Abstract
Executive Summary
Background
This national malnutrition screening survey in hospitals and community nursing units was conducted in November 2023 by IrSPEN with data collection by Dietetic teams within each of the participating units. The survey is the third of its kind in the Republic of Ireland (ROI), the previous surveys having been conducted in 2010 and 2011 as part of a larger survey of both UK and Ireland organised by
BAPEN(1,2).
Subjects and subject characteristics
This is the largest national malnutrition survey to date, with data collected for 3,755 adult patients in total. This comprised admission screening data from 3662 patients (49.1% female, mean age 69 (16–103) years, mean BMI 26.4 (SD 6.7) kg/m2) from 26 hospitals and 93 patients (59.1% female, mean age 80.7 (50 – 100) years, mean BMI 26.7(6.7 SD) from two large community nursing units.
The primary diagnoses reported as reason for admission amongst the hospital patient cohort were reported as follows: cancer 15.7%; falls/fracture 15.4%; respiratory disease 12.2% gastrointestinal (GI) disease 8.7%; neuromuscular 8.0%; genito/renal disease 7.0%; cardiovascular disease 6.3%; other 25.0%. Irrespective of reason for admission, 22.4% of patients were reported to have cancer, which is
significantly higher than found in earlier surveys although likely to be reflective of an increase in bed occupancy by cancer patients arising from an increase in cancer incidence and survival and increased hospitalisation within late-stage disease(4).
Approximately one in eight hospital patients (14.7%) were underweight (BMI < 20kg/m2), whereas almost one in four patients (23.9%) were obese (BMI > 30kg/m2).
Results
Overall, 33.8% of hospital patients were found to be at risk of malnutrition, which is a higher prevalence than found in both earlier surveys (28.4 % and 32.7% respectively). This is explained by the increased proportion of patients with cancer compared with previous surveys (22% vs 16% in 2011), which was associated with a significantly higher risk of malnutrition (44%) compared with patients reported to have no cancer (30%), and the higher mean age of subjects (69 years vs 60.1 years in 2010 and 2011).
Older patients had significantly higher rates of malnutrition risk vs younger adults, with malnutrition risk affecting 36% of over 65s vs 30% of under 65s, irrespective of primary diagnosis, ward type, source of admission or presence of cancer.
Malnutrition risk affected patients within all BMI classes. Of those identified by screening as ‘at risk’, 35% were underweight, 33% normal weight and 32% overweight or obese.
Discussion
A key factor that has contributed to both the quality of data collection and larger survey numbers has been the introduction of mandatory nutrition screening in all adult hospitals in 2020 making it possible for dietitians to obtain admission screening results from a patient’s notes. Since its introduction in December 2020, malnutrition screening is conducted routinely by trained nursing staff or other appropriate healthcare professionals in compliance with NCG22(3), whereas in previous surveys over a decade ago, the screening was conducted largely by dietitians during a designated day or days.
A surprising but very welcome finding in this survey is the significantly lower rates of malnutrition in patients on long stay wards (21% vs 35% in all others), rehabilitation units (20% vs 35%) and those admitted from other hospitals (26.4%% vs 35.5% for patients admitted from all other sources). This points to the effectiveness of systemised screening linked to initiation of oral nutrition support in those found to be at risk. This is an important finding that points to the success of both the NCG22 and other hospital food-based policies, since international studies of malnutrition point to worsening nutritional status within hospital patients, based on comparison of screening on admission and on point of discharge, termed “hospital-acquired malnutrition”(5).
Although the survey design is largely unchanged from earlier surveys, this survey included a question regarding the use of nutrition support since admission (e.g. dietary counselling, ONS/EN/PN) to allow comparison between malnutrition risk score and initiation of treatment. It found that although one third of patients screened (36.6%) were receiving some form of nutritional support, 25% and 43% of patients with a high and medium risk score respectively, were not. This may be due to a lag phase between screening on admission and initiation of nutrition support, but it requires further investigation given that all patients with high-risk scores and many patients with medium risk scores will require supplementary nutrition.
