This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the first three descriptors in the Nutrition domain and help you to assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one, two and three of this series:
The assessed levels of need in the Nutrition domain range from ‘No Need’ to ‘Severe’. Unlike the Breathing domain, Nutrition does not have a descriptor for a ‘Priority’ level of need. While nutritional needs are, of course, important, they are unlikely to result in a critical or immediate risk to life, as in the domains of Breathing, Behaviour, Medications and Altered States of Consciousness and this is reflected in the applicable levels of need.
In the 2012 version of the DST, the Nutrition domain was in the middle of the assessment, after Mobility, at domain number six. The 2018 revisions reordered the domains of the DST, with Nutrition coming second. As we considered in Parts 2 and 3, its new proximity to the Breathing domain (number 1) is important, as individuals who have swallowing difficulties are at higher risk of suffering aspiration (inhalation of food or fluid particles into the lungs). For those with existing breathing problems due to an underlying condition, aspiration is likely to cause increased exacerbations and complexity. While the MDT will consider aspiration risk and breathing difficulties separately, any interrelation between the domains of Breathing and Nutrition (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.
The following clinical factors are relevant to the assessment of ‘NO’, ‘LOW’ or ‘MODERATE’ needs in this domain:
- Can the person feed themselves independently?
- Are all nutritional/hydrational requirements met, or do they need supplementary feeding?
- Can they eat normal consistency food, or do they require liquidised meals?
- Do they require prompts, encouragement and/or assistance to take sufficient food/fluids?
- Do they require full assistance with feeding? Does this take a long time, i.e., over 30 minutes?
- Any special dietary requirements, intolerances or allergies?
- Weight chart, BMI measurements, MUST (Malnutrition Universal Screening Tool) scores.
- Are their nutritional needs met via PEG (percutaneous endoscopic gastronomy) or RIG (radiologically inserted gastronomy)? If so, is this problematic to manage?
- Is there a diagnosis of dysphagia/risk of aspiration? If so, are there any recorded episodes of choking?
IMPORTANT – The Decision Support Tool provides the following guidance to the MDT when assessing needs in this domain: Individuals at risk of malnutrition, dehydration and/or aspiration should either have an existing assessment of these needs or have had one carried out as part of the assessment process with any management and risk factors supported by a management plan. Where an individual has significant weight loss or gain, professional judgement should be used to consider what the trajectory of weight loss or gain is telling us about the individual’s nutritional status.
This underlines the importance of having clear, dated evidence to confirm any symptoms of weight loss, swallowing difficulties and/or risk of aspiration/malnutrition/dehydration, as the CCG may interpret a lack of this type of documentation as evidence of an absence of need. This is particularly important for those receiving care at home, where record keeping is often less robust.
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for the levels of need. For each descriptor, we provide a case study to give you a better understanding of how the levels of need might be applied at your or your relative’s assessment.
|Able to take adequate food and drink by mouth to meet all nutritional requirements.|
Feeds self independently.
No evidence of malnutrition or dehydration.
No problems with swallowing or risk of aspiration.
CASE STUDY – NO NEEDS
Mrs. X eats independently and has a normal diet and fluids. Her appetite is good.
She does not have any swallowing problems and her risk of choking is low.
Mrs. X has lost 6.5kg since April 2021; however, she is above normal weight, and the weight loss may be due to the fact that she had recently been prescribed diuretics (March 2021) so her limbs are less oedematous than they were previously.
December 2020 – 81.3kg
January 2021 – 81.3kg
February 2021 – 79.2kg
March 2021 – 77.4kg
April 2021 – 74.8kg BMI 26
Mrs. X has several missing teeth and does not have dentures. However, this does not appear to affect her dietary intake.
Mrs. X presents with NO NEEDS as she is able to take adequate food and drink by mouth to meet all nutritional requirements.
|Needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies).
Able to take food and drink by mouth but requires additional/supplementary feeding.
Requires full or partial assistance with feeding.
Special dietary requirements (diabetes, coeliac etc.).
Nutritional supplements prescribed, with good effect.
CASE STUDY 1 – LOW
Mrs. X enjoys a varied diet of level 6 (minced, moist, mashed, bite sized pieces of food) consistency and normal fluids.
It is noted in the Care Plans dated July 2020 that Mrs. X is able to eat independently and is able to use a spoon to eat. However, owing to increasing cognitive impairment, she now becomes very easily distracted and staff are required to prompt and encourage her, and she sometimes needs to be fed. Mrs. X is quite happy to be fed by the staff and is able to indicate when she has had enough food.
Mrs. X needs a great deal of prompting to drink fluids. Food and fluid charts are in place to monitor her intake. Mrs. X dislikes hot drinks and prefers to wait until they have cooled before she will drink them.
Mrs. X’s weight is stable, and she remains slightly overweight.
Sept 2019 – 84.6kg
July 2020 – 82kg
August 2020 – 81.86kg
September 2020 – 80.9kg
October 2020 – 81.5kg
November 2020 – 81.5, BMI 29, MUST 0
Mrs. X presents with a LOW level of need as she needs supervision, prompting with meals, or may need feeding and/or a special diet (for example to manage food intolerances/allergies).
