembly to provide support to older people (aged 50+) on various health issues, including nutrition (Welsh Assembly Government, 2005). The document outlines various proposals such as providing free transport to supermarkets, assessing the provision of a “meals-on-wheels” scheme, and providing appropriate training for caterers. The Welsh Assembly in conjunction with the FSA also launched Food and Well-being in 2003, which outlines nutritional strategies for vulnerable groups including the elderly (FSA/Welsh Assembly Government, 2003).

Figure 3 Change in food policy for the elderly requires justification and a clear set of criteria. Tangible conceptual and pragmatic restraints may impede change. A model loosely based on Kurt Lewins (1951) change framework.

DEVELOPING NEW POLICIES

Developing new nutritional polices for the elderly requires criteria that define appropriate standards and goals. The immediate concern is that policy change must be evidence-based (Khan et al, 2003). Secondly, precise objectives must be set, which can be translated into auditable action plans (e.g. increase in QALY[4], or BMI[5]). Goals must be client- or patient-centred, in keeping with professional ethical, and where possible involve input from multidisciplinary staff and carers. Once new policies are developed they have to be implemented. This entails a process of change, whereby existing standards are modified, supplemented, or replaced altogether. According to Kurt Lewin (1951) such change is occurs in an environment of restraining and driving forces (see Figure 3). Furman (2006) elucidates some of these constraints, including the lack of clear definitions about what precisely constitutes malnutrition, inconclusive diagnostic criteria, confusion about symptomatology and associated illnesses, uncoordinated care provision, limited treatment options, and improper prescriptions (e.g. medications that interfere with absorption of nutrients). Additional constraints include organisational inertia, increased workloads for care staff, entrenched behavioural norms, in both patients’ and care staff, inadequate training for all concerned, and overall, a general unwillingness amongst the elderly to change long-term lifestyles and dietary practices. Counteracting these barriers are driving forces, principally the need to improve care provision for the elderly and reduce the prevalence and incidence if malnutrition. Policy implementation is unlikely to succeed unless impediments to better nutritional health are first overcome.

RECOMMENDATIONS

Existing food policies for addressing the needs of the elderly population seem adequate at a conceptual level. Both the NICE, and FSA, offer very exact guidance on specific nutritional requirements, so that many elderly people living on their own, or being cared for in a hospital/nursing home, may in fact be feeding healthily. The problem is not the policies themselves but rather the lack of consistency of application, across different care settings and regions of the United Kingdom. The result is that the quality of nutritional care and support the elderly receive may depend heavily on where they live. Both Wales and Scotland appear to have better developed policies for promoting nutrition in the elderly. For example, in Scotland, the Nursing and Midwifery Practice Development Unit (NMPDU, 2002) has issued a ‘best practice’ statement for nutritional care of the elderly within the Scottish NHS, which includes specific action plans for nutritional assessment, diet, etc. In Wales, Welsh Assembly and FSA have both produced guidance documents specifically to promote health eating in older adults (FSA/Welsh Assembly, 2003; Welsh Assembly, 2005). However, there is less clarity about ‘best practice’ standards being applied in England and Northern Ireland, nor do there appear to be specific NHS, FSA, or House of Commons policies for England and Northern Ireland. Three salient policy issues are considered below (see Figure 4).

While the FSAs Strategic Plan for 2005-2010 outlines specific goals and actions to be taken over the next few years to improve nutritional standards, this document makes no specific reference to the elderly. It is clear that older people have very specific nutritional requirements, not to mention unique restrains that may negate proper feeding (e.g. restrictions imposed by medical or dental impairment, such as lack of mobility, difficulty cooking). Thus, it is essential for the FSA to set out age-specific proposals regarding food safety, health eating and choice, the key issues highlighted in the current document. The FSA can also help develop schemes specific to England, Scotland, and Northern Ireland, rather similar to the Food and Well-being proposals developed with the Welsh Assembly (FSA/Welsh Assembly, 2003).