This is also the first survey to include questions regarding the use and results of frailty screening, based on the persuasive body of evidence of a causal relationship between muscle loss and physical frailty(6), a particular concern in older patient populations. Frailty screening results were available for 10% of
hospital patients, the majority conducted in care of elderly wards, long stay rehabilitation units and orthopaedic wards, but 94% of community unit residents. Amongst hospital inpatients screened for frailty, just 32% were found to be robust, and 68% ranged from pre frail to severely frail. Of note is the absence of a correlation between the results of malnutrition screening and frailty screening, despite muscle loss being a major modifiable risk factor for physical frailty. This highlights the fact that malnutrition screening tools do not consider or evaluate loss of muscle mass or function, with the common risk criterion being weight loss, whereas malnutrition diagnosis frameworks such as the Global Leadership Initiative on Malnutrition (GLIM) criteria include muscle deterioration as an
indicator of malnutrition, even in the absence of a low body mass index (BMI) or significant weight loss(7).
Conclusions
This national hospital survey confirms higher rates of malnutrition on admission than any previous survey. This reflects the impact of demographic changes in the broader Irish population since the last surveys were conducted. Older people represented over two thirds of the inpatient cohort in hospitals and one in five patients were reported to have cancer, both being independent risk factors for
malnutrition(8).
It has also shown that that contrary to expectations and data obtained from international studies of hospitals and rehabilitation units(5,9), our rehabilitation and long stay units have patients with lower rates of malnutrition than the general incoming hospital population, with the highest proportion of nutrition support use amongst those at risk (88 – 91%). This is an extremely positive finding that points to the effectiveness of NCG22 implementation.
Background
This national malnutrition screening survey in hospitals and community nursing units was conducted in November 2023 by IrSPEN with data collection by Dietetic teams within each of the participating units. The survey is the third of its kind in the Republic of Ireland (ROI), the previous surveys having been conducted in 2010 and 2011 as part of a larger survey of both UK and Ireland organised by
BAPEN(1,2).
Subjects and subject characteristics
This is the largest national malnutrition survey to date, with data collected for 3,755 adult patients in total. This comprised admission screening data from 3662 patients (49.1% female, mean age 69 (16–103) years, mean BMI 26.4 (SD 6.7) kg/m2) from 26 hospitals and 93 patients (59.1% female, mean age 80.7 (50 – 100) years, mean BMI 26.7(6.7 SD) from two large community nursing units.
The primary diagnoses reported as reason for admission amongst the hospital patient cohort were reported as follows: cancer 15.7%; falls/fracture 15.4%; respiratory disease 12.2% gastrointestinal (GI) disease 8.7%; neuromuscular 8.0%; genito/renal disease 7.0%; cardiovascular disease 6.3%; other 25.0%. Irrespective of reason for admission, 22.4% of patients were reported to have cancer, which is
significantly higher than found in earlier surveys although likely to be reflective of an increase in bed occupancy by cancer patients arising from an increase in cancer incidence and survival and increased hospitalisation within late-stage disease(4).
Approximately one in eight hospital patients (14.7%) were underweight (BMI < 20kg/m2), whereas almost one in four patients (23.9%) were obese (BMI > 30kg/m2).
Results
Overall, 33.8% of hospital patients were found to be at risk of malnutrition, which is a higher prevalence than found in both earlier surveys (28.4 % and 32.7% respectively). This is explained by the increased proportion of patients with cancer compared with previous surveys (22% vs 16% in 2011), which was associated with a significantly higher risk of malnutrition (44%) compared with patients reported to have no cancer (30%), and the higher mean age of subjects (69 years vs 60.1 years in 2010 and 2011).
Older patients had significantly higher rates of malnutrition risk vs younger adults, with malnutrition risk affecting 36% of over 65s vs 30% of under 65s, irrespective of primary diagnosis, ward type, source of admission or presence of cancer.