CASE STUDY 2 – LOW
Mr. X has a poor appetite. He has a normal, soft consistency diet and normal fluids and is fed and given drinks by carers. Fluids need to be encouraged.
There is no evidence that Mr. X has any swallowing difficulties and there are no reported episodes of choking.
Mr. X was referred to the GP on 22.02.2020 due to loss of appetite, low BMI (17) and a MUST score of 4. Ensure Compact food supplements were prescribed 3 x per day and a referral was made to the Dietician. Mr. X was reviewed by the Dietician on 5.09.19 and 17.10.19: BMI now 19 MUST score 1 – the advice was to continue with food supplements and a fortified diet, milky drinks and snacks between meals.
Weight history 2020
On admission 6.2.20 – 42.3kg (BMI 17)
July 50.6kg BMI = 21
November 50.6 kg
Since his admission to the home in February 2020, Mr. X has gained 9.3kg in weight. (1.5 stones). Mr. X is now fed by carers due to declining cognition; however, he appears to enjoy his meals, which he will typically finish within 15-20 minutes. Mr. X’s weight has steadily increased since admission to the home and is now within the normal range. His BMI has increased to 21 and the Dietician reviewed him on 5th December 2020 and decreased his food supplements to x 2 per day. Mr. X will be reviewed again in January 2021 with a view to reducing the supplements to 1 per day and then discontinue.
Mr. X presents with a LOW level of need as he is able to take food and drink by mouth but requires additional/supplementary feeding.
NOTE – Mr. X has a history of weight loss and low BMI, which might suggest his nutritional status is at risk (‘high’ level of need). However, at the time of assessment, he has gained a significant amount of weight and his BMI is within the healthy range. The Dietician has reduced the prescription of supplements, with a view to discharge in the near future. To that extent, Mr. X is no longer considered “nutritionally at risk”.
|Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.
Unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.
Needs full assistance to eat, which is time intensive (over 30 minutes).
Requires liquidised food.
Nil-by-mouth but has a non-problematic PEG (percutaneous endoscopic gastronomy) or RIG (radiologically inserted gastronomy).
CASE STUDY 1 – MODERATE
October 2020 – 64.5kg
November – 63.8kg
December – 64.1kg
January 2021 – 62.5kg
February – 63kg
Mr. X has a normal consistency diet with normal thickness fluids. There is no evidence that he has any difficulty swallowing (dysphagia) and he is not assessed as being at risk of aspiration.
Mr. X’s weight is currently stable. However, he has a history of significant weight loss (2019) and was under the care of the Dietician until June 2020. Mr. X has now been discharged by the Dietetics department, but his diet is fortified with additional calories to ensure he maintains his weight.
Mr. X is severely cognitively impaired and is unable to feed himself. He needs to be fed by one member of staff to ensure adequate daily nutritional intake. Mr. X is compliant with feeding but requires much encouragement to eat and drink adequate amounts. Typically, Mr. X takes between 40 and 60 minutes to finish a meal.
Mr. X presents with a MODERATE level of need as he needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.
CASE STUDY 2 – MODERATE
Mrs. X is nil-by-mouth and all her nutritional requirements are met via PEG (percutaneous endoscopic gastronomy) . She is under the care of the dietician, who reviews her regime on a regular basis.
1000mls of Jevity feed and 1000mls of water are administered over a 12-hour period, between the hours of 7am and 7pm, per the instruction of the dietician.
Mrs. X needs to be positioned at a 45-degree angle for the duration of the feed and for 45-minutes pre-and post-feeding, to reduce the risk of choking and aspiration.
Mrs. X drools saliva from her affected side and her mouth becomes dry easily. Carers perform oral hygiene to prevent the build-up of mucous and plaque in her mouth.
Mrs. X is assessed as being at a high risk of choking. However, she is nil-by-mouth and has been discharged by the SaLT (Speech & Language Therapy) Team.
Mrs, X’s son reported that on one occasion, when he visited his mother, he found her lying flat and she was choking. The senior nurse stated that Mrs. X had used the remote control for the bed and had inadvertently lowered the head of the bed. The nurse confirmed that the remote has now been removed from Mrs. X’s reach and that staff check on her every 15 minutes while the feed is running.
Mrs. X’s weight is stable, and she appears to be well nourished and hydrated.
31.07.2020 – 64.8kg, BMI = 23
30.08.2020 – 65.8kg
15.09.2020 – 65.8kg, BMI = 24.1
MUST score = 0
Mrs X presents with a MODERATE level of need as she is unable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.
NOTE – Many people would consider Mrs. X to have a ‘HIGH’ level of need as she is diagnosed with dysphagia (swallowing difficulty and associated risk of choking). However, Mrs. X does not take any nutrition or hydration orally and receives all her food and fluids via PEG. Consequently, her risk of choking and aspiration is drastically reduced, and she does not require skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway (‘high’ level of need).
We hope this has helped you to understand the first three levels of need in the Nutrition domain. Don’t miss Part 2, coming very soon!
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