Best Practice

The Scottish NHS ‘best practice’ standards published by the Nursing and Midwifery Practice Development Unit (NMPDU, 2002) should be applicable across the UK. Currently, it isn’t clear whether these standards are implemented outside Scotland. The implementation of Nursing Home Core Standards in Scotland has been closely monitored with the publication of a report, set up by the NNMHVAC[6] (Scottish Executive, 2002). The aim of this working group was to evaluate implementation of standards, and identify examples of ‘best practice’. Similar implementation and monitoring of nutritional standards and best practice for the elderly should apply to the NHS in England, Wales, and Northern Ireland.

Nutritional Screening

Malnutrition in the elderly can have very severe health implications (Scottish Executive, 2002, p. 3). Therefore, it would seem reasonable to ensure that every older adult above a certain age is undergoes mandatory nutritional screening on a regular basis. Currently, NICE guidelines recommend screening in clinical (i.e. hospital and professional care) settings. However, Ellen (2006) emphasises the importance of nutritional assessment for the elderly across both clinical and community (i.e. home) locales, arguing that “failure to assess and treat malnutrition in community-dwelling older adults can lead to both physical and functional disabilities that result in admission to acute care hospitals, long-term care facilities, or death” (p.23). Old people who are living at home or homebound may not undergo need special arrangements to be in place (e.g. regular home screening carried out by a visiting nurse), to ensure that those with nutritional deficiencies are identified quickly. Nutritional screening should be universal and applicable to all care homes and NHS Hospital Trusts. Screening procedures published by the British Dietetic Association (BDA, 1999) can be used as a template for developing guidelines.

Other Considerations

The DEFRA Family Food survey (DEFRA, 2004) indicated disturbing age-related differentials in nutritional risk (see Figures 1 and 2). For example, 50-65 years olds seems to report particularly high levels of expenditure on alcohol (Figure 1), Calcium and Vitamin C intake both seem to drop off beyond age 75, and dietary fat consumption seems to increase exponentially from the 50-65 to the 65-75 age bracket, and beyond (see Figure 2). Such patterns may justify the development of nutritional policies tailored for specific target (age) groups even among the elderly, but this is not a major consideration.

Figure 4 Improving Nutrition for the Elderly: Three Avenues for Improvement

CONCLUSIONS

In conclusion, existing food policies for the elderly are multifaceted and applicable to a variety of settings. The adequacy of current policies is remains questionable as long as malnutrition amongst older adults continues to grow. Do new policies need to be developed? Perhaps, albeit it can be argued that existing policies are not necessarily flawed (i.e. inadequate). Rather, the problem is that implementation has been inconsistent across different parts of the UK, and also different care settings. Policy development, execution, and auditing, seem far more advanced in Scottish NHS Trusts, compared to England, Wales and Northern Ireland. The 2002 report by the Nursing and Midwifery Visiting Committee cites numerous examples of ‘good practice’ in which Nursing Home Core Standards for nutrition were implemented to promote nutrition for older patients (Scottish Executive, 2002). What is required therefore isn’t new policies, but rather the establishment of Practice Development Units across the UK. These can issue statements of best practice, and support implementation of nutritional guidelines, as is the case in Scotland (NMPDU, 2002). Guidelines must also be in place to facilitate best practice in community settings (e.g. at home), not just in professional care settings (e.g. hospitals), with special support for ‘home-alone’ or ‘home bound’ people.

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1


Footnotes

[1] Department for Environment, Food, and Rural Affairs.

[2] Not including guidelines for the care of hospital patients. This statement refers more generally to guidelines issued to the general public, primarily by the FSA. Nutrition policies in clinical settings are considered below.

[3] FSA Wales and Northern Ireland have published corresponding ‘Eat Well’ documents.

[4] Quality Added Life Years.

[5] Body Mass Index.

[6] National Nursing Midwifery & Health Visiting Advisory Committee

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