Malnutrition risk affected patients within all BMI classes. Of those identified by screening as ‘at risk’, 35% were underweight, 33% normal weight and 32% overweight or obese.
Discussion
A key factor that has contributed to both the quality of data collection and larger survey numbers has been the introduction of mandatory nutrition screening in all adult hospitals in 2020 making it possible for dietitians to obtain admission screening results from a patient’s notes. Since its introduction in December 2020, malnutrition screening is conducted routinely by trained nursing staff or other appropriate healthcare professionals in compliance with NCG22(3), whereas in previous surveys over a decade ago, the screening was conducted largely by dietitians during a designated day or days.
A surprising but very welcome finding in this survey is the significantly lower rates of malnutrition in patients on long stay wards (21% vs 35% in all others), rehabilitation units (20% vs 35%) and those admitted from other hospitals (26.4%% vs 35.5% for patients admitted from all other sources). This points to the effectiveness of systemised screening linked to initiation of oral nutrition support in those found to be at risk. This is an important finding that points to the success of both the NCG22 and other hospital food-based policies, since international studies of malnutrition point to worsening nutritional status within hospital patients, based on comparison of screening on admission and on point of discharge, termed “hospital-acquired malnutrition”(5).
Although the survey design is largely unchanged from earlier surveys, this survey included a question regarding the use of nutrition support since admission (e.g. dietary counselling, ONS/EN/PN) to allow comparison between malnutrition risk score and initiation of treatment. It found that although one third of patients screened (36.6%) were receiving some form of nutritional support, 25% and 43% of patients with a high and medium risk score respectively, were not. This may be due to a lag phase between screening on admission and initiation of nutrition support, but it requires further investigation given that all patients with high-risk scores and many patients with medium risk scores will require supplementary nutrition.
This is also the first survey to include questions regarding the use and results of frailty screening, based on the persuasive body of evidence of a causal relationship between muscle loss and physical frailty(6), a particular concern in older patient populations. Frailty screening results were available for 10% of
hospital patients, the majority conducted in care of elderly wards, long stay rehabilitation units and orthopaedic wards, but 94% of community unit residents. Amongst hospital inpatients screened for frailty, just 32% were found to be robust, and 68% ranged from pre frail to severely frail. Of note is the absence of a correlation between the results of malnutrition screening and frailty screening, despite muscle loss being a major modifiable risk factor for physical frailty. This highlights the fact that malnutrition screening tools do not consider or evaluate loss of muscle mass or function, with the common risk criterion being weight loss, whereas malnutrition diagnosis frameworks such as the Global Leadership Initiative on Malnutrition (GLIM) criteria include muscle deterioration as an
indicator of malnutrition, even in the absence of a low body mass index (BMI) or significant weight loss(7).
Conclusions
This national hospital survey confirms higher rates of malnutrition on admission than any previous survey. This reflects the impact of demographic changes in the broader Irish population since the last surveys were conducted. Older people represented over two thirds of the inpatient cohort in hospitals and one in five patients were reported to have cancer, both being independent risk factors for
malnutrition(8).
It has also shown that that contrary to expectations and data obtained from international studies of hospitals and rehabilitation units(5,9), our rehabilitation and long stay units have patients with lower rates of malnutrition than the general incoming hospital population, with the highest proportion of nutrition support use amongst those at risk (88 – 91%). This is an extremely positive finding that points to the effectiveness of NCG22 implementation.
| Original language | English |
|---|---|
| Place of Publication | Dublin, Ireland |
| Publisher | Irish Society for Clinical Nutrition & Metabolism (IrSPEN) |
| Commissioning body | Irish Society for Clinical Nutrition & Metabolism (IrSPEN) |
| Number of pages | 39 |
| Publication status | Published - 1 Jul 2024 |
Keywords
- Malnutrition
- Screening
- Nutrition
- Dietetics
- Cancer
- Frailty
- acute care
